Runner injured on Track - seeking help with diagnosis

[AnnieDC]

Hi I would welcome some advice for an injury that has now become chronic - 2.5 years ago I was running on the track on a cold Feb night and my left leg began to hurt so I stopped and have never been able to run again. I am a 37 year old fit healthy female & 53kgs. I did have 2 minor inversion sprains on the left leg previously.
My current symptoms are intense burning and pain on the medial aspect of my lower leg, pins and needles, slight numbness in my foot and intense heat in my foot with some swelling. The pain starts when I walk and subsides when sitting or lying. I have no loss of range and vigorous Yoga does not cause pain. Cycling is better than walking.
I am now on Amitriptyline 25mg which helps a little.
I have seen every poss professional that I can think off; foot and ankle specialists, podiatrists, PT's, Chiropractors, an osteopath, massage therapists,
Have had MRI of lower back and lower leg, nerve conduction study lower leg, 2 steroid injections to ankle one into the tarsal tunnel, acupuncture to lower leg, orthoses, stretches, adjustments by the chiropractor. I practice yoga every other day to keep area stretched out.
No one knows what it is as nothing sig shows up but Chiro did notice left hip was obligue up on the left side.
In the last year hip has become painful over Sacrum and into groin on left side and side of hip area.

Any suggestions would be very gratefully received I have spent so many hours searching for an idea of what may cause this and what may help to releive it,

Thank you,

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[memgem]

Hi there
It sounds like you have had an immense amount of problems with this and a lot of interventions! Im sorry to hear its not improved. When you had your nerve conduction study where and what nerves was it for and what did it show?
Have you ever had any traumatic injuries in the past? Like a car accident, falling off a horse etc things like that?

How long have you been doing yoga?

Besides the problems you have mentioned have you had any problems with your hip?

Have you had an children?

Sorry quiet a few questions but it does help to know :0)

[AnnieDC]

Thank you for replying - I don't mind lots of questions at all, it is nice of you to take an interest.

I went for Nerve Con.Study to investigate for Tarsal Tunnel syndrome. I've had 2 studies done the first showed neurogenic changes to the left ADQ. The medial plantar nerve, sural DPN and Tibial nerves were normal.
The second test said there was no evidence of TT syndrome or peripheral neuropathy. Suggested it may be SI radicular dysfunction..
I have not had any of the traumatic injuries that you mention, and no children.
The only clue may be my sacral area used to get a bit sore after running but not painful.
I did lots of ballet and gymnastics as a child and started to do yoga regularly after my injury.
After 1 year the pain then started in my left hip area. Hip flexor feels a bit restricted when leg moves into extension. The sacral area on the left can be painful and the area over the left side of my pelvis can also be a bit painful.

My current wonders are could it be Piriformis syndrome? SI dysfunction, or just chronic pain from misfiring sensory nerves?

Thank you!

[Dr Damien]

Dear Annie DC

I would have another look at your back again. Any muscle weakness...?
your description is of the L4/L5 specifically, I would trace that...anyone looked at your proximal fibula? you might have a compression there? perhaps your foot maybe unstable causing some torsion in your tibia...try tapping on your fibular head to see if this reproduces some of your symptoms...
did you have your ankle sprains before this episode or after? what part of your foot gets numb and were do you get this swelling and heat?

Are you diabetic?

The challenge will be to reproduce your symptoms....with a test...

[AnnieDC]

Thank you for your reply Dr Damien,

In reply to some of your questions, yes I do think my back / hip / sacrum area may be involved. I did only start having symptoms in this area a year ago and I have had my injury for 2.5 years now.
The chiropractor that I saw found weakness in my quadricep on the left side with the hip flexed but in neutral int.ext rotation, it was weaker when hip was in external and internal rotation. I feel I have restriction in my hip flexor on the left side when I extend beyond 90' which I feel may explain why I have pain particularly on walking as it involves this action repeatedly. However no pain with yoga?!
Chiro reports some restriction of SI joint. However after 3 months of Chiro I have had no change in my symptoms.
I certainly have had various people check the proximal tibia/fibula area but no-one has mentioned any abnormality. Would this show on an MRI? Have has 2 of those of lower limb.
Tapping the fibula head doesn't produce symptoms or seem uncomfortable.
The foot cannot now regulate tempreture so at night I have to sleep with it out of the douvet and by the window otherwise I get painful burning heat. Ice does help. Both surfaces of the foot are hot and red when this happens and the slight swelling is noticible on the anterior surface of the foot.
I am not diabetic and have no other health problems of note. I eat a health conscious diet supplementing with fish oil tablets, vit B, and Glucosoamine,

Any thougths that you may have would be gratefully received,
Thank you!

[memgem]

Annie it does seem like you have a very uncommon presentation.

I am just thinking if maybe seeing as you have a had all these tests in the lower leg nerves such as tibial nerves etc, and found no answer, maybe the problem is more proxmial with radiating/referred symptoms.

Can you explain what you mean with neutral int.ext rotation, do u mean just no rotation and in 90 degree flex.

When you flex your left hip past 90 degree , besides stiffness do you have any neural pain. Is the stiffness there at the same point when passively moved.

Is there any one movement that you have do, any palpation that you can do, or during any tests with chiro, did u feel the pins and needles, burning come on immediately.

My reasoning behind why it may be more proxmial is that in relation to Dr Damiens comment about your back. It'd be interesting to assess your lumbar spine. The femoral nerve originates at L2-L4 and is the main nerve which innervates the anterior thigh muscles. Any compression ( usually found with idiopathic femoral neuropathy) may cause weakness in the hip flexors. The neural pain may orginate in the groin and travel through the medial aspect of the leg proximally but can radiate through the saphenous nerve down to the region where you are experiencing problems. I have not read of any instances where the problem from a compression proxmially presents more distally but i have seen stranger things happen before!

In addition if you have any stiffness or tightness or muscles shortening which may be causing any nerve compression, the yoga and stretching may be giving you short term benefit by lengthening the muscle so i wouldnt expect it to cause you trouble. The fact you cannot run also indicates that immediate compressive forces cause you problems which goes in conjuction with my reasoning.

I feel that from what you have said and from the information ive read, you have had so many inconclusive investigations, id definately look closely at the femoral nerve from origin along its root and to see if any tests may provoke your symptoms. I feel that if you have any compression on the femoral nerve in your lower back or via musculature on the nerve root it may produce similar symptoms to what you have said, especially as you are now saying that you have pain in your groin too.

Like i said this is purely my own idea and i hope ive reasoned my thoughts well. Im not a narrowed minded practioner at all so would love to see other physio's inputs so we can get a clear answer!

Keep me posted

[msk101]

Hello there...

i would also suggest getting your pelvis alignment assessed by a suitably qualified physiotherapist for nutation/counternutation of the sacrum and or innominate (the hemipelvis). alignment abnormalities (as can arise after impact injuries, landing crookedly on the leg or muscle imbalance) can lead to all of the symptoms you describe due to mechanical issues but also muscle overcompensation in attempts to stabilise the pelvis. i would query that you may have an ipsilateral innominate up-slip or rotation but be careful because often innominate rotations can be misdiagnosed as upslip so you need the right treatment. someone who examines this thoroughly and uses muscle energy techniques to establish alignment and who can also provide you with suitable stretching and strengthening for maintenance of alignment would be beneficial... and Check your glute medius and abductor strength to eccentric loading, perhaps have your pelvis assessed before and after a run to see if it's a fatigue/weakness enhanced problem.

i hope that helps

msk101

[physiofixme]

Hi

I've just started following this thread. Just wondering with the tests that you've had whether or not you had any tests for compartment syndrome?? Apologies if this question has been answered in some of the other posts - I've just skim read. Tests for compartment syndrome are measured by placing a catheter in to the relevent compartment (probably in your case the anterior compartment) and measuring the pressure (recorded in mmHg) this is usually done after a period of exacerbating exercise such as running for 5 mins. If you haven't expolored compartment syndrome as a cause of your symptoms, then you may want to look in to it.

Basically compartment syndrome is when there is increased pressure within a muscle compartment. For whatever reason the fascia surrounding the compartment can become inflamed and irritated leading to thickening and decreased elasticity of the fascia. As a result, when the muscles try to expand during exercise, the surrounding fascia doesn't causing compression on the muscles, reduced blood flow and consequent pain. Your symptoms are therefore due to compression and pressure on muscle tissue and the blood vessels as opposed to nerve tissue.

Again I apologise if I've inadvertently gone over ground already covered but if it isn't something you've looked in to you may wish to!!

Rachael
Rehabilitate prevent perform physiofixme

[AnnieDC]

Thank you for your message Rachel.

I was seen by an Orthopaedic surgeon last year who suggested that it may be compartment syndrome. I understand what this is but the surgeon wasn't particularly keen to carry out the diagnostic tests that you describe; and I wasn't keen to have surgery without any diagnostic testing being done! therefore no surgery was performed. However you may be able to answer this; is it likely to be compartment syndrome when I get the pain/pins and needles etc. when I walk and swim, but not when I cycle or do yoga. My understanding of compartment syndrome is that any physical activity that involves the muscles of the lower leg is likely to bring this on,

Thank you!