MTSS and compartment syndrome

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hi all,
long time reader, first time poster.

I have a question related to a 19yo male that i recently saw. I will also preface this by saying i am not a podiatrist, i'm a physio.
he presented with MTSS from playing rugby. he was treated with manual therapy and NSAIDS etc and referred for orthotics, after several weeks of rest and treatment he began training again and the shin pain returned. bone scan showed bilateral tib stress fractures. several weeks later a sports GP sent him for compartment syndrome testing - positive both sides. i haven't seen the report so i don't know the numbers or which compartments, but his surgery is booked next week.

My question is this, is there a correlation between the compartment syndrome and the MTSS/stress fracture?. reading the other posts i see the MTSS - stress fracture connection but should everyone that presents with shin pain be cleared for compartment syndrome or is this guy just unlucky?

thanks - AJ

 

Dear AJ

This is how I would think about this problem;

Medial Tibial stress syndome has been attributed to 2 main causes;
1) Tensional stress from muscular contraction
2) Bending moment stress from the Ground reaction force.

Compartment syndrome can be attributed to muscle overuse or trauma, which causes swelling of the muscle within its sheath.

If we consider this as a biomechanical problem then the muscles that can cause excessive tensional loading to the medial tibia are those that have origins in the medial tibia or the interosseous membrane and are; both long toe flexors. tibialis posterior and soleus.

If these muscles are causing excessive tensional load then it is likely that one or more are also being traumatised by the internal stresses experienced during some activities.

If these muscles are overworked then this is probably due to excessive pronation moments that make resupination difficult and therefore the internal moments for equilibrium are likely to be high. This will of course necessitate excessive muscle tension but also the action that produces high pronation moments will also apply high medial to lateral horizontal GRF. These forces will cause increased bending moments about the tibia that will tend to abduct the lower leg. This will result in tension in the medial aspect and compression in the lateral aspect i.e. stress fractures are likely to occur in the medial borders of the tibia.

Ankle equinus may cause an excessive knee flexion compensation and possibly increased pronation to optimise saggital plane progression and so gastroc efficiency will be reduced and more stress will be induced in soleus and Post tib.

Because of the physical position of the medial muscle origins the tensional forces do also induce a bending moment on the tibia and therefore add to the bending moments of GRF.

I would conclude therefore that it is entirely possible that the two are co- related
and that the appropriate orthoses to alter GRF application would be an integral part of the therapy program.

see http://www.podiatrytoday.com/article/5031

Cheers Dave

 

AJ:

The history of this injury sounds a little suspicious. Let's see, one week he is diagnosed with medial tibial stress syndrome, several weeks late he is diagnosed with medial tibial stress fracture, then a few weeks later he was diagnosed with compartment syndrome? How do you test for compartment syndrome in a patient that has tibial stress fractures since the patient needs to be exercising vigorously to accurately do intracompartmental testing? The type, duration, how fast the pain is relieved by rest and location of pain are quite different between MTSS/MTSF and chronic exertional compartment syndrome. Are you sure this isn't just a surgeon doing the intracompartment testing and wanting to do more surgery since you don't need to do surgery on a patient to heal a tibial stress fracture? I would ask for another opinion on this 19 year old, if it were my son. This patient would be unlucky if the surgeries were done for no reason.

 

David and Kevin,

thank you both very much for your replies.

I am out of the loop, so to speek, with his care now. the sports GP who organised the compartment test and referral for the surgery is the club doctor. i saw him as a private patient and have absolutely no pull in determining overall course of treatment. I have not seen him since prior to the diagnosis of the stress #. Which again was made through the club doctor.

Kevin, you have reaffirmed my concerns regarding the course of dioagnosis, that it is, at best, unusual. At worst, completely inappropriate

is it reasonable to expect that someone with chronic MTSS and bilateral stress # would also have, at least, a very low grade positive test for compartment syndrome? (intercompartmental swelling?)

I will make every effort to get him to have a second opinion.

thanks - AJ