Sports Medicine: Just the Facts

CHAPTER 63 • SURGICAL CONSIDERATIONS IN THE LEG 375

• Indications for surgery
  
  
  • Appropriate history for chronic exertional compart-
    ment syndrome
  
  
  • One minute postexercise compartment pressure
    greater than 30 mm-Hg
  
  
  • The presence of a fascial defect
    •Surgical procedures
    •Fasciotomy divides the fascia longitudinally over
    the entire length of the involved fascia.
  
  
  • One or two incision technique may be used.
    
    
    1. Risks/benefits of a single incision technique.
       a. Benefit is a smaller skin wound.
       b.Disadvantage is that it is more difficult to
       ensure the compartment is completely released.
    
    
    2. Risks/benefits of a two incision technique
       a. Benefit is that it allows good visualization of
       the most proximal and distal portions of the
       compartment to ensure complete compart-
       mental release.
       b.Disadvantage is that there is more scarring.
    
    
    
    
  
  
  
  


• Postoperative care
  •A compressive dressing is applied.
  
  
  • Crutches are used for comfort for a few days but the
    patient begins active and passive motion immedi-
    ately. Patients may begin walking once the wound is
    healed and light jogging may begin at 2 weeks but
    no running for 6 weeks. Complete recovery usually
    takes 3 months (Chang and Harris, 1996).
  
  
  
  


• Complications
  
  
  • Most complications are due to neurovascular injury.
    A transected sensory nerve is likely to result in per-
    manent numbness and possibly a painful neuroma.
  
  
  • Symptoms may return if the compartment is not
    fully released or is allowed to scar secondary to
    immobilization.
  
  
  
  

TIBIAL STRESS FRACTURE

• Stress fractures of the tibia may occur on either the
  compression or tension side of the cortex.
  
  
  • Fractures of the proximal or distal third of the tibia
    are more likely to occur in compression. These frac-
    tures are frequently seen in undertrained or forced
    athletes, such as new military recruits.
  
  
  • Midshaft tibial stress fractures occur on the tension
    side of the bone and usually affect the well condi-
    tioned athlete involved in running and jumping
    sports.
    •Although the vast majority of stress fractures will
    heal with nonoperative treatment, surgery can be
    considered for selected individuals.
    •Surgical evaluation
  
  
  • History
    
    
    1. Patients usually report a rapid increase in inten-
       sity or duration of their workouts 1–2 months
       prior to the onset of symptoms.
    
    
    2. Patients will report dull, achy pain over the shin
       that began after strenuous exercise. Pain gradu-
       ally worsens and occurs with nonathletic activi-
       ties or even at rest.
       3.Initially the pain may be relieved with rest, ice,
       nonsteroidal anti-inflammatory drugs (NSAIDs)
       but will return as soon as activity resumes.
       •Physical examination
    
    
    
    
  
  
  
  


• The hallmark of a stress fracture is localized point
  tenderness directly over the bone.


• Occasionally there is palpable bony bump or full-
  ness representing periosteal new bone formation.
  •A tuning fork placed on the bone distant from the
  suspected fracture site will elicit pain at the fracture
  site.


• Imaging


• Plain radiographs should be included as part of the
  initial evaluation of leg pain in athletes.
  
  
  1. X-ray findings include cortical thickening, nar-
     rowing of the intermedullary canal, or evidence
     of periostitis. A complete fracture line may be
     visualized but this is usually not the case. A
     linear, unicortical, radiolucency in the anterior
     tibia represents the dreaded black line of a ten-
     sion side stress fracture (Green, Rogers, and
     Lipscomb, 1985).
     •A bone scan is the most sensitive test for stress frac-
     ture but has poor specificity (Mubarak and Owne,
     1977). A triple phase bone scan may improve speci-
     ficity. Medial tibial stress syndrome, periostitis, and
     contusion can all cause increased uptake, but the
     uptake in these conditions is more diffuse; whereas
     that of stress fracture is more focal.
  
  
  
  


• MRI scan is both specific and sensitive for stress
  fracture; however, cost is a detractor against routine
  use.


• Nonoperative treatment


• Compression side stress fractures

1. Limiting impact loading is usually sufficient in
   these fractures. Crutches can be used until the
   limp resolves. Patient needs to abstain from run-
   ning or jumping for 8–12 weeks. Nonimpact
   conditioning activities such as water running,
   cycling, and elliptical trainer can be used as long
   as they do not cause pain.
   a. A splint or pneumatic brace may be used for
   comfort.
   b.A cast may be used but only for a short dura-
   tion of time to limit atrophy and stiffness.