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Shoulder impingement syndrome (SIS) is one of the most common causes of chronic shoulder pain in adults, and one that is frequently seen in primary care. Typical symptoms include pain with overhead movements, and classic physical exam tests include Neer’s sign, Hawkins-Kennedy sign, and a painful arc.
Pain from shoulder impingement is thought to be secondary to impingement of the rotator cuff tendons due to decreased subacromial space. Subacromial space can be reduced due to multiple reasons:
- Poor posture creating a protracted shoulder girdle with internally rotated glenohumeral joint, creating a functionally reduced subacromial space
- Subacromial bursitis, either acute or chronic (although this can also be seen secondary to the former point)
- Spurring of the inferior surface of the acromion
Treatment of shoulder impingement syndrome typically involves:
- Physiotherapy to develop pain-free ROM, strengthening of the rotator cuff and periscapular muscles, improved posture, and improved scapular kinetics
- Oral NSAIDs are commonly prescribed
- Corticosteroid injection of the subacromial bursa can be considered if pain is severe or the patient has failed a trial of more conservative management
What about surgery?
- Arthroscopic subacromial decompression is a commonly performed surgery
- It typically involves shaving down the inferior aspect of the acromion, thereby creating a larger subacromial space
- A Cochrane review concluded that evidence does not support subacromial decompression surgery as a treatment for shoulder impingement, as it does not provide clinically meaningful benefits in terms of pain relief1
- The BMJ released a clinical practice guideline strongly recommending against subacromial decompression surgery for the treatment of shoulder pain2
- More recently, an RCT published in the British Journal of Sports Medicine that involved 5 year follow-up failed to detect any difference in pain between patients who underwent subacromial decompression, patients who underwent diagnostic arthroscopy (placebo surgery), or patients who completed an exercise program3
Evidence suggests that there is no benefit to subacromial decompression surgery for the treatment of shoulder impingement. Patients with this condition should be reassured that surgery is unlikely to help their symptoms, and that treatment should focus on conservative management.
Janet Barber MD, MSc, BSc
PGY3 Sport and Exercise Medicine, University of Ottawa
Advisor: Dr Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med
- Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., … & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).
- Vandvik, P. O., Lähdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., … & Noorduyn, J. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj, 364.
- Paavola, M., Kanto, K., Ranstam, J., Malmivaara, A., Inkinen, J., Kalske, J., … & Järvinen, T. L. (2020). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. British journal of sports medicine.
Calcific tendinosis is a condition that results in calcific depositions in the rotator cuff tendons of the shoulder. Many terms encompass this definition, these include calcific tendinopathy, calcific tendinitis, calcific shoulder periarthritis, calcific tendonitis, or rotator cuff calcification disease.
Contrary to popular belief, calcific tendinosis is not caused by trauma or overuse. While the exact etiology is unknown, there is evidence leading to an association with diabetes and thyroid disorders.1,2 Furthermore, there is some evidence to say those with occupations that promote internal rotation and slight abduction (impingement position) are at higher risk for this condition: desk workers, cashiers, and production line workers.3
The formation of calcium deposits is thought to be due to incorrect healing of the tendon. There are 4 distinct phases of this condition4
- Formative phase – formation of calcium deposits in the tissue
- Resting phase – deposits remain stable
- Resorptive phase – inflammatory reaction occurs, deposits are resorbed, this can cause extreme pain
- Post-calcific phase – calcium deposits resorbed, tendon returns back to normal
Presentation and Exam
The onset of pain can be chronic or acute (during the resorptive phase). There is no trauma preceding this pain. On occasion, patients may complain of night pain and decreased range of motion. On exam, patients can present with positive impingement test (Neer’s or Hawkings), painful abduction, and decreased ROM.5
Ultrasound is the best and most cost-effective modality to assess calcifications of the rotator cuff. Ultrasound also allows one to assess for tears and dynamic rotator cuff impingement. Calcifications can also be seen on plain radiographs. In those patients whom you are suspicious of a bony pathology, a standard set of shoulder radiographs should be completed (AP, axillary, outlet view).3 MRI is not recommended.
Currently, there is no gold standard treatment for calcific tendinosis.
First-line treatment includes conservative measures. These include NSAIDs, physiotherapy, manual therapy, and corticosteroid injections into the subacromial bursa (for those with an acute attack). In those with no improvement in 6 months, further treatment can be considered.3
Second-line options include shockwave therapy and ultrasound-guided needling (barbotage). These treatments are performed by specialized providers. Shockwave therapy attempts to break down calcium deposits and stimulate healing. Ultrasound-guided needling involves attempting to break up and aspirating the calcium deposits. This is complemented with a bursal injection to prevent subsequent bursitis.3 For those who respond to the treatments above, surgery can be considered to remove the calcium deposits.3
In terms of prognosis, 50% of symptomatic patients become pain-free with conservative treatments in 3 months, 20% more pain-free in 1 year. Of the remaining 30%, 20% will improve with barbotage and shockwave therapy. The remaining 10% will likely require surgery.6
Bottom line, most patients will improve with conservative treatment, in those that don’t respond you can consider referral to a provider for shockwave therapy or ultrasound-guided needling (barbotage).
Sonam Maghera, MD, BMSc
Sports and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport Med
1. Harvie P, Pollard TCB, Carr AJ. Calcific tendinitis: natural history and association with endocrine disorders. J Shoulder Elbow Surg. 2007;16(2):169-173.
2. Mavrikakis ME, Drimis S, Kontoyannis DA, Rasidakis A, Moulopoulou ES, Kontoyannis S. Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis. 1989;48(3):211-214.
3. Sansone V, Maiorano E, Galluzzo A, Pascale V. Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment. Orthop Res Rev. 2018;10:63-72.
4. Uhthoff null, Loehr null. Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. J Am Acad Orthop Surg. 1997;5(4):183-191.
5. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-158.
6. Noël E. Treatment of calcific tendinitis and adhesive capsulitis of the shoulder. Rev Rhum Engl Ed. 1997;64(11):619-628.
URL for picture above – Up-To-Date
Does an intra-articular corticosteroid injection lead to systemic steroid absorption? Yes.
There is ample evidence that intra-articular injections of corticosteroids lead to numerous systemic effects. Most common steroids injectates can result in adrenal suppression for over a month. Accordingly, should a patient contract COVID-19 in the month following the injection, the steroid may continue to have a systemic effect.
The evidence for the use of corticosteroids in COVID-19 illness is limited and mixed. At the time of this publication, many societies in Canada and globally, including WHO, recommend against the routine use of steroids for the treatment of viral pneumonias.
The translation of this recommendation to intra-articular injections remains ambiguous. Whether or not the systemic effect of an intra-articular cortisone injection is sufficient to have an impact on the course of illness is completely unclear. Yet, given the uncertainty, prudence would suggest against their use.
If still unconvinced, another consideration could be the impact on the care your patient would receive should he/she suffer from severe illness. Currently, many novel treatment modalities are limited to clinical trials, and a recent corticosteroid injection may impact eligibility for enrolment.
What can you do instead?
Go back to basics! An evidence-based physical therapy program for arthritis is a great place to start, even during a pandemic. While many GLA:D programs are closed, information about their exercises can be found at: https://gladcanada.ca/index.php/what-is-glad-canada-2/. Many insurance providers are also moving to cover virtual visits with physiotherapists, allowing patients to receive customized treatment programs.
Alternative pain management modalities include ice, heat, self-massage, and acetaminophen. Of course, reminding patients that while a pandemic does not make it easier, weight management is the cornerstone of happy joints and a healthy body. A reminder that every kilogram of weight loss results in 4 kg off their knee never hurts!
Nitai Gelber, MD, CFPC
PGY-3 Sport and Exercise Medicine, University of Ottawa
Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med
BCCDC. “Unproven Therapies for COVID-19.” 30 Mar. 2020, http://www.bccdc.ca/Health-Professionals-Site/Documents/Guidelines_Unproven_Therapies_COVID-19.pdf.
Fascia, Daniel, et al. “The Safety of Corticosteroid Injections during the COVID-19 Global Pandemic.” AMSIG, 30 Mar. 2020, http://www.amsig.org/recommendations-from-bssr-the-safety-of-corticosteroid-injections-during-the-covid-19-global-pandemic/.
Messier, Stephen P., et al. “Weight Loss Reduces Knee-Joint Loads in Overweight and Obese Older Adults with Knee Osteoarthritis.” Arthritis & Rheumatism, vol. 52, no. 7, 2005, pp. 2026–2032., doi:10.1002/art.21139.
Russell, Beth, et al. “COVID-19 and Treatment with NSAIDs and Corticosteroids: Should We Be Limiting Their Use in the Clinical Setting?” Ecancermedicalscience, vol. 14, 2020, doi:10.3332/ecancer.2020.1023.
WHO. “Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease Is Suspected.” 13 Mar. 2020, http://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf.
Stress fractures are common injuries in athletes and account for 10% of all sport injuries. Ninety percent of stress fractures are located in the lower extremities. The risk factors related to stress fractures consist of the following: a history of past stress fractures, female sex, training regimen, footwear, training surface, and type of sport with repetitive loading (such as running and jumping). Non-steroidal anti-inflammatory drugs should be avoided in all fractures as they may inhibit callus formation and slow down the initial healing process.
In the management of stress fractures, 7 aspects should be considered:
- Is the fracture low or high risk?
- What is the optimal imaging modality?
- Conservative versus surgical treatment?
- What technique is chosen if surgical?
- What optimal rehabilitation schedule if conservative treatment?
- How fast can sport be resumed?
- What preventive program is available for this type of fracture?
In all stress fractures, radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. In most stress fractures, the radiographs are negative although clinical symptoms are present. When a high-risk stress fracture is considered and radiographs are negative, a bone scan, CT scan or MRI is recommended. MRI is highly sensitive with findings ranging from periosteal edema of bone marrow to intracortical signal abnormality.
Conservative management ranging from non-weightbearing with a cast or Aircast with crutches to limited weightbearing crutch-assisted without pain is usually the optimal treatment when possible, even in high risk fractures.
High risk stress fractures;
A stress fracture is considered high risk because it is located either on the tension side of the bone or in an area of limited vascularity. Therefore, they are at increased risk of fracture propagation, displacement, non-union or delayed union. High risk stress fractures should be referred to orthopedic surgery with immediate cessation of activity as they might need surgical treatment. Those include distal anterior tibial diaphysis, fifth metatarsal base, medial malleolus, lateral femoral neck, tarsal navicular and great toe sesamoid. These fractures require specialized imaging to define and quantify the injury. The location of injury and response to initial conservative treatment will determine whether surgical management is needed.
High risk sport related stress fractures include the following:
Anterior tibial diaphysis:
In 85% of cases, the radiographs are negative although clinical symptoms are present which should accelerate the request for a bone scan, CT or MRI. Treatment protocols consist of conservative management for 3 to 6 months with crutch-assisted weightbearing until resolution of pain in lower grade injuries and of casting in higher grades of injuries. In case of failure of conservative treatment, then a surgical intervention is recommended. The return times to sports for such injury is usually 7 months for both conservative and surgical management. However, the return to sports rates differed with 71% for conservative management and 96% for surgical management.
An exception is made when a complete fracture line is seen with both cortices involved. In this case, the stress fracture should be managed as an acute fracture. If the fracture is undisplaced, conservative management is recommended. If the fracture is displaced, a surgical intervention with an intra-medullary nail is required. The return times for these injuries then increases to 11.5 months for conservative management and 7 months for surgical management. The return rates remain similar with 67% for conservative and 100% for surgical management. For conservative management, recommended rehabilitation techniques consist of activity cessation, with avoidance of heavy loading of the tibia, limited weightbearing with crutches for 3 to 6 months. For surgical management, rehabilitation involves a progressive weight-bearing program supervised by a physiotherapist starting the first week following surgery with return to full loading activities between 6 and 8 weeks after surgery.
Fifth metatarsal base:
These stress fractures present on radiographs as a sclerotic or radiolucent line at the proximal aspect of the fifth metatarsal. These changes can be absent on radiographs in up to 69% of patients for this type of fracture. Again, MRI is the second line imaging. CT can be used to assess if there is fracture union after conservative treatment. Treatment of these fractures depends on the radiologic “Torg” classification. Conservative treatment is now often favored except in high level athletes and in high repetitive loading sports (running, jumping) where surgery is considered first line. If there is delayed union (Torg 2) or non-union (Torg 3), surgery is also recommended.
Radiographs can be negative in 55% of cases. For undisplaced fractures, they can be treated conservatively in low level athletes although a good evaluation has to be done as these fractures tend to contribute to long term ankle instability. These injuries must be followed by strengthening, range of motion and proprioception training with a physiotherapist to prevent ankle instability.
Lateral (tension side) femoral neck:
Theses stress fractures occur most commonly in marathon and long distance runners. They are not seen on radiographs in up to 80% of cases. This stress fracture is treated with urgent surgical fixation to prevent fracture displacement and associated risk of avascular necrosis (AVN) of the femoral head. A minimum of 2 years clinical and radiographic follow-up should be done to ensure that delayed post-treatment AVN does not occur.
These stress fractures present most commonly in sprint runners. In high level athletes, surgical management may result in faster return to sport time but some randomized control studies are still needed to confirm this.
Sesamoids (great toe):
These stress fractures occur most commonly in sports such as dancing, gymnastics and sprinting; all involving forced dorsiflexion of the great toe. Medial sesamoid fracture is more common than lateral sesamoid as load occurs on the medial aspect of the toe with gait. Conservative treatment is the first line approach. However, if the patient remains symptomatic after 3 to 6 months, surgery should be considered because of a high rate of delayed union, non-union and fragmentation.
Low risk stress fractures:
Low risk fractures are treated with rest and exercise limitation because of the low risk of fracture propagation, non-union or delayed union. These include posteromedial tibial diaphysis, metatarsal shafts, distal fibula, medial femoral neck, femoral shaft and calcaneus.
In the majority of low risk stress fractures, a bone scan or radiographs are sufficient and the x-ray can be repeated instead of ordering a CT scan or MRI. In the case of medial femoral neck, femoral shaft or calcaneus fracture suspicion, an MRI should be requested because of the possibility of surgical management or to exclude other diagnoses.
Medial femoral neck:
If a fracture line is more than 50% of the femoral neck width or is displaced, a surgery is required to stabilize the fracture.
Displaced fractures, delayed union and non-union require surgical consultation.
MRI can help to eliminate differential diagnoses such as plantar fasciitis, Achilles tendinosis and retrocalcaneal bursitis. These stress fractures are also difficult to detect on radiographs and may require surgical intervention if there is subtle displacement.
Metatarsal shafts fractures:
Among metatarsals, the second is the most common affected, followed by the third and fourth metatarsals. These fractures are usually treated conservatively with activity limitation for 6 to 8 weeks with an Aircast boot, short leg cast or fore-foot offloading shoe. Progressive return to exercise as pain allows can then be started.
In conclusion, it is important to remember that negative plain radiographic findings should not be considered alone but in conjunction with clinical findings. In the case of negative imaging with positive clinical findings, if there is a suspicion of high-risk stress fracture, additional imaging (bone scan, CT, or MRI) must be requested and conservative treatment implemented immediately for optimal treatment. If a low risk stress fracture is suspected, additional bone scan and serial plain radiographs are sufficient with conservative treatment, except in the case of femoral fractures suspicion.
In all stress fractures, independent of whether management is conservative or surgical, full level sport should not be started until there is clear evidence of clinical and radiological union and pain free ambulation.
Marie-Ève Roy, MD, CCFP
Sports and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor, BKin, MSC, MD, CCFP (SEM), Dip Sport Med
Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017 Mar 18;8(3):242-255.
Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018
Matcuk GR Jr, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 2016 Aug;23(4):365-75
Quick & Simple: Knee ultrasounds rarely have any use in the diagnosis of acute knee injuries.
Acute knee injuries are a common presentation in the family practice office. Depending on the suspected injury, the most common imaging modalities ordered are X-ray, ultrasound, and MRI. While the exact total cost of imaging is not widely accessible, the cost of each scan includes the technician’s time, radiologist’s report, and machine use. Thankfully, many acute knee injuries can often be diagnosed clinically without need for further imaging.
Knee ultrasounds can most reliably identify injuries to the external tendons and ligaments of the knee due to the limitation of the ultrasound waves from penetrating bones and thereby assessing deeper structures. This fact may appear confusing, as the radiology reports may comment on the meniscus and even the ACL but with very limited accuracy.
This is where an understanding of the literature becomes important. While some studies may report surprisingly high specificities and sensitivities for evaluation of deep knee structures, they often do not reflect true values for imaging done in the community. From our perspective as clinicians, ultrasound offers a partial and often unreliable evaluation of deep knee structures.
- Knee ultrasounds are most reliable for evaluations of quadriceps and patellar tendons, MCL, LCL, and bursitis.
- While reliable, these diagnoses should be made clinically and immediate imaging is often not indicated.
- While tempting, at this point, ultrasound does not offer reliable assessments of the meniscus and ACL and should not be ordered routinely for these suspected injuries.
- Given our LHIN resources, knee ultrasounds should rarely be ordered given the cost and minimal impact on prognosis or treatment.
As always, if in doubt, consider contacting your local sport medicine physician for advice regarding which imaging modality is most appropriate.
Nitai Gelber, MD, CFPC
PGY-3 Sports and Exercise Medicine, University of Ottawa
Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med
“AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination.” Journal of Ultrasound in Medicine, vol. 31, no. 9, 2012, pp. 1473–1488., doi:10.7863/jum.2012.31.9.1473.
Alves, Timothy I., et al. “US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions.” RadioGraphics, vol. 36, no. 6, 2016, pp. 1759–1775., doi:10.1148/rg.2016160019.
Cova, Maria, and Emilio Quaia. “Faculty of 1000 Evaluation for Clinical Indications for Musculoskeletal Ultrasound: A Delphi-Based Consensus Paper of the European Society of Musculoskeletal Radiology.” F1000 – Post-Publication Peer Review of the Biomedical Literature, 2012, doi:10.3410/f.715297848.790852873.
Trochanteric bursitis has mistakenly been the diagnosis of choice in the past years to describe any pain over the greater trochanter. Surgical, histological and imaging studies have shown that most patients who receive a diagnosis of bursitis actually have “greater trochanteric pain syndrome” (GTPS) attributable to medius and/or minimus gluteal tendinopathy or tears, thickened ilio-tibial bands (ITBs) or external coxa saltans (i.e. snapping hip) with little to no evidence of actual bursitis. Two or more of these diagnoses are often seen concomitantly. In a recent study from the American Journal of Roentgenology, in 877 sonograms of patients presenting with greater trochanteric pain, 50% had gluteal tendinosis, 28,5% had thickening of the ITB, 0,5% had a gluteal tear and 20% had trochanteric bursitis.
A proposed cause of GTPS is repetitive friction between the greater trochanter and ITB associated with overuse, trauma, and altered gait patterns. GTPS affects patients between 40 and 60 years old, and predominantly females. Likely risk factors include elevated body mass index (BMI), overuse, and abnormal hip biomechanics.
On history, patients commonly present with lateral hip pain, localized to greater trochanter, which is worse with weight-bearing activities, lying on the affected side at night, side-bending and prolonged sitting. Hip and back pain commonly coexist. Pain can worsen with time and be exacerbated by falls, sporting overuse such as long-distance running or unaccustomed exercise. The ability to “put on shoes” can help distinguish between osteoarthritis (unable) and GTPS (no pain or difficulty).
On physical examination, the clinician should look for a standing posture with slightly flexed hip and ipsilateral knee or listing to the contralateral side on sitting. Examination of the gait should be done to identify an antalgic or Trendelenburg gait. Direct palpation of the greater trochanter has a positive predictive value of 83% (for positive MRI findings). Provocative tests that aim to increase the tensile load on the gluteus tendons used for diagnosis are FABER, FADER (flexion, adduction & external rotation) and passive adduction. Other tests that aid diagnosis and rule out other pathologies are the dial test (for capsular laxity), Ober test, log rolling, the impingement test, the internal snapping of the iliopsoas tendon and the straight leg raise. A combination of these tests should be used to increase diagnostic accuracy.
The differential diagnosis includes hip osteoarthritis, femoroacetabular impingement (FAI), lumbar spine referred pain and pelvic pathology.
GTPS is a clinical diagnosis however in recalcitrant cases or those with unclear history or clinical findings, imaging can be used to exclude other pathologies and confirm the diagnosis. Hip X-ray is useful as first-line investigation to exclude osteoarthritis of the hip, femoroacetabular impingement (FAI) and fractures. Ultrasound or MRI of the hip is the second-line imaging of choice as it has a high positive predictive value for diagnosis of GTPS.
Conservative treatment results in 90% improvement for patients with GTPS. The main goals are to manage load and reduce compressive forces across greater trochanter, strengthen gluteal muscles and treat comorbidities. This includes weight loss, NSAID, physiotherapy, load modification and biomechanics optimization. Referral to a Sport Medicine physician might be necessary for cases that do not respond to conservative treatment. Adjunct treatments include modalities such as shock wave therapy and the positive results usually persist for 12 months post-treatment. Corticosteroid injections can be helpful in some refractory cases. Interestingly, platelet-rich plasma (PRP) injections showed clinically and statistically significant improvement in recalcitrant patients in a patient reported-outcomes study. However, more studies are needed to ascertain the impact of this treatment.
Surgical interventions are extremely rare and only for advanced refractory cases, failing optimal conservative treatments. Surgery can include minimally invasive endoscopic bursectomy, ITB and fascia lata release or lengthening, trochanteric reduction osteotomy or gluteal tendon repair. Often surgery incorporates a combination of these interventions. The functional outcomes of surgery are usually favourable.
Marie-Ève Roy, MD, CCFP
Sports and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor, BKin, MSC, MD, CCFP (SEM), Dip Sport Med
- Speers CJ & Bhogal GS, Greater trochanteric pain syndrome: a review of diagnosis and management in general practice, Br J Gen Pract.2017 Oct;67(663):479-480
- Reid D., The management of greater trochanteric pain syndrome: A systematic literature review, Journal of Orthopaedics 13 (2016) 15-26
- Redmond JM, Chen AW, Domb BG, Greater trochanteric pain syndrome, J Am Acad Orthop Surg 2016;24:231-240
We have all heard of compartment syndrome. This is a medical emergency where increased pressures within a compartment can lead to rapid ischemia, muscle damage, and even potential amputation after a trauma or injury.
How many of us have heard of chronic exertional compartment syndrome (CECS)?
CECS is a cause of chronic exertional leg pain. Most often seen in young runners and elite athletes, it is a relatively unknown and underdiagnosed condition. Its incidence and pathophysiology are not well understood. One theory suggests a noncompliant fascia that cannot accommodate the expansion of muscle volume during exercise, causing increased intracompartmental pressures.
Suspect CECS with athletes who present with chronic anterior/lateral leg pain that worsens with prolonged use and resolves shortly upon cessation of activity. Most cases will occur in the anterior or lateral compartments. Classically, these athletes will be able to tell you that a specific time, distance, or intensity will bring on the symptoms, characterized as burning, aching, cramping, or pressure. It usually resolves fairly shortly if they stop the activity unless they continue to push through the symptoms for longer durations. It is fairly common to be bilateral. They may have some numbness/tingling in the dermatomal distribution of the nerve that runs through the compartment and weakness of those muscle groups.
Physical exam is often normal at rest. Some people will have visible painless fascial herniations. On physical exam immediately after exercise, there may be pain on palpation of the muscles involved, pain with passive stretching of the muscles, and the compartments may be quite firm. No imaging is necessary but will commonly be done to rule out other diagnoses such as a stress fracture. The diagnosis of CECS can be made clinically but given its non-specific nature, it can be confirmed using immediate post-exercise intracompartmental pressure testing. If confirmed, a surgeon may be consulted for an ELECTIVE fasciotomy.
The differential diagnosis includes medial tibial stress syndrome (shin splints), stress fractures, fascial defects, nerve entrapment syndromes, popliteal artery entrapment syndrome, and vascular or neurogenic claudication.
It is important to note that shin splints present with pain on the medial border of the tibia. Shin splints are NEVER lateral! A high level of suspicion is required for the diagnosis of ant/lat CECS as all imaging will be reported as normal.
While uncomfortable, there is no evidence to suggest that the pain from CECS indicates any muscle damage or has long-lasting implications. Modified activity is a reasonable treatment option. People may choose to avoid continuous running and opt to bike, swim, skate or play shorter shifts. Hopefully, this brief introduction sheds some light on the subject.
Jim Niu MD, CCFP
Sport and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med
Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis
Enke, Oliver, et al. “Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.” CMAJ 190.26 (2018): E786-E793.
Back pain is a common issue seen in the family medicine practice that can result in significant morbidity. There are many therapies and pharmacological options available for the treatment of back pain, but high-quality studies showing efficacy are lacking for many of these options. In 2012, a BMJ review showed treatment benefit of gabapentin for low back radicular pain based on one study, and a few although not all guidelines subsequently suggested a trial of anticonvulsants for patients with acute neuropathic pain. This has resulted in a significant increase in the use of anticonvulsants in the family practice setting for low back pain. This review examines the use of anticonvulsants (topiramate, gabapentin or pregabalin) to treat low back pain with or without radicular pain. 9 studies were examined for a total of 859 participants. Of note, however, this study was not able to perform any significant subgroup analysis, such as acute vs chronic low back pain.
- Low back pain with or without radiating leg pain
- No effect for pain in short term. High-quality evidence.
- No effect for pain in the intermediate term, low-quality evidence
- Small clinically significant improvement pain in short-term, moderate evidence
- No effect on disability in short-term
- Lumbar radicular pain
- Gabapentin or pregabalin
- No effect on pain in intermediate term, high quality evidence
- No effect on disability in short, intermediate, and long term, moderate evidence
- No effect on pain or disability in short term. Low quality evidence
- Adverse events
- Higher in anticonvulsants compared to placebo, high quality evidence
- Most common side effects: drowsiness, somnolence, dizziness, nausea
- Gabapentin or pregabalin
In summary, this review suggests that anticonvulsants do not appear to improve patients’ pain or disability with regards to back pain, with or without radicular pain. While there are many nuances, the key to treating back pain without red flags remains centred on patient education, exercise therapy, and getting a multidisciplinary treatment program involved whenever possible.
Jim Niu PGY3 Sport and Exercise Medicine Fellow
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport Med
By Dr. Aly Abdulla,
BSC, MD, LMCC, CCFPC, DipSportMed CASEM, FCFCP, CTH (ISTM), CCPE, Masters Cert Phys Leader
Medical Director The Kingsway Health Centre
FHO Lead Manotick Rideau River South BAPH
Assistant Professor The University of Ottawa Faculty of Medicine
Clinical Instructor The University of Ottawa Faculty of Nursing
Ottawa West LHIN Subregional Clinical Lead
I am a family doctor in Manotick in a 20 doctor Family Health Organization (FHO). I am also a sports medicine doctor so I receive many referrals for various musculoskeletal issues. The most common referral is for chronic low back pain (LBP). These patients don’t seem to get better with conventional therapy or after so many weeks. There is a consideration for an MRI and a neurosurgeon consult but the wait list is too long so they decide to send the patient to me. Many doctors (and patients) find this challenging.
But there is another option:
The ISAECS Interprofessional Spine Assessment and Education Program is a great resource in our community to manage these cases. In addition, they provide a robust educational program online (for patients and doctors) at your convenience to improve outcomes. Here are some highlights:
- Is your pain back or leg dominant?
- Is the pain constant or intermittent?
- What position makes it worse/better (flexion or extension)?
- What have you tried and failed?
- How disabled are you?
- The use of red flags (NIFTI guide for critical pathology),
- yellow flags or STarT Back (for risk of chronicity) and
- the Opioid Risk Tool (to prevent addiction).
The biggest benefit is the patient self-management and the CORE back tool home exercises.
The ISAEC program provides optimisation of conservative management including exercise prescription, education and advice, support and appropriate referral if needed.
Helping patients manage their pain is complex. To support primary care providers as they navigate this challenging landscape, partners across Ontario have come together to provide a one-stop spot for family physicians, nurse practitioners and other primary care clinicians to find resources to help manage their patients’ pain.
A range of supports – from guidelines on appropriate opioid use to CME-accredited webinars on topics like chronic pain – are included. Plus, access direct links to medical mentors who can provide timely advice and guidance on challenging care issues.
Resources are updated regularly and can be found at: http://www.hqontario.ca/Quality-Improvement/Guides-Tools-and-Practice-Reports/Primary-Care/Partnered-Supports-for-Helping-Patients-Manage-Pain
For more information about this coordinated approach to provide clinicians in Ontario with pain management resources contact: http://www.hqontario.ca/