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Bilateral Shins and Calves, Seeking Advice

Exit forum ID Forum Discussion Bilateral Shins and Calves, Seeking Advice

This topic contains 4 replies, has 4 voices, and was last updated by   drjeff@barefootrehab.com December 13, 2019 at 1:58 pm.

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  • #8773

    drjeff@barefootrehab.com

      Hey all, I wanted to know if I am missing anything with this case:

      1st order Hx:
      38 y/o F
      Complaint: Bilateral Shins and Calves
      Specific symptom locations + quality (there were several):
      – Left Shin: Middle 1/3 of Anterior Tibia = Stiffness, Discomfort, Throbbing
      – Right Shin: Middle 1/3 of Anterior Tibia = Stiffness, Discomfort, Throbbing
      – Right Posterior Lower Leg: Middle 1/3 (Distal to Gastoc heads) to Upper Lower 1/3 = Stiffness, Discomfort, Throbbing
      – Right Posterior Lower Leg: Middle 1/3 (Distal to Gastoc heads) to Upper Lower 1/3 = Stiffness, Discomfort, Throbbing

      Sx Intesnity
      – Current: 4 out of 10/Avg: 7 out of 10/ Worst: 10/10 (caused by running)
      P+ = 1) Running – sx increase 5 to 10 minutes in, 15 min on treadmill is max capacity, sx continue to worsen after onset. 2) Walking – sx increase after a couple hours, no max capacity, 3 to 4 out of 10, Inclines are are wose. 3) Walking upstairs – increase in sx after prolonged activity, no max capacity, 3 to 4 out of 10

      P- = Not running, rest, stretching/foam rolling (temporary releif), Ice (temporary relief)

      2nd order Hx:
      – Onset: Years ago in high school, Cause – noticed it first week of try-outs for field hockey freshman year – sx went away as season progressed (re-occurred every season). Most recent episode – began 2 years ago when she started at Orange Theory
      – Course: getting worse since original onset
      – Occ: operation/logistics/ freelance hair and make-up
      – Rec: weights, running, spinning; Exercise 3 to 4 times per week (Orange Theory)

      Dx Hypothesis
      1) Adhesion – Anterior Compartment Bilaterally
      2) Adhesion – FHL, FDL, Soleus, Tibialis Posterior Bilaterally
      3) Shin splints Bilaterally (I now understand that this Dx should have been more tissue and pathology)

      Worst Tests
      1) Right Dorsiflexion – 4.75″, 79%
      2) Left Dorsiflexion – 4.75″, 79%
      3) PK – Full bilaterally, Bilateral stretch mid-shin, moderate
      4) Lunge – R: Add/Heel faults L: Heel fault
      5) Lockout: Single R – 4.75″, Single L – 4.25″

      Additional Information as of visit 14
      * Left Ankle dorsiflexion – 5.75″
      * Right Ankle dorsiflexion – 4.75″
      * At visit 11 – LD: ran 1 mile “Shins screaming” by 2 minutes bilaterally, within 1 minute: achy radiating on impact
      * Was casted for and given Sole support Orthotics
      * No imaging has been done at this point

      My questions
      1) Is there anything I’m missing with this case?
      2) What would be recommended next steps?
      3) Any additional thoughts?

      Thank you in advance for the feedback!

      – Dr. Jeff

      #8774

      Adam Holen D.C.

        Jeff, good work restoring her function and treating the adhesion effectively.
        A few things jump out:
        – 10/10 symptom intensity suggests more than adhesion.
        – Throbbing points more toward a vascular issue (not every time, but most of the time)
        – Sometimes patients can feel throbbing just from blood flow to nerves/muscles as they are used
        – “Heel” faults? If I understand correctly, you mean she’s doing toe on/off? Along with adduction, this would suggest a compromise of the sciatic nerve. Whether that’s at external rotators, hamstrings, or from the low back would need to be evaluated further.
        – If there’s a force production problem due to neural compromise, that can definitely overload the shins/calves and create symptoms with extended use.

        What is her overall % improved (subjectively)? How does she feel about care thus far?

        If she’s responding well, my first thought would be to assess higher up the kinetic chain with the knee, hips, and low back testing. However, with that being said I’m still suspicious of something “more” going on with this story. The things that come to mind are anterior compartment syndrome, unhealed avulsion fractures of the shins (FDL, EDL), or tibial stress fractures. Again a 10/10 is really really difficult to get to with only a soft tissue problem unless the tissues are tearing/fraying.

        Let me know your thoughts or if you have any more case-specific details to shed some more light.

        #8775

        Keith Puri, DC
        Participant

          To stair step on Adam’s post, 10/10 pain is a massive red flag for non-msk pathology and/or biopsychosocial overlay considering the patient is 38 and her s/s initially began ~ 24 years ago.

          Given her response to skilled manual care, symptom quality, location, intensity, provocative and palliative factors I would strongly consider looking into small-fiber polyneuropathy, vascular compromise (compartment syndrome, popliteal artery entrapment syndrome) and metabolic disorders (relative energy deficiency syndrome, bone stress injuries).

          With her age, gender, and reported activity level I would consider referring to a ‘female athlete program’ or the Women’s Sports Medicine Center at HSS for a work-up. One of the co-directors of the program, Dr. Callahan is a friend of a patient of mine who I sent to and was very responsive to the treatment and diagnostic considerations I offered.

          This certainly sounds like a difficult case. Good luck!

          https://www.hss.edu/womens-sports-medicine-center-what-we-do.htm

          #8789

          Carl Nottoli, DC
          Participant

            Instructor Coaching: 16 F Bilateral Leg Pain

            The link above is from a coaching call of one of Dr. Lytle’s patients. Something to consider would be true compartment syndrome. A pressure test done by a surgeon specializing in fasciotomy or shin splints would help. We get into some of the tissue and pathology specifics of compartment syndrome on this call as well that should help.

            #8813

            drjeff@barefootrehab.com

              Apologies for the delayed reply. Thank you all for your input, I greatly appreciate the feedback and insight. I agree with that there is something more going on and will pursue further testing accordingly!

              a) Adam
              – Regarding the “Heel” faults, yes going toe on/off is what I was referring to.
              – Her overall subjective self-improvement is 60%, which she has been holding at since visit 6. Regarding care, she has not raised any objections or questions thus far. I have tried to be as transparent with her as possible.

              b) Keith
              – Thank you for the link and recommendation to the Women’s Sports Medicine Center at HSS.

              c) Carl
              – Thank you for posting the link to the coaching session. I began listening to it a few weeks back on my own, but was not able to finish the full video. I will re-watch it this weekend.

              Again, thank you guys for the advice. I will keep you updated on her progress.

              Cheers!

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