Lower Extremity Group 4. Intake Form 22 year old female Treatment for pain box checked Primary Complaint: Pain in both legs while exercising. Boxes Checked:

Lower Extremity

Group 4

Intake Form

• 22 year old female• Treatment for pain box checked• Primary Complaint: Pain in both legs while

exercising.• Boxes Checked: Sharp, Numb, Tingling and

Burning• Pt. doesn’t know what is causing complaint

Intake Form

• Exercises 3x/wk-- 2x run 4 miles– 1x run 6 miles

• No hx trauma/illness• Mother had breast cancer (in remission)

OPQRST• Onset: four months ago• Provocation: After 10 mins of activity burning and

sharp pain in both shins. Tightness, sometimes tingling. Sometimes her left foot feels numb.

• Palliative: Pain goes away once she stops the activity.

• Quality: Burning, Sharp – Pain is hard to point out direct area.

• Radiating: It stays in the shin, with symptoms in her feet if she tries to push through.

OPQRST Cont.

• Severity: Pain gets to point where it is unbearable.• Timing: only after 10 minutes of moderate exercise.• Treatment: none• Activities of daily living: They are not directly

affected but exercise is big part of life.• Environmental: none• Medications: Tylenol / Aspirin

Preliminary Diagnosis

• Shin splints • Deep Vein

Thrombosis• Tibialis posterior

tendinitis• Somatic Dysfunction

of Lower Extremity

• Tibialis anterior tendinitis

• Pes Anserinus bursitis

• Tibial Stress Fracture

• Lower Cross Syndrome

Initial Exam Posture Findings-

• Hyperlordosis lumbar• Anterior head carriage • High right shoulder • Internal rotation of shoulders

Chiropractic Listings

• C4 RP• L1 LP• L5 LP• Bilateral AS ilium fixation

Measurement Normal % of normal

Flexion 50 60 83

Extension 35 25 140

Left Lat Flexion 20 25 80

Right Lat Flexion 20 25 80

Lumbar Range of Motion:

Inspection

• Inspect legs bilaterally for 5 P’s:– Pain– Pallor– Paresthesias– Paralysis– Pulselessness

Initial Exam Findings

• Neurological– Unremarkable

• Vascular– Unremarkable

• MMS– 4/5 bilateral extensor hallucis longus, extensor digitorum

longus, tibialis anterior, peroneus longus, brevis, tertius

• Orthopedic– Unremarkable

Exam• Pts exam findings were not conclusive to

expected finding of fx.• Lumbar Series - Ferguson line measured 54 degrees.

• Further investigation warranted.• X-ray series taken of both legs rule out

pathology– Negative

Exam cont…

• Stress fx suspected as finding. • Refer out for Triple Phase Bone Scan

(TPBS).• Research stats (TPBS) is gold standard

and “test of choice” for differential diagnosis and clinical management.

• Use MRI- where avoidance of radiation exposure is desirable

Results of TPBS

• Healed stress fracture • No current bone abnormalities

Follow up questions

• Running terrain?– Flat, uphill, downhill, track, grass, concrete

• Willing to change?– Running vs. cycling

Exam

• What is causing Pain?

• Repeat exam after exertion of pain.• Have pt. run on treadmill until pain is

unbearable.• Exam before run, immediately after, 5

minutes, 10 minutes and when symptoms no longer present.

Follow up Exam

• Prior to running (Reexamination)– Findings WNL

• Post exercise– 5 minutes, 10 minutes and when symptoms

no longer present

Inspection

• Immediately after exertion-• Inspected legs bilaterally for 5 P’s:

– Pain– Pallor– Paresthesias– Paralysis– Pulselessness

Neurological Testing

Initial• Neurological

– Unremarkable


• MMS– 4/5 L Dorsiflexors


Post• Tight sensation anterior

legs & dorsum of feet• decreased sensation on

dorsum L foot, altered sensation between 1st & 2nd toes

• decrease vibratory sensation of pure patch

Vascular Testing


– Unremarkable




Post• decreased dorsalis

pedis pulse

MMS Testing


– Unremarkable




Post• Dorsiflexion of ankle

– Tibialis anterios: 3/5

• Toe extension– Extensors hallicus

longus & digitorum longus: 3/5

• Passive stretch deep, achy pain

Orthopedic Testing


– Unremarkable




Post• Deep palpation elicited

pain

After 5 minutes

• Findings same after immediate exercise.

• No worsening noted

After 10 minutes

• Pt. describes decrease in tightness.

• Pt. sensation on dorsum of feet increased.

• Vibratory sensation still affected.• Deep palpation elicited pain• Noticeable increase of dorsalis pedis

pulse

33 Minutes

• Pain symptoms no longer present

• Decrease vibratory sensation of the first 2 toes still noted

• Deep palpation elicited pain.

• Dorsalis pedis pulse strong and symmetrical

• Dorsiflexion (Tibialis anterior) 4/5

Compartment SyndromePressure Measurements


• Simple Needle– 18 gauge– Least accurate– Usually gives falsely

higher reading

• Slit Catheter and Side ported needle– No significant difference– More accurate

Side port

• Measurements must be made in all compartments

• Anterior and deep posterior are usually highest• Measurement made within 5 cm of fx• Marginal readings must be followed with repeat

physical exam and repeat compartment pressure measurement


Diagnosis

• Chronic Anterior Compartment syndrome 729.72

• Muscle weakness 728.87

• Lower Cross Syndrome 781.92

• Somatic Dysfunction of Lower Extremity 739.6

• Pelvic Somatic Dysfunction 739.4

Anterior Compartment Syndrome

Etiology

Two main types

• Acute - associated with trauma in the affected compartment.

• Chronic - aka exertional compartment syndrome (CECS)

• leg is divided into 4 compartments

• Surrounded by inelastic fascial

• ↑pressure damaged muscles

• Predominantly a problem amongst athletes– Accounting for up to 60% of all lower leg injuries [2] but can

occur in the general population

• CECS– an activity-related – reversible increase in intracompartmental

pressure – results in decreased tissue perfusion and

abnormal neuromuscular function. [2]

Symptoms

• Muscle pain, tenderness, fatigue, damage, inflammation, edema and increased compartment pressure have been known to result from eccentric exercise.

• Increased pressure Numbness paresthesia ischemia

Just prior to heel contact the body weight is forward of the opposite forefoot while the contact leg is

falling toward the floor, resulting in an abrupt loading of the heel with an acceleration of the bodyweight [13]. Ground reaction forces are

approximately 110-125% of bodyweight during this period.

“Anterior Compartment Pressures in Cyclists”

• Many of the literature suggests there are no cases of CECS in cyclists.

• Cycling – Non-weight bearing activity – Tibialis anterior only contracts

concentrically.

Differentiating Among Types

• Type I– Pain associated with healing stress

fractures

• Type II– Pain at the same level of activity or

distance

• Type III– Pain that increases after activity

Management

• Conservative treatment

• Open contact with Orthopedic Surgeon

• Surgical treatment final option

Phase 1

• Stop all activities that cause symptoms

• Frequency: 3x’s/wk for 4 wks

• Graston along with PIR

• Adjustment: postural abnormalities, hyperlordosis

• Reduce inflammation with nutrition

• digital foot scan (Stabilizers)

Phase 2

• Frequency: 2x/wk for 4wks

• Adjustment

• Therapeutic Exercises

• Stretches

• Continued Nutritional support

• Standing shin Stretch

• Anterior, Lower Leg Flexion:

• Tibialis Anterior, Dorsi Flexors

• Sit up straight with your legs in front of you (use a back support if necessary). Place the exercise handle across your toes.

Phase 3

• Adjustments

• Therapeutic Exercises

• Continued Nutritional support

• Start Biomechanical reeducation

• Taping

Goals

• Eliminate Chronic Anterior Compartment Syndrome

• Decrease/eliminate risk of acute compartment syndrome.

• Avoid Fasciotomy

• Postural correction

• Core strengthening

• Pt. able to return to normal exercise routine

• Proper biomechanics while running

Progress and Measurements

• The First Phase of treatment should reduce pain and inflammation and improving muscle strength.

• Decrease dural adhesions, facial thickening, and break up scar tissue.

• Manual muscle strength of foot and toe dorsiflexors and foot everters.

• Improve cervical and lumbar ranges of motion and decrease fixations.

•

Progress and Measurements:

• The Second Phase of treatment includes improving muscle strength, cervical and lumbar range of motion.

• Begin running again in small amounts (1 mile max). • Manual muscle strength of foot and toe dorsiflexors

and foot everters to 5/5.• Improve cervical and lumbar ranges of motion to

normal.

Progress and Measurements:

• The Third Phase of treatment is to maintain the results in phase I and II.

• Patient should be able to run at the level she was prior to when pain started.

• Maintain manual muscle strength of foot and toe dorsiflexors and foot everters to 5/5.

• Maintain normal cervical and lumbar ranges of motion.

•

references

• [1] “A Comparison of anterior compartment pressures in competitive runners and cyclists.– The American Journal of Sports Medicine. Vol. 21, No. 1, pg

36, 1993.

• [2] “Chronic Exertional compartment Syndrome’– The American Journal of Sports Medicine. Vol. 31, No. 5, pg

770, 2003.

References

• Souza, Thomas A. Differential Diagnosis and Management For the Chiropractor.4th edition.Jones and Bartlett Publishers 2009. pgs 434-437

• Deirdre B. Birtles et. Al.Venous Obstruction in Healthy Limbs: A model for Chronic Compartment Syndrome.Medicine &Science in Sports & Exercise.1638-1644, 2003.

references

• [1] “A Comparison of anterior compartment pressures in competitive runners and cyclists.– The American Journal of Sports Medicine. Vol. 21, No. 1, pg

36, 1993.

• [2] “Chronic Exertional compartment Syndrome’– The American Journal of Sports Medicine. Vol. 31, No. 5, pg

770, 2003.

Documents

Lower Extremity Group 4. Intake Form 22 year old female Treatment for pain box checked Primary Complaint: Pain in both legs while exercising. Boxes Checked: