Exertional Leg Pain In A Long-distance Athlete - Page #4
 

Working Diagnosis:
Chronic exertional compartment syndrome (CECS)

Treatment:
Fasciotomy was initially declined by the patient and he opted for non-operative management. Custom made orthotics, neoprene compression sleeves, the POSE method of running, and activity modifications were instituted.
Osteopathic Manipulative Treatment (OMT) was performed utilizing deep myofascial release, fascial distortion model, and lymphatic techniques. PB underwent 6 sessions of OMT over a 4 month period. After each treatment he gradually eased back into running and progressed to more aggressive runs on flat ground and finally on hills. He was able to regain full activity of running on flat surfaces and achieve further distances before becoming symptomatic on hills.Case Photo #1 Case Photo #2

Outcome:
PB initially did very well with the non-operative management of his CECS.
His symptoms worsened after reintroducing hills into his workout running routine. He eventually underwent fasciotomy to release all four compartments bilaterally.
He was able to return to running 7 weeks after the fasciotomy. Case Photo #3Case Photo #4Case Photo #5]Eight weeks post-operatively he was able to run pain free but still had significant stiffness and swelling. PB hopes to return to running marathons in the near future.

Author's Comments:
CECS should always be considered in the differential diagnosis of exertional shin pain.
Obtaining appropriately performed exertional compartment pressure testing is imperative for making the diagnosis of CECS.
While OMT was not able to entirely correct the fascial restriction of this patient, it should be considered as an adjunctive treatment in the osteopathic physician’s armamentarium.

Editor's Comments:
This case represents a fairly classic presentation of CECS with pain developing at a predictable time during exercise and resolving quckly upon cessation. The pain is usually thight and cramp-like and physical exam is usually normal.
Like this patient, some patients may respond to conservative measures, especially if they are willing to discontinue participation in the offending physical activity. However, many athletes, especially those that want to continue the exercise that causes symptoms.

This case highlights an important lesson. As physicians we are reluctant to repeat expensive or uncomfortable tests. However, if a test was not performed appropriately we must not be afraid to repeat the test.

References:
Bradshaw C, Hislop M, Hutchison M. Shin Pain. Clinical Sports Medicine, Third Edition. 30:555-577; 2006.
DiGiovanna, E, Schiowitz S, Dowling DJ. Myofascial Techniques. An Osteopathic Approach to Diagnosis and Treatment, Third Edition. 12: 80–82; 2005.
Glorioso JE, Wilckens JH. Compartment Syndrome Testing. Sports Medicine: Just the Facts. 22:130-134; 2005.
Pedowitz RA, Hargens AR, Murbarak SJ, et al. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 18:35; 1990.
Touliopolous S, Hershman B. Lower leg pain: Diagnosis and treatment of compartment syndrome and other pain syndromes of the leg. Sports Med. 27:193-204; 1999.
Typaldos S. Clinical And Theoretical Application Of The Fascial Distortion Model Within The Practice Of Medicine And Surgery. 1997.

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