Bilateral anterior compartment pain

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Bi-Lateral Compartment Pain

Hi, I have recently seen a 57 year old male, who is overweight, complaining of pain in the region of the Anterior Compartment of both lower limbs. The information provided and results of examination were:

 The problem has been present for over two years, the patient does not run but does play a lot of golf.
 The pain is brought on after walking for over an hour, it is worse when walking downhill or on a hard surface. Walking on grass does not cause as much discomfort but the pain is still present.
 The patient describes the pain as a diffused aching (indicated quite clealry the area of the Anterior Compartment). I was unable to replicate the discomfort either by direct palpation or when putting the lower limb and muscles through their ROM/testing strength.
 Upon examination, there were no obvious muscle weakness or abnormalities of the lower limbs that could be the cause of the problem – fully appreciate I may have missed something obvious.
 The patient has tried to treat with rest and NSAID but the discomfort always comes back. There is no history of trauma, the patient is healthy and not on any medication.


I have ruled out Anterior Compartment Syndrome and also a stress fracture – the description of the pain and other symptoms does not fully support this. After doing a bit more research the symptoms seem to be pointing more towards atrophy of the Tibialis Anterior/periostitis of the Tibia.

I have also spoken with a physiotherapist, she felt the bi-lateral pain was more indicative of nerve entrapment in the spine - any comments?

For the next two weeks I have advised the patient to treat according to PRICE and will review in three weeks. I am considering looking at temporary insoles to offload the Anterior Tibialis and introduce strengthening exercises. If there is no improvement I will look to refer to the GP for a scan to check for atrophy of the Tibialis Anterior/periostitis and also stress fracture (although unlikely).

I would be grateful if anyone could provide some advice, I am concerned I am missing the obvious, or my approach to the treatment plan may not be the best way forward. Look forward to hearing from you all.

Rgds

S Dennison

 

Re: bi lateral anterior compartment Pain

This is likely anterior tibial muscle strain caused by some mechanical factor, if the tenderness is in the anterior tibial muscle and not on the anterior tibial crest.

First of all check out his ankle joint dorsiflexion. My guess is that ankle dorsiflexion is limited. Put him on a 3 time a day gastrocnemius and soleus stretching exercises if dorsiflexion if not at least 10 degrees. Secondly, put him on anterior tibial strengthening exercises including 100 ankle dorsiflexion exercises (e.g. sock tied into a knot with a 2 kg weight hanging off the forefoot and foot lifted slowly up and then slowly down). Also, try putting him into a softer heeled shoe and avoid shoes with hard heels with posterior heel flares. Often times, I will grind away 2-3 mm or posterior heel of the shoe sole to decrease the ankle plantarflexion moment arm from the shoe that occurs during the contact phase of walking.

Hope this helps.

(Simon Spooner concurs with this diagnosis and treatment....he's sitting next to me at the back of the lecture hall at the Belgian seminar.)

 

Thanks Kevin and Simon, I am seeing the patient on two weeks so will check the ankle ROM and instigate the Ant Tib exercises. Thanks again, S