LOWER EXTREMITY AND
CORE SYNERGY:
WHAT TO DO WHEN IT’S NOT
COMPARTMENT SYNDROME
CORINA MARTINEZ PT, DPT, SCS, LAT, ATC
DISCLOSURES
•  None financially
•  I’m a PT
•  I think DOs are great
MAY 7, 2016
OSTEOPATHIC TENETS
TYING IT TOGETHER
1.  The body is a unit; the person is a unit of body, mind, and spirit.
2.  The body is capable of self-regulation, self-healing, and health
maintenance.
3.  Structure and function are reciprocally interrelated.
4.  Rational treatment is based upon an understanding of the basic principles of
body unity, self-regulation, and the interrelationship of structure and
function.
•  Garrett: Changing how we think about ACL injury, knee force vectors
•  Potter: Injury prevention and hip biomechanics – treat functionally
•  Tortland: “The eyes see what the mind knows”
•  Hip is like the shoulder girdle of the LE
•  Perspective matters
OBJECTIVES
EPIDEMIOLOGY OF SHIN PAIN
•  Epidemiology
•  Not much in literature, possibly due to non-reporting since people stop activity
•  Clinical Presentation
•  Differential Diagnosis
•  MTSS 10-15% of running injuries, 60% of leg pain syndromes
•  CECS incidence 14-33%, 2nd most common cause of exertional leg pain
•  Diagnostic Imaging/Tests
•  Anatomy and Biomechanics Review
•  Males and females affected equally
•  Alternative Treatment Options
CLINICAL PRESENTATION
•  Runners and jumpers - often endurance athletes
•  Onset of pain with activity, time to onset variable by individual
•  Pain relief with rest, but returns upon resuming activity
•  May present with numbness/tingling as well as pain
IT’S POLL TIME!!!!
DIFFERENTIAL DIAGNOSIS
DIAGNOSTIC IMAGING/TESTING
•  Chronic exertional compartment syndrome
•  MTSS
•  Posterior tibialis tendinopathy
•  Popliteal artery entrapment
•  Stress reaction or stress fracture
•  Sural nerve entrapment
•  Lumbar radiculopathy
•  MRI arteriogram
ANATOMY REVIEW
•  X-ray
•  Diagnostic MSK US
•  Compartment Pressure testing
•  Bone scan
•  Doppler US
COMPARTMENTS OF THE LOWER LEG
SUPERFICIAL
POSTERIOR
ANTERIOR
LATERAL
•  Ligaments – interosseous membrane
•  Nerves – common fibular, tibial, sural, saphenous
Tibialis anterior
Peroneus longus
Gastrocnemius
Tibialis posterior
Extensor hallucis longus
Peroneus brevis
Plantaris
Flexor hallucis longus
Extensor digitorum longus
N/V: superficial peroneal n
Soleus
Flexor digitorum longus
•  Vascular – popliteal artery
•  Muscles – 13 of them
Peroneus tertius
N/V: sural n
Popliteus
•  Bones – tibia and fibula
N/V: deep peroneal n, anterior
tibial vessels
DEEP POSTERIOR
N/V: tibial n, posterior tibial
vessels
LOWER LEG MUSCLE FUNCTION
BIOMECHANICS REVIEW
•  To control movement at the ankle and foot (and sometimes the knee)
•  Movement follows the path of least resistance
•  Primary and secondary movers allow body to achieve
•  So why are we asking those muscles to also control our body in space during
running and jumping?
desired motion
•  May not be most efficient movement pattern
•  What muscles extend hip?
•  Literally at the bottom of the totem pole
•  STRUCTURE AND FUNCTION ARE RECIPROCALLY INTERRELATED
•  Closed vs open chain movement
GET UP! STAND UP!
BIOMECHANICAL SCREEN
•  1. Squat
•  Important to identify which muscles groups are being utilized during movement
•  Double leg squat: targets glutes, quadriceps
•  2. Balance on one leg
•  3. Balance on the other leg
•  4. Mini-squat R
•  5. Mini-squat L
•  Open chain to isolate muscle activation
•  Closed chain to utilize muscles functionally
•  common mistakes: use back, shins, over-utilize quads causing knee pain
•  Single leg balance: hip strategy vs ankle strategy
•  Easier to start stabilized over base of support vs trying to recover and pull back to center
•  Single leg squat: indicative of running mechanics
•  look for anterior or medial knee movement, increased dorsiflexion, poor trunk control
•  If poor control, consider that they are repeating poor movement pattern every step during run
PHYSICAL THERAPY FOR SHIN PAIN
FIND THE CAUSE
•  Typical treatments include:
•  Challenge is to find why the shin muscles are being over-used
•  THE BODY IS A UNIT
•  History and clinical exam
•  Assess muscle strength, activation, and timing with manual muscle testing
•  Assess dynamic strength and activation with biomechanical testing
•  Can the patient properly recruit core and gluteal muscles to efficiently perform
•  Modalities for pain management
•  STM
•  Stretching
•  Ankle/Calf strengthening?!?!
•  LET’S THINK ABOUT THIS! Treating overuse injury by using it even more?
•  Rational treatment is based upon an understanding of the basic principles of body
unity, self-regulation, and the interrelationship of structure and function.
running motion?
CASE REPORT
OBJECTIVE FINDINGS
•  25 y/o female distance runner
•  Pain rating 7/10
•  Decreased muscle activation for glute max, glute med, TFL
•  Increased activation of back and hamstring muscles
•  Difficulty with core stabilization
•  Normal strength with ankle manual muscle testing
•  Normal flexibility
•  Normal LE alignment
•  History of bilateral lower leg pain for 8 months
•  Goal to run Marine Corps marathon in 8 weeks
•  Planned to do race with or without pain
•  Pain, swelling, numbness/tingling in bilateral feet 1 mile into runs; 30 mi/wk
•  Symptoms resolve with rest and ice within 1 hour
COMPARTMENT PRESSURE TESTING
OBJECTIVE FINDINGS
•  Squat mechanics – hip internal rotation, pain in knee and shins with motion
•  Single leg balance – Fair balance bilaterally, but ankle strategy vs hip
strategy
•  Single leg squat – Increased hip IR, anterior and medial knee translation,
decreased trunk stability
•  *mimics landing mechanics during running
CORE MUSCULATURE
EXTERNAL OBLIQUES
CORE MUSCULATURE
INTERNAL OBLIQUES
RECTUS ABDOMINIS
TRANSVERSE ABDOMINIS
INTERVENTIONS
•  TrA contractions ! stabilization – BREATHING!
•  Manual treatment to lower leg muscles
•  Activation vs Strengthening
•  Hip rotators, abductors, extensors
•  Functional movement patterns
•  Controlled sit to stand, eccentric hip control
•  Balance activities
•  Must demonstrate ability to control body over leg with single leg squat
•  Usually gradual return to running progression with walk/jog increments
OUTCOMES
•  Patient relocated for work, but continued with strengthening program
•  Completed Marine Corps marathon with no numbness until 21 miles
•  1 month later completed Spartan Beast race (12+ miles, 30+ obstacles)
•  UPDATE:
•  Recently ran half marathon without any symptoms
•  Plans to run Chicago half marathon in October
QUESTIONS?
TAKE HOME POINTS
Thank you.
corina.martinez@duke.edu
•  If continued lower leg pain and all differential dx cleared, consider looking at
body as unit and assessing movement biomechanics
•  Just because they can do the move doesn’t mean that they are doing it
correctly OR Perfect practice makes perfect
•  Lower leg pain is often the result of ”lazy butt syndrome”
•  Find a PT friend!
MARINE CORPS MARATHON
SPARTAN BEAST
12+ miles, 30 obstacles
REFERENCES
•  Reinking M. Exercise Related Leg Pain (ERLP): a Review of The Literature. N
Am J Sports Phys Ther. 2007 Aug; 2(3): 170–180.
•  Anuar K, Gurumoorthy P. Systematic review of the management of chronic
compartment syndrome in the lower leg. Physiotherapy Singapore. 2006;
9:2-15.