Chronic Bilateral Leg Pain In A Dual Sport Athlete

HISTORY: A 26 yo male presented with persistent 18 months bilateral leg pain which was reproduced 5 minutes following exertion. He worked as a police officer and used to running and swim for fitness. The symptoms were also limiting his job performance. The patient reported pain in the posterior region of the leg specially during running and reported a pain of 9 out of 10 in the VAS. He had tried reducing training levels, use of NSAIDs and more than one hundred sessions of physical therapy with strengthening/stretching exercises, massage and transcutaneous electrical nerve stimulation. PHYSICAL EXAMINATION: Patient reported pain on palpation of the posterior muscle belly of the medial and lateral gastric and diffuse mild pain on palpation of the anterior tibia. He had also a small fascial hernia in the lateral compartment palpable bilaterally. No reduction of strength or numbness were notable and the other points of the examination were unremarkable. DIFFERENTIAL DIAGNOSIS: 1. Tibial Stress fracture 2. Chronic Exertional Compartment Syndrome. 3. Muscle herniation. TEST AND RESULTS: MRI with fluid sensitive sequences after physical exertion revealed bilateral volumetric enhancement of the deep posterior compartments when compared to pre-exertional sequences.Enhancement of the signal of the muscular bellies of the flexor digitorum longus and flexor hallucis longus. FINAL WORKING DIAGNOSIS: Chronic exertional compartment syndrome. TREATMENT AND OUTCOMES: A fasciotomy of the 4 compartments of the lower extremity. First, a medial incision of 4 cm allowed release of the superficial and deep posterior compartments and two lateral incisions of 4 cm which allowed fasciotomy of anterior and lateral compartments. The fascia was incised with a curved Metzenbaum scissor and compartments released. The limbs were protected with standard dressing and weight bearing immediately allowed as tolerated. At the first postoperative visit after one week the patient was able to walk with no need of crutches and had normal strength of all muscular groups of both legs and no complaint of paresthesia. After six weeks he returned to strengthening activities at the gym and was able to run without pain.