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Radiologic Imaging of Lower Leg Injuries

  • L. S. Kox
  • Jan L. M. A. Gielen
  • Mario Maas
Chapter

Abstract

Lower leg injuries are a common problem in athletes. One-third of injuries in long-distance runners are lower leg injuries (Brewer and Gregory 2012). The spectrum of lower leg injuries in athletes contains a number of injuries with very similar presentations. In a retrospective review assessing 150 athletes with exercise-induced leg pain, 33 % had chronic compartment syndrome, 25 % had a stress fracture, 13 % had medial tibial stress syndrome and 10 % had a nerve entrapment syndrome (Clanton and Solcher 1994). Another study among 98 patients with recurrent lower leg pain reported medial tibial stress syndrome in 42 %, chronic compartment syndrome in 27 % and entrapment of the superficial peroneal nerve in 13 % of patients (Styf 1988). This chapter aims to offer a few key points that differentiate between these injuries both in clinical presentation and in imaging characteristics.

Keywords

Stress Fracture Popliteal Artery Bone Marrow Oedema Medial Gastrocnemius Fascial Defect 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Abbreviations

ABI

Ankle-brachial index

BMI

Body mass index = mass (kg)/(height (m))2

CECS

Chronic exertional compartment syndrome

CT

Computed tomography

CTA

Computed tomographic arteriography

FS

Fat suppression

MIP

Maximal intensity multiplanar reconstruction

MPR

Multiplanar reconstruction

MRI

Magnetic resonance imaging

MTJ

Musculotendinous junction

MTSS

Medial tibial stress syndrome

ROM

Range of motion

SI

Signal intensity

References

  1. Anderson MW, Ugalde V, Batt M, Gacayan J (1997) Shin splints: MR appearance in a preliminary study. Radiology 204(1):177–180CrossRefPubMedGoogle Scholar
  2. Anouchi YS, Parker RD, Seitz WH (1987) Posterior compartment syndrome of the calf resulting from misdiagnosis of a rupture of the medial head of the gastrocnemius. J Trauma 27:678–680CrossRefPubMedGoogle Scholar
  3. Arendt E, Agel J, Heikes C, Griffiths H (2003) Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. Am J Sports Med 31(6):959–968PubMedGoogle Scholar
  4. Batt ME, Ugalde V, Anderson MW, Shelton DK (1998) A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc 30(11):1564–1571CrossRefPubMedGoogle Scholar
  5. Beck BR, Bergman AG, Miner M, Arendt EA, Klevansky AB, Matheson GO et al (2012) Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT severity grades to clinical severity and time to healing. Radiology 263(3):811–818. Radiological Society of North America, IncGoogle Scholar
  6. Bennell KL, Brukner PD (1997) Epidemiology and site specificity of stress fractures. CSM 16(2):179–196Google Scholar
  7. Bergman AG, Fredericson M (1999) MR imaging of stress reactions, muscle injuries, and other overuse injuries in runners. Magn Reson Imaging Clin North Am 7(1):151–174–ixGoogle Scholar
  8. Bergman AG, Fredericson M, Ho C, Matheson GO (2004) Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners. AJR Am J Roentgenol 183(3):635–638CrossRefPubMedGoogle Scholar
  9. Blackman PG (2000) A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc 32(3 Suppl):S4–S10PubMedGoogle Scholar
  10. Boden BP (2000) The leg. In: Garret WE, Speer KP, Kirkendall DT (eds) Principles and practice of orthopaedic sport s medicine. Lippincott Williams and Wilkins, Philadelphia, pp 869–892Google Scholar
  11. Bong MR, Polatsch DB, Jazrawi LM, Rokito AS (2005) Chronic exertional compartment syndrome: diagnosis and management. Bull Hosp Jt Dis 62(3–4):77–84PubMedGoogle Scholar
  12. Brewer RB, Gregory AJM (2012) Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health 4(2):121–127PubMedCentralCrossRefPubMedGoogle Scholar
  13. Brukner P (2000) Exercise-related lower leg pain: bone. Med Sci Sports Exerc 32(3 Suppl):S15–S26PubMedGoogle Scholar
  14. Clanton TO, Solcher BW (1994) Chronic leg pain in the athlete. CSM 13(4):743–759Google Scholar
  15. Davey JR, Rorabeck CH, Fowler PJ (1984) The tibialis posterior muscle compartment. An unrecognized cause of exertional compartment syndrome. Am J Sports Med 12(5):391–397CrossRefPubMedGoogle Scholar
  16. Deutsch AL, Mink JH (1989) MRI of musculoskeletal injuries. Rad Clin NA 27:983–1002Google Scholar
  17. Edwards PH Jr, Wright ML, Hartman JF. (2005) A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med 33(8):1241–1249Google Scholar
  18. Ehsan O, Darwish A, Edmundson C, Mills V, Al-Khaffaf H (2004) Non-traumatic lower limb vascular complications in endurance athletes. Review of literature. Eur J Vasc Endovasc Surg 28(1):1–8CrossRefPubMedGoogle Scholar
  19. Eskelin MK, Lötjönen JM, Mäntysaari MJ (1998) Chronic exertional compartment syndrome: MR imaging at 0.1 T compared with tissue pressure measurement. Radiology 206(2):333–337CrossRefPubMedGoogle Scholar
  20. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS (1995) Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23(4):472–481CrossRefPubMedGoogle Scholar
  21. Fredericson M, Jennings F, Beaulieu C, Matheson GO (2006) Stress fractures in athletes. Top Magn Reson Imaging 17(5):309–325CrossRefPubMedGoogle Scholar
  22. Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D et al (2005) CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities1. Radiology 235(2):553–561CrossRefPubMedGoogle Scholar
  23. Gaeta M, Minutoli F, Vinci S, Salamone I, D’Andrea L, Bitto L et al (2006) High-resolution CT grading of tibial stress reactions in distance runners. Am J Roentgenol 187(3):789–793CrossRefGoogle Scholar
  24. Gielen JL, Peersman B, Peersman G, Roelant E, van Dyck P, Vanhoenacker F, Roeykens J (2009) Chronic exertional compartment syndrome of the forearm in motocross racers: findings on MRI skeletal radiology. Skeletal Radiol 38(12):1153–1161CrossRefPubMedGoogle Scholar
  25. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S (2002) Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med 12(2):79–84CrossRefPubMedGoogle Scholar
  26. Jacobson HG (1989) Musculoskeletal applications of magnetic resonance imaging. JAMA 262:2420–2425CrossRefGoogle Scholar
  27. Jones BH, Harris JM, Vinh TN, Rubin C (1989) Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev 17:379–422PubMedGoogle Scholar
  28. Kaeding CC, Miller T (2013) The comprehensive description of stress fractures: a new classification system. J Bone Joint Surg Am 95:1214–1220CrossRefPubMedGoogle Scholar
  29. Kiuru MJ, Pihlajamäki HK, Ahovuo JA (2004) Bone stress injuries. Acta Radiol 45(3):317–326CrossRefPubMedGoogle Scholar
  30. Kortebein PM, Kaufman KR, Basford JR, Stuart MJ (2000) Medial tibial stress syndrome. Med Sci Sports Exerc 32(3 Suppl):S27–S33PubMedGoogle Scholar
  31. Koulouris G, Ting AY, Jhamb A, Connel D, Kavanagh EC (2007) Magnetic resonance imaging findings of injuries to the calf muscle complex. Skeletal Radiol 36(10):921–927CrossRefPubMedGoogle Scholar
  32. Lassus J, Tulikoura I, Konttinen YT, Salo J, Santavirta S (2002) Bone stress injuries of the lower extremity: a review. Acta Orthop Scand 73(3):359–368CrossRefPubMedGoogle Scholar
  33. Lewis MM, Reilly JF (1987) Sports tumors. Am J Sports Med 15:362–365CrossRefPubMedGoogle Scholar
  34. Liong SY, Whitehouse RW (2012) Lower extremity and pelvic stress fractures in athletes. Br J Radiol 85(1016):1148–1156PubMedCentralCrossRefPubMedGoogle Scholar
  35. Magnusson HI, Westlin NE, Nyqvist F, Gärdsell P, Seeman E, Karlsson MK (2001) Abnormally decreased regional bone density in athletes with medial tibial stress syndrome. Am J Sports Med 29(6):712–715PubMedGoogle Scholar
  36. Mattila KT, Komu ME, Dahlström S, Koskinen SK, Heikkilä J (1999) Medial tibial pain: a dynamic contrast-enhanced MRI study. Magn Reson Imaging 17(7):947–954CrossRefPubMedGoogle Scholar
  37. Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC (2009) Medial tibial stress syndrome: a critical review. Sports Med 39(7):523–546CrossRefPubMedGoogle Scholar
  38. Moen MH, Schmikli SL, Weir A, Steeneken V, Stapper G, Slegte R et al (2012) A prospective study on MRI findings and prognostic factors in athletes with MTSS. Scand J Med Sci Sports 24(1):204–210CrossRefPubMedGoogle Scholar
  39. Morel-Lavallée (1863) Décollements traumatiques de la peau et des couches sous-jacentes. Arch Gen Med 1:20–38, 172–200, 300–332Google Scholar
  40. Mulligan ME (1995) The “gray cortex”: an early sign of stress fracture. Skeletal Radiol 24(3):201–203CrossRefPubMedGoogle Scholar
  41. Neal C, Jacobson JA, Brandon C et al (2008) Sonography of Morel-Lavallee lesions. J Ultrasound Med 27(7):1077–1081PubMedGoogle Scholar
  42. Newman P, Witchalls J, Waddington G, Adams R (2013) Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. OAJSM 4:229PubMedCentralCrossRefPubMedGoogle Scholar
  43. Pacheco RA, Stock H (2013) Tennis leg: mechanism of injury and radiographic presentation. Conn Med 77(7):427–430. ReviewGoogle Scholar
  44. Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ (2012) Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg 43(2):208–217CrossRefPubMedGoogle Scholar
  45. Pedowitz RA, Gershuni DH (1995) Pathophysiology and diagnosis of chronic compartment syndrome. Oper Tech Sports Med 3(4):230–236, ElsevierCrossRefGoogle Scholar
  46. Rajasekaran S, Beavis C, Aly A-R, Leswick D (2013) The utility of ultrasound in detecting anterior compartment thickness changes in chronic exertional compartment syndrome: a pilot study. Clin J Sport Med 23(4):305–311CrossRefPubMedGoogle Scholar
  47. Styf J (1988) Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Am J Sports Med 16(2):165–169CrossRefPubMedGoogle Scholar
  48. Sullivan D, Warren RF, Pavlov H, Kelman G (1984) Stress fractures in 51 runners. Clin Orthop Relat Res (187):188–92Google Scholar
  49. Tejwani SG, Cohen SB, Bradley JP (2007) Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league. Am J Sports Med 35(7):1162–1167CrossRefPubMedGoogle Scholar
  50. Toorop R, Poniewierski J, Gielen J, Maes M, van Schil P, d’Archambeau O (2004) Popliteal artery entrapment syndrome. Journal Belge de Radiologie [Belgisch Tijdschrift voor Radiologie] 87(3):154–155Google Scholar
  51. Verleisdonk EJ, van Gils A, van der Werken C (2001) The diagnostic value of MRI scans for the diagnosis of chronic exertional compartment syndrome of the lower leg. Skeletal Radiol 30(6):321–325CrossRefPubMedGoogle Scholar
  52. Yates B (2004) The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med 32(3):772–780CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • L. S. Kox
    • 1
  • Jan L. M. A. Gielen
    • 2
    • 3
    • 4
  • Mario Maas
    • 1
  1. 1.Department of RadiologyAcademic Medical Center (AMC)AmsterdamThe Netherlands
  2. 2.Department of RadiologyAntwerp University HospitalEdegemBelgium
  3. 3.Department of Sports MedicineAntwerp University HospitalEdegemBelgium
  4. 4.Department of MedicineAntwerp UniversityEdegemBelgium

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