Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review

Abstract

Background: Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions.

Methods: Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions.

Results: One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2).

Conclusion: Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation.

Keywords: Chronic exertional compartment syndrome; Exercise induced leg pain; Lumbar-sacral radiculopathy; McArdle’s syndrome; Medial tibial stress syndrome; Myofascial tears and accessory/low-lying soleus muscle syndrome; Popliteal artery entrapment syndrome; Superficial peroneal nerve entrapment syndrome; Tibial stress fractures.

Fig. 1

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow chart

Fig. 2

This bar chart details the frequency with which each of the 25 most common elements of the patient’s history were reported as being relevant to each condition. Column headers indicate the condition and the number of relevant manuscripts in brackets. CECS = chronic exertional compartment syndrome, MTSS = medial tibial stress syndrome, tibial SF = tibial stress fracture, SPNES = superficial peroneal nerve entrapment syndrome, PAES = popliteal artery entrapment syndrome, ALLSMS = accessory/low-lying soleus muscle syndrome. Px = Pain. Hx = History

Fig. 3

This bar chart details the frequency with which each of the 24 most common elements of the patient’s symptoms were reported as being relevant to each condition. Column headers indicate the condition and the number of relevant manuscripts in brackets. CECS = chronic exertional compartment syndrome, MTSS = medial tibial stress syndrome, tibial SF = tibial stress fracture, SPNES = superficial peroneal nerve entrapment syndrome, PAES = popliteal artery entrapment syndrome, ALLSMS = accessory/low-lying soleus muscle syndrome. Px = Pain. LBP = low back pain

Fig. 4

This bar chart details the frequency with which each of the 41 most common elements of the patient’s physical findings were reported as being relevant to each condition. Column headers indicate the condition and the number of relevant manuscripts in brackets. CECS = chronic exertional compartment syndrome, MTSS = medial tibial stress syndrome, tibial SF = tibial stress fracture, SPNES = superficial peroneal nerve entrapment syndrome, PAES = popliteal artery entrapment syndrome, ALLSMS = accessory/low-lying soleus muscle syndrome. Px = Pain. ROM = Range of motion

Fig. 5

This bar chart details the frequency with which each of the 21 most common elements of the further investigation’s modalities were reported as being relevant to each condition. Column headers indicate the condition and the number of relevant manuscripts in brackets. CECS = chronic exertional compartment syndrome, MTSS = medial tibial stress syndrome, tibial SF = tibial stress fracture, SPNES = superficial peroneal nerve entrapment syndrome, PAES = popliteal artery entrapment syndrome, ALLSMS = accessory/low-lying soleus muscle syndrome. CT = computed tomography scan. USS = Ultrasound scan. MRI = Magnetic resonance imaging. ABPI = Ankle brachial pressure index. ICP = Dynamic intracompartment pressure

Fig. 6

This bar chart details the frequency with which each of the 26 most common diagnostic criteria were reported as being relevant to each condition. Column headers indicate the condition and the number of relevant manuscripts in brackets.CECS = chronic exertional compartment syndrome, MTSS = medial tibial stress syndrome, tibial SF = tibial stress fracture, SPNES = superficial peroneal nerve entrapment syndrome, PAES = popliteal artery entrapment syndrome, ALLSMS = accessory/low-lying soleus muscle syndrome. CK = Creatine kinase. So2 = Oxygen saturation. NIRS = Near-infrared spectrometry. ABPI = Ankle brachial pressure index. ICP = Dynamic intracompartment pressure. DTR = Deep tendon reflex. Hx = History