Medical Advice

WHY DO I HAVE SHIN PAIN?

Shin pain is a common occurrence among athletes, particularly long distance runners.1 There are several problems that can cause shin pain including: shin splints, stress fractures, sprains, strains and compartment syndrome.

Runners who experience lower leg muscle pain with running which is improved after they have stopped running may be experiencing Chronic Exertional Compartment Syndrome (CECS). Compartment syndrome can occur in various areas of the body, but most frequently occurs in the lower leg. The lower leg is divided into four compartments (anterior, lateral, superficial posterior, and deep posterior) that are surrounded by thick connective tissue called fascia. Compartment syndrome occurs when increased pressure impedes local muscle blood flow thereby impairing neuromuscular function of tissues within the specific compartment.2 CECS is a reversible form of the abnormally increased intramuscular pressure that occurs during exercise/exertion secondary to fascial space that is noncompliant with muscle volume expansion during exercise.2,3 A second type of compartment syndrome is acute compartment syndrome that is typically caused by direct trauma to the leg, results in immediate swelling and pain, and is a medical emergency.

The incidence of CECS in those with undiagnosed lower leg pain or chronic exercise-induced anterior lower leg pain has been shown to range from 14-27%.4 This problem is especially prevalent in runners, seventy percent of patients with chronic exertional compartment syndrome in the anterior compartment are runners.2,5,6 The condition is nearly evenly split between males and females. Compartment syndrome occurs in recreational and elite runners equally.5 Symptoms associated with CECS may include cramping, burning, pain, tightness, aching, numbness, or tingling into the lower leg with exercise. Symptoms typically are alleviated when running/activity is stopped. Tightness or pressure of the tissue in the lower leg may also be present to the touch.

The diagnosis of compartment syndrome is made primarily based on clinical symptoms however active pressure testing through the use of small needles inserted in to the lower leg can provide a definitive diagnosis.5,6,8,9 Compartment Pressure Measurement Testing can be painful. A numbing medication is usually injected into each compartment first for pain control. Pressure measurements can be taken both at rest and after activity. This procedure can be performed at the UW Sports Medicine Clinic for diagnostic purposes.

Treatment for chronic exertional compartment syndrome is often physical therapy. This may involve stretching, soft tissue mobilization, activity modification, as well as modifying aspects of a runner’s mechanics, such as stride length, stride rate, foot strike, etc. It also often involves exercises to eliminate muscle imbalances that create undesirable running mechanics or movement. Surgical intervention may be warranted based on patient’s symptoms and response following conservative treatment.

Amy Schubert, MPT, DPT practices physical therapy at the UW Health Sports Rehabilitation Clinic. She specializes in treating athletes with lower-extremity injuries related to running and is a clinician in the Sports Medicine Runners Clinic. Amy sees patients upon referral and through Physical Therapy Direct Access (self referral).

References:
1. Brukner P, Khan K. In: Clinical Sports Medicine. New York, NY: McGraw-Hill.
2. Styf, J. Definitions and Terminology. Etiology and Pathogenesis of Chronic Compartment Syndrome. In: Compartment Syndromes: Diagnosis, Treatment, and Complications. Boca Raton, FL. CRC Press LLC.
3. Wilder, RP. Exertional Compartment Syndrome. Clin Sports Med. 2010;29:429-435.
4. Bong MR, Polatsch DB, et al. Chronic exertional compartment syndrome: diagnosis and management. Bulletin of NYU Hosp for Jt Diseases. Winter-Spring 2005.
5. Brennan FH Jr, Kane SF. Diagnosis, Treatment Options, and Rehabilitation of Chronic Lower Leg Exertional Compartment Syndrome. Curr Sport Med Report. 2003;2:247-250.
6. Shah SN, Miller BS, Kuhn JE. Chronic Exertional Compartment Syndrome. Am Jour Ortho. 2004;335-341.
7. Hutchinson MR, Lloyd Ireland M. Common Compartment Syndromes in Athletes: Treatment and Rehabilitation. Sports Med. 1994;17:200-208.
8. Fraipont MJ, Adamson GJ. Chronic Exertional Compartment Syndrome. J Am Acad Ortho Surg. 2003;11:268-276.
9. Gill CS, Halstead ME, Matava MJ. Chronic Exertional Compartment Syndrome of the Leg in Athletes: Evaluation and Management. Physician and Sportsmed. 2010;38:1-7.

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