Chronic Compartment Syndrome of the Lower Extremity

About Compartment Syndrome

Compartment syndrome refers to a painful condition in which the pressure within a group of muscles rises to potentially dangerous levels. Compartment syndrome can occur in several locations within the body, and may be categorized as either acute or chronic. Acute compartment syndrome usually develops as the result of a serious injury, and is classified as a medical emergency. Without immediate treatment, it can result in permanent muscle damage. Chronic compartment syndrome, also known as exertional compartment syndrome, generally occurs as an overuse injury. This overview will focus on compartment syndrome of the lower extremity, a condition that arises most commonly among athletes such as long-distance runners, skiers, basketball players, and soccer players.

The lower leg is divided into four compartments; anterior, lateral, posterior, and deep posterior. Each of these compartments contains several muscles, along with corresponding nervous tissue and blood vessels. The compartments are separated by fascia (thick layers of tissue) that to not stretch or expand easily. Therefore, when swelling occurs within a compartment, increased pressure can be placed on the muscles, capillaries and nerves. In the case of chronic compartment syndrome, this results in pain, cramping, tingling and/or numbness during activities such as running. These sensations tend to go away once the activity has stopped, though the muscles in the area of the symptoms may feel tight.

Chronic compartment syndrome of the lower extremity most commonly occurs in the anterior compartment, which houses the dorsiflexors of the foot and ankle (tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius) as well as the anterior tibial artery and the deep peroneal nerve. This simply means that the characteristic symptoms of compartment syndrome are usually experienced in the front of the lower leg. Chronic compartment syndrome usually occurs bilaterally, meaning that symptoms are present in both legs.

Risk Factors

The only true risk factor for chronic or exertional compartment syndrome is participation in activities that involve repetitive motions. This condition is most commonly found in long-distance runners, but other sports listed as risk factors include cycling, soccer, and gymnastics. Chronic compartment syndrome most frequently occurs in athletes under the age of 40, though age is not considered to be a risk factor.

Treatment

-          Surgery: Unfortunately, surgical procedures seem to be the most effective treatment for chronic compartment syndrome. The most common surgery for compartment syndrome is a fasciotomy, or compartment release, which involves cutting the fascia to allow the muscle swell, and subsequently relieving the excess pressure. There are several techniques for performing this surgery, though the most common is the double-incision fasciotomy (shown on right). Rehabilitation is required after surgery, so compartment syndrome patients (especially athletes) should anticipate a fairly long recovery time before returning to normal activity.

-          Non-Surgical Treatments: Chronic compartment syndrome may be treated conservatively; however, these treatments have not proven to be extremely effective in relieving symptoms over the long term. Pain medications, stretching and strengthening regimens, and biomechanical corrections (such as orthotics) are often used to delay the need for surgery. Generally speaking, if an athlete wishes to continue with the sport that caused the injury, he or she will most likely need surgery in order to return to full ability.

An Ounce of Prevention

Unfortunately, very little can be done to prevent the onset of compartment syndrome. General suggestions for reducing any chronic overuse injury include proper warm-ups and cool-downs with exercise, gradual approaches to increased training, proper footwear, and running on a variety of surfaces.  

Sources and Additional InformationAmerican Academy of Orthopaedic Surgeons http://orthoinfo.aaos.org/topic.cfm?topic=a00204
Mayo Clinic http://www.mayoclinic.com/health
http://emedicine.medscape.com/article/1270542-treatment
Lippert, Clinical Kinesiology and Anatomy, 4th edition

Impingement Syndrome

About Impingement Syndrome

The shoulder joint is a complex structure that allows for a very large range of motion, but has very little stability. This makes the shoulder a common site of injury. The shoulder girdle is comprised of three bones; the humerus (upper arm), the scapula (shoulder blade), and the clavicle (collarbone). The scapula contains a bony protrusion called the acromion process, which allows it to connect to the cavicle. The humerus is connected to the scapula by the rotator cuff, which consists of four muscle tendons. Impingement syndrome is a painful shoulder condition that occurs when the tendons of the rotator cuff rub against the acromion process. This rubbing or “impinging” action can cause inflammation of the bursa overlying the rotator cuff, or of the tendons themselves, and results in pain and limited range of motion at the shoulder.

Typical symptoms of impingement syndrome include a generalized minor pain in the shoulder, even during rest, as well as sudden pain with lifting and reaching movements. One characteristic sign of impingement is a sharp pain when the individual reaches for his or her back pocket. As the condition progresses, discomfort increases. The joint may become stiff, and overhead athletes may have a very difficult time completing the tasks required in their respective sports.

Risk Factors

-          Repetitive Overhead Motions: The primary risk factor for impingement syndrome is involvement in activities that require excessive repetitive overhead motions. The force of these movements can cause attrition in the rotator cuff tendons. This occurs in sports such as tennis, throwing, and swimming, and is also common in certain occupations, such as carpentry.

-          Weak or Inflexible Rotator Cuff Muscles: The four muscles of the rotator cuff are the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles perform abduction, external rotation, internal rotation, and horizontal abduction. If these muscles lack strength and flexibility, added force is likely to irritate the tendon at the rotator cuff and can lead to symptoms of impingement.

-          Age: Though impingement syndrome can occur at any age, it is more common in young athletes and middle-aged people. Younger patients tend to recover more easily, whereas older patients are more likely to require surgical treatment.

Treatment

-          Rest: The first step with nearly any overuse injury is to take a break from the activities that cause painful symptoms. Unfortunately, for athletes this may mean some time off from their sport. If possible, activities can be modified so that the humerus is kept below 70 degrees of abduction. This is done to protect the bursa and the rotator cuff tendons from further irritation due to impingement.

-          Ice and Anti-Inflammatory Treatment: Pain and inflammation can be treated conservatively with ice and over the counter nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen. These treatments should be applied consistently, but within moderation. Ice should not be applied for longer than 15 to 20 minutes at a time, and anti-inflammatory medications should not be taken for extended periods of time as they may result in adverse side effects. If these basic anti-inflammatory procedures do not work, a doctor might suggest a cortisone injection for a temporary, but strong, anti-inflammatory effect.

AAROM Excercise for Shoulder Abduction

-          Physical Therapy: Physical therapy for impingement syndrome aims to reduce pain and inflammation, while reestablishing full range of motion at the shoulder joint. This is often accomplished by a combination of ice and heat therapy, isometric strengthening exercises in all of the muscles of the shoulder (not just the four rotator cuff muscles), active-assistive range of motion (AAROM) exercises, and sometimes neuromuscular control exercises. This could include transcutaneous electrical nerve stimulation (TENS), ultrasound, and iontophoresis, as well as several others. Physical therapy can be very effective, as long as the patient is consistent with his or her home exercises, and follows orders on what movements should remain limited.

-          Surgery: In the rare event that 3 to 6 months of the above conservative treatments have not improved symptoms, surgery may be required to treat impingement syndrome. The goal of surgical treatment is to increase the space between the rotator cuff tendons and the acromion process, allowing the head of the humerus to move freely in the subacromial space. This act of relieving pressure from the subacromial tissues is referred to as subacromial decompression, and is usually performed by removing part of, and reshaping the acromion. This is also known as acriomioplasty. Surgery for impingement syndrome can be performed openly or arthorsocpically, depending on the case and the preferences of the surgeon. Rehabilitation, usually in the form of physical therapy, is required after surgery. This can be a long process, as this surgery may take a while to recover from.  

An Ounce of Prevention

For overhead athletes and workers who may be at a high risk of impingement syndrome, several preventative measures can be taken. Instruction on proper warm-up techniques and strengthening exercises may help decrease the risk of shoulder injury. These individuals should also be aware of the early signs of impingement syndrome, so that early conservative treatment can be applied before the condition has a chance to progress to the point of inability to complete daily tasks.

Sources and Additional InformationAmerican Academy of Orthopaedic Surgeons http://orthoinfo.aaos.org/
http://emedicine.medscape.com/article/92974-overview
Lippert, Clinical Kinesiology and Anatomy, 4th edition

Patellofemoral Pain Syndrome

About Patellofemoral Pain Syndrome

Patellofemoral pain, better known as “runner’s knee,” refers to a dull, aching pain under or around the patella (kneecap) where it articulates with the distal femur (thigh bone). This type of pain may occur in one or both knees, and tends to worsen with activity. The patella can move up and down, side to side, tilt and rotate against the femur. Overuse and/or overload of this mechanism can cause irritation to the cartilage on the underside of the patella. In later-stage cases, even prolonged periods of sitting can be painful due to the extra pressure between the patella and femur during knee flexion. The exact cause of patellofemoral pain is unknown, and is likely to be a combination of several factors.

Risk Factors

-          Q Angle: The Q angle, or patellofemoral angle, is the angle between the quadriceps muscles (namely the rectus femoris) and the patellar tendon. This angle is determined by drawing a line from the anterior superior iliac spine (a prominent bone marking on the front of the hip) to the midpoint of the patella, and measuring the angle between this line and the vertical. Normal Q angles range from 13 to 18 degrees. Due to wider pelvic girdles, women tend to have higher Q angles than men. Larger Q angles are associated with a greater risk of knee and patellar problems.

-          Muscle Weakness or Imbalance: Because the knee is so central to the lower limb, imbalances and weaknesses in one or several of the muscle groups in the leg can lead to knee problems. Because of the close relationship of the quadriceps muscle insertion and the patella, weak quads can lead to poor knee tracking. Conversely, if the hamstrings are tight, more posterior stress may be placed on the knee and this can also lead to patellar pain. Some studies have even shown correlations between weakness in the hip muscles and patellofemoral pain. Finally, imbalances within any of the major muscle groups of the leg (such as the lateral quad muscle being stronger than the medial) can cause the patella to be pulled off center, leading to pain and irritation.

Excess movement of the patella can be
caused by a number of factors.

-          Foot Pronation: Many overuse injuries of the lower limb can be linked, at least partially, to foot mechanics. Overpronation, or excess “rolling in” of the foot during weight bearing, is very common, but can cause problems all throughout the leg. When the foot and ankle roll in excessively, the tibia or femur may rotate internally to compensate. For this reason, overpronation can upset the patellofemoral mechanism, and is thought to be a contributor to patellofemoral pain syndrome.

-          Athletics: Any one or combination of the aforementioned biomechanical risk factors may predispose an individual to patellofemoral pain syndrome. The risk goes up substantially if these factors are present in an athlete involved in any of the many sports that place a lot of stress on the knee joint. This includes, but is not limited to; running, jumping, skiing, cycling and soccer. Playing competitive sports is almost always a risk factor for overuse injury.

Treatment

-          Rest: In the case of patellofemoral pain, all activities that induce symptoms should be stopped until the patient is pain free. Many athletes choose to take up non-weight bearing activities, such as swimming, to maintain fitness during recovery

-          Ice and Anti-inflammatory Treatment: Applying ice for 10 to 20 minutes after activity can help reduce the pain and inflammation of patellofemoral pain syndrome, as can over the counter anti-inflammatory medications such as ibuprofen or naproxen.  However, these medications should not be used over a long period of time, as they can have adverse side effects.

-          Physical Therapy: Physical therapy is often the best treatment option for overuse injuries. Since so many biomechanical factors are thought to contribute to patellofemoral pain syndrome, physical therapy can provide exercises to strengthen more than one potential cause at a time. Often times, physical therapy for patellofemoral pain will focus on the quadriceps muscle groups. Physical therapists are able to test for muscle imbalances, and can tell which parts of the lower extremity need to improve in strength and/or flexibility. Regardless of whether or not these are the direct causes of patellofemoral pain, several weeks physical therapy and/or an at-home strengthening program, have been shown to be quite effective in treating knee pain symptoms.

-          Proper Footwear/Orthotics: Since many common biomechanical factors can lead to patellar pain, braces, orthotic inserts, and proper footwear have been shown to provide relief in some patients. Certain knee braces and taping techniques have been shown to stabilize the patella. Orthotic inserts and proper footwear can correct exaggerated pronation patterns in the foot, which allows the entire lower leg to function more efficiently and can also prevent a multitude of other lower leg overuse injuries.

An Ounce of Prevention

Because the exact cause of patellofemoral pain is unknown, it can be difficult to prevent. However, there are a number of measures that can be taken to reduce the risk of nearly any lower limb overuse injury. Staying in shape and maintaining a healthy weight are often the first steps to preventing knee pain. Major leg muscle groups (such as quadriceps, hamstrings, hip abductors and adductors, etc.) should be strengthened equally to avoid muscle imbalances. With the onset of any new form exercise, the training load should be increased gradually. Individuals who overpronate, or have very high or low arches, should consult with a local running store to be properly fitted for running shoes, and older shoes should be replaced after 300-500 miles. It is also important to maintain proper running form during exercise, and in the case of knee pain, steep downhill runs should be avoided where possible.

Sources and Additional Information
American Academy of Orthopaedic Surgeons http://orthoinfo.aaos.org/
American Association of Family Physicians http://www.aafp.org/
Lippert, Clinical Kinesiology and Anatomy 4th edition.

Lateral Epicondylitis

About Lateral Epicondylitis

Lateral epicondylitis, or “tennis elbow,” is an overuse injury characterized by an inflammation of the muscle tendons that attach to the outside of the elbow. The lateral epicondyle is a bone marking on the distal humerus that serves as the origin for several muscles of the forearm. Of these muscles, the extensor carpi radialis brevis (ECRB) muscle is most commonly involved with tennis elbow. When the ECRB gets weakened from overuse, micro tears can form in the tendon near the lateral epicondyle, resulting in pain and inflammation.

As with many overuse injuries, the symptoms of lateral epicondylitis develop gradually. As symptoms worsen over time, lateral epicondylitis patients commonly report pain or burning sensations on the outside of the elbow, which may radiate to the forearm and wrist. Other common symptoms include forearm weakness, weak grip strength, and pain during simple motions such as shaking hands or turning a doorknob.

Risk Factors

Unlike many overuse injuries, tennis elbow is not associated with a long list of risk factors. There does not appear to be any form of predisposition to this condition, nor is it higher in incidence among women than men. Studies have noted that most patients with lateral epicondylitis are between the ages of 30 and 50, but with overuse anyone can experience symptoms.

Though overuse is the only truly known risk factor, the forearm tendons of the lateral epicondyle can be overworked in many ways. Unsurprisingly, lateral epicondylitis has a high incidence among tennis players and generally occurs as a result of repetitive backhand strokes with poor technique. However, though the condition has earned the nickname “tennis elbow,” lateral epicondylitis very often occurs as a result of painting, plumbing, raking, and other common forearm motions. Generally speaking, individuals who perform these types of repetitive motions for at least two hours a day are at a higher risk of developing lateral epicondylitis.

Treatment

-          Pain and Inflammation Relief: As with most inflammatory conditions, lateral epicondylitis can be treated at home with ice and nonsteroidal anti-inflammatory medications, such as ibuprofen or naproxen. However, tennis elbow can take 6 months to several years to go away on its own, and often times patients seek out additional treatment methods to ensure a quicker recovery.

-          Physical Therapy: Physical therapy for tennis elbow focuses on strengthening the muscles of the forearm, which perform wrist extension. Stretching routines are also an important component of physical therapy.

-          Corticosteroids: Corticosteroid injections can have very powerful anti-inflammatory effects and are often able to provide great amounts of pain relief in the short term. Corticosteroids can also be taken orally, or absorbed topically through treatments known as phonophoresis and iontophoresis. However, these treatments have not yet proven as effective as physical therapy exercises.

-          Surgery: Only 10% of lateral epicondylitis cases progress to the point where surgery is necessary. Typical surgical procedures involve removing diseased muscle and reattaching healthy muscle to the humeral lateral epicondyle. Rehabilitation in the form of physical therapy almost always follows surgery.

An Ounce of Prevention

-          Use Proper Technique: Since many lateral epicondylitis injuries do occur in tennis players, these athletes may reduce their risk of developing this painful condition by insuring proper technique in their strokes. Tennis players concerned with preventing lateral epicondylitis should consult with a coach or tennis professional to review their techniques and determine whether proper form is being maintained. Tennis players should focus on using more of their entire body in their strokes, rather than just the wrist.

-          Check Equipment: Along the same lines, athletes who participate in racquet sports looking to prevent lateral epicondylitis should check to make sure they are using the right equipment for their purposes. Smaller racquets and racquets that are strung more loosely can reduce the amount of stress placed on the forearm muscles, and thus reduce the risk of developing tennis elbow.

-          Stretch and Strengthen: Doing very basic exercises with free weights can be an effective way to reduce the risk of lateral epicondylitis. Simple wrist flexion and extension motions can be done at home. It is also important to do some gentle stretching exercises as part of a warm up before repetitive forearm activities.

Carpal Tunnel Syndrome

About Carpal Tunnel Syndrome

The carpal tunnel is a narrow passageway in the wrist through which several tendons and the median nerve pass. The tunnel is formed by the carpal bones (hand bones) on the bottom, and the transverse carpal ligament on the top. The purpose of this narrow tunnel is to secure the tendons that flex the fingers; however, in order to do so, the carpal tunnel must form a very tight and narrow area. Because of this, any minor swelling, inflammation, or tightness in the area can result in compression of the median nerve, or carpal tunnel syndrome.

The classic symptom of carpal tunnel syndrome is a painful burning or tingling sensation in the medial hand, thumb, index, middle, and ring fingers. This is because these regions of the hand are supplied by the compressed median nerve. Other symptoms include sensitivity to touch, weakness in the hand and wrist, as well as radiating pain up the arm. Symptoms generally begin at night, but may worsen and become more chronic with time. Patients commonly report symptoms to be at their worst during activities that require finger flexion, such as gripping a steering wheel or holding a phone. In more extreme cases, patients may lose their ability to distinguish between hot and cold by touch.

Risk Factors

-          Gender: Women are three times more likely to develop carpal tunnel syndrome than men. Fluid retention associated with pregnancy and menopause can sometimes be a cause of carpal tunnel syndrome.

-          Heredity: An individual may have a significantly higher chance of developing carpal tunnel syndrome if he or she has relatives with the condition. This is due to inherited factors such as the shape of the wrist and the size of the carpal tunnel itself. Those with more narrow carpal tunnels are more likely to develop carpal tunnel syndrome.

-          Preexisting Health Conditions: Trauma to the wrist, in the form of a strain, sprain, fracture, etc. can sometimes lead to carpal tunnel syndrome. Other health conditions that may predispose an individual include hypothyroidism, diabetes, obesity, rheumatoid arthritis, and end-stage kidney disease. These conditions may cause water retention leading to swelling (and subsequently increased pressure) at the wrist.

-          Overuse: A common misconception is that carpal tunnel syndrome occurs as a result of repetitive computer use, though little scientific evidence exists to support this theory. However, some research does suggest that carpal tunnel syndrome can result from overuse in activities that require repetitive forceful or awkward movements of the hand, such as heavy assembly line work and power tool use.

Treatment

-          Wrist Splinting: For mild to moderate symptoms, splinting the wrist at night can help relieve symptoms of tingling and numbness. Some patients choose to wear a wrist brace throughout the day as well.

-          Pharmacological Treatments: Nonsteroidal anti-inflammatory drugs may be used to treat minor or acute symptoms of carpal tunnel syndrome. These are best used in conjunction with other conservative treatments, as these drugs are rarely enough to treat the condition by themselves. Doctors may prescribe a diuretic (“water pill”) to decrease any swelling due to water retention, or a corticosteroid (either oral or via injection) to relieve pressure on the median nerve and provide a more immediate relief to carpal tunnel syndrome.

TENS Treatment

-          Physical or Occupational Therapy: Because carpal tunnel syndrome affects the fine motions of the hand, patients may see either a physical therapist or an occupational therapist as an effective form of treatment. Therapy sessions may include heat and ice treatments, as well as exercise regiments custom-tailored to the individual. In the case of physical therapy, ultrasound or transcutaneous electrical nerve stimulation (TENS) may be used to alleviate nerve symptoms. These treatments involve the placement of electrodes on the skin, and can serve as a painless moderately effective way of treating carpal tunnel syndrome.

-          Surgery: If carpal tunnel symptoms persist for more than six months, surgery may be the best treatment option. Carpal tunnel release surgery is one of the most common surgical procedures in the United States, and has a very high rate of success. It is a simple surgery, involving cutting the transverse carpal ligament to relieve pressure on the median nerve. This procedure can be, but is not always, performed with endoscopic technology. The recurrence of carpal tunnel syndrome after this surgery is rare, as the majority of patients recover completely.

An Ounce of Prevention

For individuals who are predisposed, either genetically or by a preexisting health condition, carpal tunnel syndrome may be difficult to prevent. For those who work in environments that require overuse of the hands and wrists, taking frequent breaks and performing stretching and strengthening exercises a few times a day may decrease the risk of developing carpal tunnel syndrome.

Sources and Additional InformationMayo Clinic http://www.mayoclinic.com/
National Institute of Neurological Disorders and Stroke http://www.ninds.nih.gov/
Lippert, Clinical Kinesiology and Anatomy, 4th edition

Piriformis Syndrome

About Piriformis Syndrome

The piriformis is one of the six small muscles of the hip that make up the deep external rotators. Though relatively small, the piriformis can cause a great deal of pain and discomfort in a condition known as piriformis syndrome. Because of its proximity to the sciatic nerve (a very large nerve that, along with its branches, supplies the entire leg), inflammation and tight spasms in this small muscle can cause pain that radiates to a large area. For this reason, piriformis syndrome is considered a neuromuscular condition.

Best described as a “pain in the butt,” piriformis syndrome is characterized by deep buttock pain (usually unilaterally, or on just one side of the body) that is difficult to pinpoint. This pain is typically worsened by sitting, climbing stairs, and performing squatting motions. Apart from this most commonly reported symptom, piriformis syndrome can manifest itself in many different ways. Some patients report tightness and decreased mobility in the hip and hamstrings. Piriformis syndrome also commonly causes sciatica-like pain radiating down the leg, which often leads to this condition being confused with herniated discs and other lumbar spine and spinal nerve disorders. Diagnosis of piriformis syndrome is often achieved by ruling out these other possibilities.

Risk Factors

-          Gender: as with many chronic overuse injuries, women are affected by piriformis syndrome more often than men. This is most likely due to structural differences in hips of men and women. Women have a higher Q angle, or the angle between bone markings on the front of the hip and just below the knee. Because women have wider pelvic girdles, they are generally at a higher risk for injury.

Lumbar Lordosis

-          Lordosis: Individuals with an excessive curve in their lumbar spines, resulting in a “sway back” tend to have tight piriformis muscles, increasing the risk of irritation to these muscles.

-          Prolonged Sitting: Some evidence suggests that people who work in jobs that require them to sit for extended periods of time are at a higher risk for developing piriformis syndrome and/or sciatica. Prolonged sitting may be due to an office job, frequent extended periods of time sitting in a car, etc. The body is designed to function at its best in a standing position, so prolonged sitting is likely to cause irritation to the muscles and nerves in the hip/buttocks region. Poor posture in seated positions can exacerbate this risk factor.

-          High Running Volume: Distance runners and other athletes who spend a great deal of time running have a high susceptibility to almost every overuse injury involving the lower limbs. The repetitive nature of running can lead to a muscle imbalance in which certain muscle groups become much stronger than others. Because the piriformis performs hip external rotation, which is not a typical running motion, it may be disproportionately weak and at a higher risk for strain and irritation.

Treatment

-          Early Conservative Treatment: Treatment for piriformis syndrome should begin as soon as possible after symptoms first appear. When caught early, simple conservative treatments can be the most effective. Nonsteroidal anti-inflammatory drugs can be used in conjunction with ice and rest to control early symptoms.

-          Pharmacological Treatments: If home treatment is unsuccessful, doctors may prescribe muscle relaxants to patients suffering from piriformis syndrome. Also, patients sometimes opt for local steroid injections for an anti-inflammatory effect on the piriformis muscle. These have proven to be effective with little complications other than infections at the site of injection.

-          Physical Therapy: Strengthening routines prescribed by physical therapists are another effective treatment for those suffering from piriformis syndrome. This usually requires 2-3 therapy sessions a week for 6-8 weeks. Exercises generally focus on strengthening the muscles of the hip, specifically the adductor and abductor muscles. Physical therapy also entails a great deal of stretching. The stretch shown on the right is a classic way to isolate the piriformis muscle. Physical therapists might also incorporate myofascial release techniques, massage, tissue mobilization, ultrasound and/or iontophoresis into therapy sessions. However, the effectiveness of these treatments varies among individuals and is still being researched.

-          Surgery: Only in very extreme cases, surgery may be necessary to treat piriformis syndrome. Surgical procedures usually entail a tendon release of the piriformis, and if additional pressure needs to be released from the sciatic nerve, a portion of the piriformis muscle may be removed. Surgery is typically followed by physical therapy.

An Ounce of Prevention

The risk of piriformis syndrome can be reduced with regular (but not excess) exercise. Training loads should be increased gradually to prevent piriformis syndrome, as well as a multitude of other overuse injuries. Warming up before exercise and cooling down and stretching afterwards can help reduce the risk of muscle injuries. Prolonged periods of sitting should be avoided where possible. While seated, it is best to maintain good posture and keep feet flat on the ground, rather than crossing the legs.

Sources and Additional Information
Sports Physical Therapy Institute http://www.sportspti.com/research
Sports MD http://www.sportsmd.com/SportsMD_Articles/id/327.aspx
Journal of the American Osteopathic Association http://www.jaoa.org/
Milton J Klein, DO. Piriformis Syndrome http://emedicine.medscape.com/article/308798-followup

Medial Tibial Stress Syndrome

About Medial Tibial Stress Syndrome

Medial Tibial Stress Syndrome, more commonly known as “shin splints,” refers to exercise-induced pain along the lower half of the medial edge of the tibia (shin bone). Medial Tibial Stress Syndrome (MTSS) is one of the most frequently reported lower leg injuries in athletics, and accounts for up to 16% of all running injuries. For as common of an injury as it may be, the exact cause of MTSS is still undergoing much debate. Though it is relatively speaking not a serious injury, MTSS can be very chronic and irritating, and can lead to more serious conditions, such as stress fractures.  

The primary symptom of shin splints is a dull aching pain that is made worse with exercise. The site of the injury is often sensitive to pressure and in some cases there may be minor swelling and redness. This is the result of inflammation of the periosteum (a membrane surrounding the bone) and the muscles that attach to it. The lower leg muscled most commonly associated with MTSS are the tibialis muscles, anterior and posterior. The posterior muscle, which is located deep within the lower leg, runs from the top of the shin bones to the foot. This muscle primarily performs ankle inversion and is unique in the sense that it nearly makes a 90 degree turn as it enters and attaches to the foot. Because of its attachment on the navicular bone, the tibialis posterior is integral in maintaining the medial longitudinal arch of the foot.  Thus, the tibialis posterior is placed under a lot of stress in individuals who overpronate (roll their foot inward) during weight-bearing, as this is virtually the opposite motion of ankle inversion. The anterior tibialis muscle may also be associated with MTSS as it, too, runs from the proximal tibia to the foot and helps to perform ankle inversion.

Risk Factors

-          Too much, too soon: The most common cause of shin pain is a rapid increase in training. MTSS is a very common injury in runners, and especially among those just starting a running program. In these cases, the tibialis muscles are not given adequate time to adjust and strengthen accordingly to the increased load, and inflammation is likely to occur.

-          Foot mechanics: Overpronation and low arches have been linked to MTSS. Because the insertion location of the posterior tibialis muscle is the keystone of the medial longitudinal arch of the foot, fallen or strained arches often transfer stress through the muscle, causing the characteristic pain and inflammation of shin splints. For more information on pronation and foot mechanics, see plantar fasciitis.

Treatment

Medial Tibial Stress Syndrome is treated conservatively and only requires injections or surgery in very rare cases, usually complicated by other factors. However, these simple at-home treatments require discipline and often must be applied frequently and aggressively in order to have a timely recovery. Treatment should begin immediately upon the onset of symptoms.

-          Rest: The first and foremost step to treating MTSS is to avoid the activities that cause pain. These are usually weight-bearing exercises, such as running. However, resting does not mean that all physical fitness must be compromised. Low-impact activities such as swimming, aqua jogging, biking, and using elliptical trainers can serve as painless alternatives to running and can help maintain a relatively high degree of fitness.

Ice massage cup

-          Ice and Elevate: Ice treatment can be effective in treating the pain and inflammation associated with shin splints. Ice should be applied several times a day, for no longer than 15 to 20 minutes in duration. Ice treatments lasting longer than 20 minutes may actually have reverse effects on the anti-inflammatory process. Ice can be applied in the form of frozen cold packs, bags of ice cubes, or even bags of frozen vegetables. However, many runners and long-time sufferers of shin splints have noted that ice massages can be even more effective. This can easily be performed at home by freezing small paper cups filled with water. The resulting large cube is used to massage the painful region, and the paper can be peeled back as the ice melts. Finally, if athletic training facilities are available, cold whirlpool treatments have also provided relief to some sufferers of MTSS.

-          Proper Footwear and Inserts: Individuals suffering from shin splints should make sure they are wearing shoes with good shock absorption and arch support at all times. Various heel and arch inserts may be considered to dissipate the amount of force acting on the inflamed areas. These types of shoes and inserts should be worn whenever possible, not just during times of exercise.

-          Return Gradually: Once the symptoms are gone and the individual is ready to return to normal activity, it is very important to do so slowly. If for example, the activity that caused the injury is running, and the athlete has been aqua jogging as a form of cross training, the return to running should begin as splitting the workout between running and aqua jogging. The duration of running can then increase by a couple of minutes each day, assuming the athlete is pain free, until normal activity levels are resumed. Careful precaution should be taken to prevent the reoccurrence of shin pain. Suggestions for prevention are listed below.

An Ounce of Prevention

Medial Tibial Stress Syndrome can be difficult to prevent. Those who are prone to shin pain, or have the biomechanical risk factors explained above, should take special care when beginning a training program or sports season. The key to avoiding shin splints is to ease gradually into weight-bearing exercise routines.

MTSS can also be prevented by ensuring that proper footwear is worn at all times, and especially during weight-bearing exercise. Individuals who pronate excessively should look for a shoe marked “stability” or “motion control.” Athletes can be fitted for proper running shoes at virtually any local running store. Footwear is also important during everyday activity. If one is prone to MTSS, he or she should avoid wearing flip-flops and other shoes with thin soles and low arch support, as stress can be placed on the tibia and its surrounding muscles simply by walking around.

Theraband exercise for ankle dorsiflexion

Strengthening exercises focusing on the tibialis muscle groups may also play a role in preventing MTSS. These exercises can be as simple as a few sets of toe-walking, heel-walking, and walking on the insides and outsides of the foot. These lower leg muscles can also be strenghtened by using a towel or TheraBand as resistance for dorsi and plantar flexion, as well as inversion and eversion.

Finally, runners looking to prevent MTSS should try to vary the terrain of training wherever possible. Running on grass and softer surfaces dissipates more force away from the lower leg and helps with shock absorption. Grass, soft dirt trails, and rubber tracks are preferable to asphalt and cement.

Plantar Fasciitis

About Plantar Fasciitis

The plantar fascia (or plantar aponeurosis) is a dense connective tissue structure, similar to a tendon or ligament, which extends along the bottom of the foot. It consists of three bands (medial, central, and lateral) and runs from the calcaneus (heel bone) to the heads of the metatarsals and proximal phalanges (ball of foot), providing a strong mechanical linkage between these structures. The plantar fascia plays an integral role in maintaining the medial longitudinal arch and increasing the stability of the foot during weight-bearing activities.

Plantar fasciitis refers to a condition typically resulting in pain near the origin of the plantar fascia, on the underside of the foot, just in front of the heel.  Patients often report the pain being at its worst first thing in the morning, decreasing throughout the day while walking around. This plantar pain often returns near the end of the day if the individual spends a lot of time on his or her feet.

The suffix “-itis” generally indicates a condition of inflammation, though some histological studies have reported an absence of inflammatory infiltrate in plantar fasciitis patients. These studies have linked plantar fasciitis with more degenerative changes in the plantar fascia, such as collagen degeneration, micro tears and calcification, especially in older patients. Whatever the exact cause may be, plantar fasciitis can be very painful and limits the lifestyles of many active individuals.

Risk Factors

Plantar fasciitis is a fairly common overuse injury that affects more than two million Americans each year. Any combination of certain risk factors significantly increases an individual’s chance of developing this painful condition.

-          Gender: Women are more likely to develop plantar fasciitis than men.

-          Age: Plantar fasciitis can occur at any age, though most commonly reported in patients between the ages of 40 and 60.

-          Weight: Overweight and obese individuals are more likely to develop plantar fasciitis, due to the strain that extra weight places on the plantar fascia.

-          Lifestyle and Activity Level: Plantar fasciitis has a much higher incidence in individuals that spend a considerable amount of time on their feet, especially on hard surfaces. Waiters/waitresses, teachers, and factory workers are common sufferers of plantar fasciitis. Additionally, athletes who regularly participate in high-impact activities, such as jumpers, dancers, and long-distance runners are at an increased risk.

-          Foot Mechanics: Plantar fasciitis is linked to several variations in foot structure and gait patterns. Individuals with very low or very high arches tend to be at a higher risk for this injury. Low arches can put stress on the plantar fascia by forcing it through excess motion, and are correlated with overpronation (or “rolling in”) of the foot during weight-bearing. This causes an overstretch of the plantar fascia which can lead to the characteristic pain of plantar fasciitis. High arches, on the other hand, can lead to plantar pain as a result of the foot’s inability to dissipate force. The tightness and rigidity found in a high-arched foot often lead to underpronation, sometimes referred to supination (or “rolling out”) of the foot during weight-bearing. Many other biomechanical aspects of the foot, as they related to plantar fasciitis, are still being studied. Some studies also suggest that a limited range of ankle dorsiflexion and tight Achilles tendons are associated with a higher risk of plantar fasciitis.

-          Improper Footwear: Spending significant amounts of time in improper footwear can be a major risk contributor, especially for those who are already predisposed to plantar fasciitis by one of the aforementioned factors. Flip-flops, ballet flats, and other shoes with thin soles and little arch support should be worn in moderation, as they can lead to flattening of the foot and excess strain on the plantar fascia. High heels can cause the Achilles tendon to contract and shorten and should also not be worn for extended periods of weight-bearing.



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As far as athletic footwear, individuals with low arches, or those who overpronate, should look for shoes marked as “stability” or in more severe cases “motion control.” These shoes incorporate a more rigid material along the medial longitudinal arch of the foot to help prevent the foot from rolling in excessively. Athletes with high arches, or those who underpronate, should select shoes with higher cushioning and less rigid stability. Proper footwear selection is critical for athletes such as cross country runners, who spend great amounts of time doing repetitive weight-bearing activity. These should be replaced every 300-500 miles.   

Treatment

The extensiveness of the treatment required to improve plantar fasciitis symptoms varies greatly among individual cases. For some patients, taking a few weeks off from activities (i.e. jumping, running) that put excessive strain on the heel is enough of a remedy.

-          Pain and Inflammation Relief: Though debate remains as to whether or not plantar fasciitis is an inflammatory condition, many patients find that ice and anti-inflammatory drugs (such as ibuprofen, aspirin, or naproxen) help to relieve symptoms. Ice should be applied several times a day, usually after periods of weight-bearing or strenuous activity. Duration of each ice application should not exceed 20 minutes.

-          Structural Support: Some patients choose to wear specially designed splints at night, which hold the foot in a slightly dorsiflexed position during sleep. This stretches the plantar fascia and can help to relieve morning pain. During the day, selection of proper footwear is critical (see above). Those inflicted by plantar fasciitis might consider being fitted for the right shoe at a running store. Other structural options include the insertion of orthotic devices into old shoes. Heel inserts are available at most drugstores, and have been shown to decrease impact on the heel. Plantar fasciitis patients should never go barefoot.

-          Stretching: Gentle stretching of the plantar fascia has proven to be an effective way of restoring flexibility and reducing pain. There are a number of different ways to do this, but most involve variations of dorsiflexion in the foot. Simple stretching programs can be designed by physical therapists, athletic trainers, etc. and most often include stretching of the calf muscles, Achilles tendon, and of the plantar fascia itself. The ProStretch is a common device used for stretching the fascia.

-          Strengthening: Physical therapy is often very beneficial to plantar fasciitis patients and consists of a series of stretches and strengthening exercises. Strengthening exercises are often focused on the intrinsic muscles of the foot (muscles with origins and insertions both within the foot itself). These exercises include toe curls with a towel and toe taps. If the cause of the plantar fasciitis symptoms is linked to overpronation or underpronation that can be attributed to a muscle weakness somewhere else in the leg, these muscles are also treated with strengthening routines.

-          Injections: Sometimes, in the case of chronic or reoccurring plantar fasciitis, a patient will elect to try corticosteroid injections for pain relief. These injections have proven to be about 70 percent effective, but are associated with a risk of rupturing the plantar fascia entirely. It is for this reason that injections are often reserved for instances where other treatments are ineffective.

-          Surgery:  In rare instances (5-10% of cases) where the individual does not respond to any of the more conservative forms of treatment, he or she may consider surgical release of the plantar fascia (plantar fasciotomy). This surgery has been reported to have a 70 to 90 percent effectiveness rate, but like all surgeries, is associated with some risk.

An Ounce of Prevention

As with any overuse injury, prevention methods are the most effective way to avoid chronic plantar pain. Though the wide array of risk factors associated with plantar fasciitis predisposes a large population, many of these risk factors can be counteracted.

For obese and overweight individuals, the best way to prevent plantar fasciitis (as well as many other conditions and injuries) is to lose weight. For people who work in environments or lead lifestyles that require a great deal of standing and walking, proper footwear is essential. Athletes, especially those participating in high-impact sports, should take extra caution to be sure they are wearing a shoe that corresponds with their foot type (see above). Stretching and strengthening routines can easily be performed at home to prevent injury and the necessity for physical therapy. Remember, overuse injuries are much easier to prevent than they are to cure!


Sources and Additional Information
Journal of Athletic Training http://www.ncbi.nlm.nih.gov/pmc/articles/PMC385265/
American Academy of Family Physicians http://www.aafp.org/afp/2001/0201/p467.html
Mayo Clinic http://www.mayoclinic.com/
Harvard Women's Health Watch http://www.health.harvard.edu/
Lippert, Clinical Kinesiology and Anatomy, 4th Edition.