Leg Pain in a 200 mile runner

Leg Pain in a 200 mile runner:

Submitted by : Alby Dean, Certified Athletic Trainer and PT assistant- Barton Hospital & Andy Pasternak, MD, MS

History:

A 55-year-old male runner was competing in the Tahoe 200 miler race.  Approximately 60 miles into the race he was running through a dust cloud at night which resulted in poor ground visibility.   Because of the decreased visibility, he took a “strange step” and felt a twinge in his left leg.    Soon after he noted a rash on the leg, which he attributed to friction from his gaiters.  At mile 62, he stopped to do some blister care.   At mile 72, he reexamined the rash and noted it was spreading.

In the next 16 miles be began having increasing pain with ankle planar flexion and tried to duct tape his leg.   When he arrived at the aid station, medical staff evaluated him.  It was recommended that he be evaluated at the hospital before continuing, as it was 20 miles to the next aid station.

Exam: Upon arrival at the local hospital, he had an 8 x 27 cm area of redness over his leg with firmness over the anterior and lateral compartments.   He was also noted to have severe pain with dorsiflexion and ROM of his toes in the anterior/lateral aspect of his leg.   Dorsalis pedis and posterior tibial pulses were noted to be normal as was capillary refill.     Lab testing revealed a WBC count of 11.9 (mildly elevated) with a CPK level of 1323 and a C-reactive protein of 1323.   Compartment pressures were not obtained

Treatment/Disposition: The runner was diagnosed with cellulitis with acute compartment syndrome based on his clinical presentation.    A fasciotomy was performed to open the anterior and lateral compartments and he was started on IV antibiotics.   He was put on three weeks of bed rest and then started increasing physical activity. He was back running/walking 3 months later.  Nine months after surgery he finished the Tahoe Rim Trail 100 miler and returned to complete the Tahoe 200 in 2016.

Take Home Points:

Acute Compartment Syndrome presents with “pain out of proportion” to the apparent injury.   Patients describe a deep ache/burning pain not relieved with rest along with paresthesias.  Exam findings include pain with passive stretch of the muscles, “wood-like” feel to the compartments on exam, decreased sensation, and muscle weakness.  Pulses/pallor may not necessarily be compromised.   Obtaining compartment pressures is helpful but not necessary to make the diagnosis.  If compartment pressures are obtained, fasciotomy is indicated if the ACS pressure is 30 or less (ACS pressure is calculated by the diastolic BP-compartment pressure).