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Lower Leg Pain: Shin Splints vs. Compartment Syndrome

By Lyndon B. Gross, MD, PhD – The Orthopedic Center of St. Louis -

While running is one of the easiest and cost effective means of exercise, it can also lead to significant injuries. One of the most common complaints in runners is lower leg pain.

Lower Leg PainShin Splints or Medial Tibial Stress Syndrome (MTSS) is a common term for pain in the tibia or shin bone. The tibia is the main weight bearing bone of the lower leg. This bone is the attachment site for many muscle groups involved in walking and running. Most of the time, the pain will occur in the middle to lower portion of the tibia.

Causation: The most common cause of MTSS is cumulative stress on the tibia from the “pounding” associated with walking, running, jumping, or other loading activities. People with “flat feet” or those who walk on the inside of their feet (over-pronation) can stress the muscles on the inside of the lower leg.

Symptoms: It is best described by a generalized pain along the tibia bone. This pain can be with activity, rest, or to the touch.

Diagnosis: Plain film x-rays are usually negative, but plain film x-rays and MRI studies may be ordered to rule out a stress fracture.  The examination of the lower leg should include looking at foot alignment and mechanics as well as muscle flexibility.

Prevention/Treatment: Symptom reduction can be achieved by cross training in the form of cycling, elliptical, or swimming which will reduce the load on the lower legs and decrease pain. After returning to running, monitor the number of miles run and the condition of your foot wear. Running shoes should be replaced every 250-400 miles or sooner if there are signs of breakdown. For patients that over-pronate, shoe inserts, or orthotics, may provide correction and better alignment.

MTSS canLeg Pain progress into a stress fracture if the symptoms are ignored or left untreated.

Chronic Exertional Compartment Syndrome (CECS) is an uncommon condition, and many times is overlooked or not properly diagnosed in active people. CECS is best defined as an increase in pressure within the compartments of the lower leg. This pressure build-up causes a compression of the nerves and blood vessels that serve the lower leg muscles. In 75-90% of patients, it is diagnosed in both legs.

The lower leg is comprised of four compartments: Anterior, Lateral, Deep Posterior, and Superficial Posterior.

Leg PainEach compartment houses a grouping of muscles that is encased in a thick connective tissue called fascia.

Symptoms: CECS is best characterized by aching, burning, tightness, and cramping pain in the muscles of the lower leg. Due to the increased pressure, patients may also experience a tingling sensation into the foot or toes. Patients present most often with pain in one or perhaps two compartments of the leg. The Anterior and Lateral compartments are affected 76% of the time, followed by the Deep Posterior 16%, and Posterior Superficial 12%.

As the patient continues their activity, the pressure builds in the compartments of the lower leg and unfortunately, it has nowhere to go. After 15 minutes or more of activity, the symptoms usually present themselves and force the patient to stop their activity; after a brief amount of rest the symptoms resolve. This rollercoaster of symptoms with activity can cause significant frustration for the physically active patient.

Diagnosis: There are two different methods to properly diagnose CECS: Compartment Pressure Testing and Pre-/Post-Exercise Magnetic Resonance Imaging.

Compartment Pressure Testing: This is the most commonly used method to determine CECS. The test involves inserting a small pressure probe (pressure manometer) into the compartments of the lower leg while the patient is at rest. Then, the patient is instructed to perform exercise such as walking or jogging on a treadmill with a slight incline, and the measurements are taken 5 minutes after activity is discontinued.

Pre- and Post-Exercise Magnetic Resonance Imaging:
MRI scan is a non-invasive way to determine a true diagnosis of CECS.  A MRI is performed both before and after exercise to determine the amount of edema or swelling within the muscles of the lower legs.

Although a relatively new method, it has been shown in some studies to be comparable in accuracy as Compartment Pressure Testing.

Surgical Treatment: Non-surgical treatment is not effective in relieving symptoms, but there is a surgical procedure that is highly successful for relieving the symptoms of CECS. It is called a fasciotomy in which the surgeon, through on or two incisions into different areas of the lower leg, cuts the fascia, or connective tissue that bundles the muscle groups together to “release” the pressure from these compartments.

Leg Pain
Summary
Lower leg pain can be frustrating for many of our active patients.  Remember that pain over the bone is more often related to MTSS. Pain that comes on with activities and goes away with a few minutes of rest is more indicative of CECS.

Both syndromes are treatable so if you are having pain and it is affecting your activities, contact your orthopedist right away.

Meet Lyndon B. Gross, MD, PhD
Lyndon B Gross, MD, PhDDr. Gross is an Orthopedic Surgeon who specializes in preventing, diagnosing and treating injuries related to participation in sports and/or exercise in patients of all ages. His area of specialty is sports medicine, specifically ailments of the shoulder, knee and elbow. He performs advanced arthroscopic procedures, joint reconstruction procedures, cartilage restoration procedures and joint replacement surgery. He and his staff have truly raised the expectations of orthopedic care by treating their patients with compassion and flexibility in an effort to make the process of returning them to activities as convenient as possible.

Dr. Gross is the Assistant Team Physician for the St. Louis Cardinals, and Team Physician for Lindbergh High School, and St. Louis Bombers-Rugby. He was honored to be voted one of St. Louis Magazines Best Doctors 2008-Present. He was also selected by his peers as one of the Best Doctors in America since 2007, which is an honor only given to 5% of the doctors practicing in the U.S.

Dr. Gross is proud to announce that in 2009 he has earned his Subspecialty Certificate in Orthopaedic Sports Medicine from the American Board of Orthopaedic Surgery (ABOS). This is a new certification and will become the standard of Sports Medicine care in conjuncture with Fellowship training.

Dr. Gross is a former athlete who holds the distinction as an Orthopedic Surgeon who specializes in sports medicine. He earned many awards in Football and Rugby including 1986 MVP Cornell Football and played for the USA Rugby East Sevens All Star Team from 1991-1992. Because of his previous athletic experience he truly understands the complexity and dynamics of treating an athlete.

Lyndon B. Gross, MD, PhD
The Orthopedic Center of St. Louis
14825 N. Outer Forty Road • Suite 200 • Chesterfield, MO 63017
Phone: (314) 336-2566
www.drlyndongross.com

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About Lyndon B. Gross, MD, PhD

Lyndon B. Gross, MD, PhD
Dr. Gross is an Orthopedic Surgeon who specializes in preventing, diagnosing and treating injuries related to participation in sports and/or exercise in patients of all ages. His area of specialty is sports medicine, specifically ailments of the shoulder, knee and elbow. He performs advanced arthroscopic procedures, joint reconstruction procedures, cartilage restoration procedures and joint replacement surgery. He and his staff have truly raised the expectations of orthopedic care by treating their patients with compassion and flexibility in an effort to make the process of returning them to activities as convenient as possible.

Dr. Gross is the Assistant Team Physician for the St. Louis Cardinals, and Team Physician for Lindbergh High School, and St. Louis Bombers-Rugby. He was honored to be voted one of St. Louis Magazines Best Doctors 2008-Present. He was also selected by his peers as one of the Best Doctors in America since 2007, which is an honor only given to 5% of the doctors practicing in the U.S.

Dr. Gross is proud to announce that in 2009 he has earned his Subspecialty Certificate in Orthopaedic Sports Medicine from the American Board of Orthopaedic Surgery (ABOS). This is a new certification and will become the standard of Sports Medicine care in conjuncture with Fellowship training.

Dr. Gross is a former athlete who holds the distinction as an Orthopedic Surgeon who specializes in sports medicine. He earned many awards in Football and Rugby including 1986 MVP Cornell Football and played for the USA Rugby East Sevens All Star Team from 1991-1992. Because of his previous athletic experience he truly understands the complexity and dynamics of treating an athlete.
Melander Sports Medicine St. Louis