Shin Splints

Lower Leg  Four Fascial Compartments    

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Anterior Lateral Superficial posterior Deep posterior

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Anterior  Tibialis anterior  Extensor digitorum longus  Extensor hallicus  Deep peroneal nerve  Anterior tibial artery and vein

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Lateral  Peroneus longus  Peroneus brevis  Superficial peroneal nerve

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Superficial Posterior  Soleus  Gastrocnemius  Tendons of the plantaris

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Deep Posterior  Flexor digitorum  Flexor hallicus longus  Tibialis posterior  Peroneal and posterior tibial artery and vein  Tibial nerve

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Compartment Muscles  Anterior  

Extensors Shock absorbers

 Lateral 

Evertors

 Superficial Posterior 

Plantar flexors

 Deep Posterior  

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Invertors Stabilizers overpronation 6

Shin Splints  Tendinitis  Periostitis  Muscle strain  Interosseus membrane strain

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Types of Shin Splints  Anterior   

Tibialis anterior Extensor hallucis longus Extensor digitorum longus

 Posterior   

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Tibialis posterior Flexor hallucis longus Flexor digitorum longus 8

Presentation  Pain is often at the middle or lower third of tibia.  Anterior 

Lateral to the middle tibia.

 Posterior 

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Posteromedial to the middle or lower tibia.

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Treatment  Acute    

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Rest Ice Support – elastic tape Support at the foot – taping and/or medial heel wedges. Orthotics – recurrent/chronic Calcium – one study 10

Compartment Syndrome  Presentation  

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Most common is the athlete/exercise. Complains of aching or cramping of leg following exercise. Pain is relieved by rest initially. Numbness/paresthesia may be present into parts of the foot, in the distribution of the corresponding nerve. Local trauma or fracture may also result in this syndrome. Fascial defects with muscle herniations are present in ~ 40% of patients.

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Etiologies for Pressure in Compartments  Patients who have crush injuries or fractures with marked swelling are at risk for developing ACS.  Patients who have had reduction of long-bone fractures and those who have experienced prolonged external pressure from pneumatic antishock garments, casts, or tight-fitting or blood-soaked dressings.  ACS occurs when the function of muscles, blood vessels, and nerves is jeopardized by the pressure within the layers of semirigid fascia that support and partition them.

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Pathophysiology of Compartment Syndrome  After an injury to an extremity, an immediate inflammatory response results in decreased blood flow distal to the injury and tissue hypoxia.  Inflammatory mediators are released and cause the capillary wall to lose integrity and colloid proteins to leach into the soft tissue, drawing more fluid into the soft tissue.  This fluid shift causes increased edema, and the cycle is perpetuated.  The imbalance in pressures between inflow of arterial blood and outflow of venous blood eventually culminates in total cessation of blood flow into the affected extremity. 07/18/09

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Compartmental Pressures  Intracompartmental pressures in excess of 30 to 40 mm Hg can cause muscle ischemia; pressure greater than 55 to 65 mm Hg causes irreversible muscle death.  Normal pressure within a compartment is 8 mm Hg or less. Even within four to six hours of the onset of ACS, a patient may develop irreversible muscular damage.  ACS sequelae can run the gamut from foot drop due to peroneal nerve injury to something as severe as a completely insensate, nonfunctional extremity with muscle fibrosis and joint contracture (Volkmann's ischemic contracture).  Potential systemic complications include myoglobinuria, which can lead to renal failure, and untreated infection of an extremity, leading to sepsis.  In a worst-case scenario, a patient may require amputation. 07/18/09

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Evaluation  Symptoms usually occur within 10-30 minutes of exercise.  Pain will subside over minutes or hours following activity.  Pulses are often normal distally.  Examination is often normal between exacerbations. 07/18/09

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Signs of ACS  The key signs and symptoms of ACS can be summed up by the "six P's.“      

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Pain Paresthesia Pressure Pallor Paralysis Pulselessness

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Pain  Is a crucial, though not specific, early sign.  Red flags include: 

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Patient's complaint of diffuse pain that's not relieved by analgesics Pain that's greater during passive motion rather than during active motion. Severe pain that's out of proportion to the injury.

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Paresthesia  Abnormal sensations such as burning, may be the first symptom to appear, as nerves are very sensitive to pressure.

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Pressure  Refers to tension felt during palpation.  As compartment pressure rises, the affected area becomes extremely taut and feels firm to the touch.

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Pallor  Caused by pressure in the compartments that suffered arterial injury, is a late and ominous sign.

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Paralysis  Is usually a late symptom.  It is caused by either prolonged nerve compression or irreversible muscle damage.

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Pulselessness  Is a late and ominous sign, indicating death of tissue.  A pulse is present in the limb until the very late stages.

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Patient Assessment  Compare the injured limb with the non-injured limb at least every one to two hours, or more frequently depending on the patient's status and the physician's orders.  Prompt recognition and intervention are essential.  If you suspect ACS, the physician will need to measure the compartment pressure by inserting a needle, wick, or slit catheter into the compartment.  Depending on the reading, a surgeon may need to perform a fasciotomy —an incision into the fascia of the affected compartment to relieve the pressure and restore circulation.  Precisely how high a reading merits a fasciotomy is controversial. Some clinicians will do a fasciotomy if the compartment pressure is 33 mm Hg; more conservative clinicians might do one only if the reading hits 60 mm Hg. 07/18/09

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Management  Acute 

Conservative care •

If patient does not respond to conservative care, fasciotomy is the treatment of choice.

 Chronic 

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Rest for 4 to 8 weeks.

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