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noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

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Compartment syndrome/ vascular issues

noreply@blogspirit.com (PhysioCharlie) — Fri, 19 Sep 2008 10:45:00 +0200

I found this discussion on iCSP:

Hi I am in search of some diagnostic help.

I assessed a 44 year old woman who is a keen runner in clinic today. She is currently training for a marathon which is 5 weeks away. She has been running seriously for the past 7 years, however has a chronic problem in her right calf.

She describes symptoms consistent with compartment syndrome in that her calf becomes very painful and rock hard after running approximately half a mile or when walking up a steep hill. However her symptoms are not behaving like a compartment syndrome. She is able to ease her symptoms by stopping and simply shaking her leg, pumping her ankle and then continue running for half a mile before she has to repeat this routine. She has to do this every half a mile for the 1st 3 miles and then she is able to continue running with no problems. She is up to running 16 miles at present. Can I please emphasise that this problem is not a result of an increase in training load, change of footwear or any obvious cause. This has been happening for her entire running career and nobody has been able to give her a diagnosis. She saw an orthopaedic consultant last year who palmed her off with compartment syndrome without doing any investigations or suggesting any further intervention. There has been no trauma other than a hyaline fracture many years ago, before she begun running, and healed with no dramas and has had no problems since.

On examination today there appears to be no biomechanical abnormality. Leg lengths are equal, there is no over pronation/supination and she wears a neutral running shoe. She has full ROM at her ankle with no suggestion of muscle shortening. There is no localised tenderness on palpation. NAD was detected on assessing Lx. The only muscle imbalance abnormality was minimal shortening of TFL on the problematic side.

I put the patient on the treadmill today to assess her gait and to try and reproduce her symptoms. To the eye there appears to be no major issues around her pelvis. I was able to reproduce her symptoms following 4 mins of incline walking (10% gradient). The lateral half of her calf became solid and very tender on palpation. Medially was relaxed with no tenderness. This settled within 60 seconds.

Please correct me if I am wrong but if this was a true compartment syndrome she would not be able to continue running with no problems in the pattern she describes above. The symptoms have not worsened. But have frustrated her as she is unable to keep up with her running group for the 1st 3 miles. If its of relevance she runs 9 minute miles. I am wondering whether this could be a vascular problem but I have not come across anything like this before. Any ideas on pathology and diagnostic tests would be hugely appreciated.

Regards,
Math

Showing 1 to 10 of 15

Title:	Compartment Syndrome Diagnosis
Added by:	maginty
Posted:	19 September 2008 09:24

Hi Math,
I have seen several patients with very similar symptoms, being based in the Newcastle area we see lots of people training for the Great North Run. My clinical area of interest is visceral fascial release and I have found that most of these clients have fascial restrictions around the first part if the large intestine which seems to create vascular problems of the lower limb. An obvious cause can be an appendix scar but it is not always as blatant as that. I do not, as yet, have a full physiological explanation but all of these patients have had some degree of SIJ restsritions, tight hip flexors and tight plantar flexors.
Good luck with your client.
Best wishes
Graham

Title:	intrigued
Added by:	willow8
Posted:	18 September 2008 13:10

I see, yet again, physio mitch has suggested fatigue of the sympathetic nervous system as the diagnosis for this patient.
If so,I wonder if you could shed some light on why her symptoms are only evident for the first 3 miles? Is her sympathetic nervous system not fatigued for the rest of her run?

Math, crude as it maybe, I would look at pre and post exercise pulse palpation as a method of identifying a possible vascular origin of her symptoms.
good luck

Title:	? Vascular
Added by:	Alan Taylor
Posted:	18 September 2008 12:55

Interesting thread! . . . . Sportex Medicine published "How to recognise vascular flow problems in athletes;a clinical reasoning exercise"
Taylor & Kerry Issue 35 Jan 08 That may be helpful?

Cheers

Alan

http://books.google.co.uk/books?hl=en&lr=&id=SwhoZYtgVd8C&oi=fnd&pg=PA517&dq=vascular+flow+problems+in+athletes&ots=7sDpsHkTk4&sig=hHnQM0moZuesyfAKJyBzPLaAe0A#PPA518,M1

Title:	Calf pain
Added by:	paul.davidson
Posted:	18 September 2008 12:21

Hi

I would agree if this was true compartment syndrome, the lady would be unable to run once the symptoms occur. It sounds vascular, there was a paper (case study) a few years ago that if my memory serves had a similar presentation. It was found that there was popliteal artery occlusion brought on only during/after exercise.

Hope this helps

Title:	nothing odd about this
Added by:	physiomitch
Posted:	18 September 2008 10:19

Hi

This is anot an uncommon or odd case. The basic foundation of this problem is one of overuse. If I may, I would like you to picture this typical scenario. The end result may differ from person to person, but the underlying factors are very common.

Runners, in my view, do too much running as a part of their training. Running mare than twice a week can be a form of overload/overuse. The body needs 48 hours to recover from exercise including the immune system Studies have shown white cell count to increase during exercise, reduce after exercise (to BELOW normal numbers), and then to return to normal levels 48 hours later.

The scenario of a typical runner can go as follows. Please note this is my opinion after 16 years of treating runners and other sports persons:

- Too much running (or any exercise for that matter) without sufficient rest in between (48hrs) can lead to fatigue of the sympathetic nervous system. This system controls the rate of blood flow through controlling the tone of the arteries and their peristaltic movements.
- Fatigued nerve cells mean they cannot feed thmselves enough blood to recover and thus get stuck in a state of fatigue
- This leads to slower rates of blood flow to, eg the lower limbs
- This results in muscle weakness (often evident in the hips initially) and tightness of the myofascial units (stiffness and weakness go together)
- This now produces a mechanical problem, with weakness in the hip abductors resulting in compensatory overuse of the thigh and calf muscles to maintain good function of the lower limb
- It is this overuse that often manifests as thigh, knee or calf pain. The tightening of the calf is mostly due to a chronic loss of good blood flow rate, resulring in fascial tightening. This is why she can relieve the symptoms by stopping and moving the foot about, thus restoring some blood flow (similar to intermittant claudication, but without the physical vessel constriction).
- The more she runs the more she demands increased rates of blood flow to the muscle. This stresses the sympathetics more, and the cycle goes on. Muscle fatigue is often an indication of nerve cell fatigue in the sympathic nervous system.

From your explanation and from my own experience with this type of condition I would suggest she has a chronic fatigue of the sympathetic nervous system (T10 to L2) with resulting muscle weakness and fascial shortening (ITB tightness being evidence of this). Even a little tightness in ITB can be very harmful. The calf tightness is a symptom of this problem, not the cause. You will need to accurately assess hip strength, left and right, TFL strength, knee flexion/extension and ankle plantar/inversion and dorsiflexion strengths. Any weakness may be caused by poor blood flow and/or tight fascial sheaths. T10 to L2 needs to be assessed as discussed above, and any corrections made, preferably through myofascial release. She should not be running now!!! It may mean missing the marathon, but there are plenty more. She may recover in time, but running during treatment is detrimental to recovery. Rest will assist in recovery of the sympathetic nervous system, as well as some form of treatment to the affected area of the spine.

Hope this helps

Title:	Compartment Syndrome Diagnosis
Added by:	icspteam
Posted:	18 September 2008 09:31

Originally Added by: daveharvey
Hi,
This ladies start of symptoms seem a bit too young to be caused by spinal stenosis if she has had these symptoms for her entire running career. Aggravation of her calf pain during uphill walking as u know I'm sure is also not classic spinal stenosis presentation. I assume she is not exhibiting any circulatory symptoms?
Popliteal Artery Entrapment Syndrome is a rare but potential diagnosis for this lady as it tends to affect runners with well developed calf muscles.
Check out this article...
www.dirjournal.org/pdf.php3?id=52

Best test to rule out vascular probs seems to be the angiograph done whilst exercising the ankle. Clinical tests that we can do basically involve testing leg pulses pre/post producing symptoms and with ankle dorsi and then plantarflexed to see if they diminish.
Good luck!

Title:	Similar symptoms?
Added by:	m160318
Posted:	18 September 2008 09:30

I am a taekwondo player and compete regularly and suffered from a similar problem for nearly three years. No one could tell me what was wrong. I was investigated extensively for stress fractures, medial tibial stress and for compartment syndrome and had pressure tests taken. The pain was exercise induced. After approximately 4 minutes of exercise my calves would become very tight and this would cause pins and needles and numbness into my feet with some reduced circulation. I occasionally suffered from pitting oedema around the posterior medial tibia. It got to the stage that I couldn't stand anyone touching my shins.

I was under the care of three consultants, (orthopaedic, biomechanic, vascular) none of which were sure of the cause of my symptoms. By chance I attended an SIJ course. The course leader assessed me and I had quite a marked SIJ dysfunction which was causing neural tension. I had no pain in the SIJ region itself, the problems manifested itself in my shins. The course leader treated me and I have had no problems since. Maybe assess this patient's SIJ?

Shirin

Title:	pathohaemodynamics
Added by:	icspteam
Posted:	18 September 2008 09:30

Originally Added by: Tim.Pigott
sounds more vascular to me....

check pulses and BP at ankle vs arm

if Ok at rest, get her on a treadmill until the symtoms come on, and re-test.

Title:	Compartment Syndrome Diagnosis
Added by:	icspteam
Posted:	18 September 2008 09:29

Originally Added by: patsuth
Had a sort of similar problem with a 45yr old man some years ago. He wasn't a runner, but a keen hillwalker. He first presented with calf pain which appeared to be local in origin. I suspected Compartment Syndrome, and he went for an orthopaedic opinion. Orthopod thought it was vascular. To cut a long story short, he had Spinal stenosis. (No Hx of any back pain or injury, and Lx assessment had not been significant) Surgery alleviated the problem. Not quite your scenario, but worth considering maybe.

Title:	calf pain
Added by:	stuarthattan
Posted:	18 September 2008 09:21

If as you say, this lady has had this all her running life then there is a high chance she has a unilateral congenital limb hyperplasia. There is no remedy for this pathology. It relates directly to muscle bulk. If the pulses are normal at rest there is unlikely to be an arterial issue. The only other diagnosis is a vascular abnormality, which would require a duplex scan. ABPI does not help but you should find girth of the calf larger at rest on the affected side. Send her to a vascular surgeon for confirmation.

Physio Charlie - vascular

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Compartment syndrome/ vascular issues