Exertional Leg Pain

Conservative Management and Postoperative Return to Sport in Endurance Athletes with Flow Limitations in the Iliac Arteries: A Scoping Review

BACKGROUND

Flow limitations in the iliac arteries (FLIA) is a sport-related vascular condition increasingly recognised as an occupational risk for professional cyclists and other endurance athletes. Surgical reconstruction is the definitive treatment for athletes wishing to continue competition. However, less information has been published regarding conservative management options and return-to-sport (RTS) guidelines.

OBJECTIVE

Our aim was to review the existing literature on conservative treatment of FLIA, identify knowledge gaps and propose an RTS framework for athletes returning to competition.

METHODS

A comprehensive literature review was performed using the Ovid-MEDLINE, PubMed, Embase and PEDro databases for publications relevant to conservative management of FLIA. A scoping review was conducted following PRISMA-ScR guidelines. Original, peer-reviewed publications in English describing conservative or postoperative management for athletes with FLIA were included. Additional grey literature and clinical expertise were consulted to inform RTS guidelines.

RESULTS

Overall, 62 studies were included in this review. In total, 11 categories of conservative modalities were extracted and presented qualitatively in terms of the information source (discussion or results statements) and perspective of the authors (positive, negative or mixed). We have proposed RTS guidelines covering pre-operative preparation and postoperative rehabilitation based on the available literature, clinical experience, and drawing from other areas of sports medicine research.

CONCLUSION

There is insufficient literature evaluating the effectiveness of conservative management options for FLIA to establish best practices. Considering the importance of RTS for competitive athletes, we proposed practical guidelines to help with clinician and patient decision making. Future consensus should be sought for RTS best practices.

Popliteal Artery Entrapment Syndrome: Updates for Evaluation, Diagnosis, and Treatment

ABSTRACT

Popliteal artery entrapment syndrome remains difficult to diagnose. Meanwhile, our limited knowledge and understanding make treatment decisions complex. The list of differential diagnoses for exertional leg pain is broad. Oftentimes, patients exhibit confounding and coexisting diagnoses. However, accurate and rapid diagnosis of popliteal artery entrapment syndrome is essential to reduce potential lasting damage to the popliteal artery. A combination of clinical history, physical examination, ankle-brachial index, along with dynamic and static imaging such as duplex ultrasound, computed tomography angiogram, and magnetic resonance angiography, aids diagnosis. Surgical treatment may be definitive depending on the type of popliteal artery entrapment syndrome, but there have been recent advances in diagnostics with intravascular ultrasound and nonsurgical treatment with botulinum toxin type A. Further research is needed to standardize diagnostic criteria, uncover innovative diagnostic methods, and validate promising nonoperative treatment options.

Concurrent Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome

Exertional leg pain occurs with notable frequency among athletes and poses diagnostic challenges to clinicians due to overlapping symptomatology. In this case report, we delineate the clinical presentation of a young collegiate soccer player who endured two years of progressive bilateral exertional calf pain and ankle weakness during athletic activity. The initial assessment yielded a diagnosis of chronic exertional compartment syndrome (CECS), predicated on the results of compartment testing. However, her clinical presentation was suspicious for concurrent type VI popliteal artery entrapment syndrome (PAES), prompting further radiographic testing of magnetic resonance angiography (MRA). MRA revealed severe arterial spasm with plantarflexion bilaterally, corroborating the additional diagnosis of PEAS. Given the worsening symptoms, the patient underwent open popliteal entrapment release of the right leg. Although CECS and PAES are both known phenomena that are observed in collegiate athletes, their co-occurrence is uncommon owing to their different pathophysiological underpinnings. This case underscores the importance for clinicians to be aware that the successful diagnosis of one condition does not exclude the possibility of a secondary, unrelated pathology. This case also highlights the importance of dynamic imaging modalities, including point-of-care ultrasound, dynamic MRA, and dynamic angiogram.

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

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.

Association Between Intracompartmental Pressures in the Deep Posterior Compartment of the Leg and Conservative Treatment Outcome for Exercise-Related Leg Pain in Military Service Members

Objective

To evaluate the relationship between intracompartmental pressure (ICP) values of the deep posterior compartment and the outcomes of a comprehensive conservative outpatient treatment program in service members with chronic exercise-related leg pain.

Design

Historic cohort study.

Setting

Department of sports medicine at a military secondary care facility.

Participants

During the 5-year study period, 266 military patients completed a treatment program for chronic exercise-related leg pain. Eighty-three service members with 145 affected legs met all inclusion criteria (N=83; 59 men, 24 women; median age, 22 years).

Main Outcome Measures

The primary outcome measure was return to active duty. The secondary outcome measure was development of acute on chronic compartment syndrome. A generalized linear mixed model was used to identify predictor variables associated with return to active duty, including ICP values of the deep posterior compartment and Single Assessment Numeric Evaluation (SANE) score.

Results

Sixty service members (72%) successfully returned to active duty. No association between ICP values of the deep posterior compartment and treatment outcome was found (odds ratio, 1.02; 95% confidence interval, 0.97-1.07; P=.50). A low SANE score (ie, more severe symptoms at baseline) was negatively associated with primary outcome (odds ratio, 0.95; 95% confidence interval, 0.90-0.99; P=.01). None of the patients developed acute on chronic compartment syndrome during the treatment program.

Conclusions

There was no association between a single postexercise ICP value of the deep posterior compartment of both legs in military service members and return to active duty after a comprehensive conservative outpatient treatment program. None of the patients developed acute on chronic compartment syndrome. In this population, ICP measurement of the deep posterior compartment can be safely postponed until conservative treatment fails and surgical treatment is considered.

Familial mediterranean fever patients may have unmet needs for the treatments of exertional leg pain and enthesitis

INTRODUCTION

Exertional leg pain (ELP) and enthesitis are musculoskeletal findings in familial Mediterranean fever (FMF). They are not accepted as principal treatment targets. In this study, we assessed the effectiveness of treatments on ELP and enthesitis.

MATERIAL AND METHODS

We have included 218 FMF patients to the study. We retrospectively compared the FMF attacks' frequency, duration and intensity (FMF attack VAS score) and levels of ELP VAS and enthesitis VAS scores between pre-treatment stage and while patients were on treatment at the last visit.

RESULTS

Forty-nine (22.5%) and 52 (23.9%) of the patients had enthesitis and ELP respectively. All patients were on colchicine treatment. Serositis attacks respond the treatments significantly. Moreover, both ELP VAS scores (p=0.002) and enthesis VAS scores (p=0.17) were improved with treatment. But only improvement in ELP VAS scores was significant.

CONCLUSION

FMF treatments had favourable effect on ELP and enthesitis in FMF patients. However, the response rates would be inadequate. Therefore, there would be unmet need for treatment of both conditions.

Radiological Prevalence of Popliteal Artery Entrapment in Individuals With Anterior Leg Compartment Chronic Exertional Compartment Syndrome

OBJECTIVE

Determine the radiological prevalence of popliteal artery entrapment (PAE) in subjects with anterior leg compartment chronic exertional compartment syndrome (CECS).

DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

Of 71 patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based magnetic resonance imaging (MRI), 64 also completed Fast Imaging Employing Steady-State Acquisition (FIESTA) imaging.

INTERVENTIONS

Electronic health records of patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based MRI between 2009 and 2018 were reviewed.

MAIN OUTCOME MEASURES

Demographics, symptom laterality, and results of vascular work-up.

RESULTS

Magnetic resonance imaging was positive for PAE in 33 of 64 (51.6%). Vascular evaluation was performed in 30 of 33 (90.9%). Of these 30, ankle-brachial indices (ABIs) with PAE maneuvers were performed in 29 (96.7%) and positive in 25 (86.2%). Pre-exercise and post-exercise ABIs were performed in 29 (96.7%) and abnormal in 20 (69.0%). Thirteen arterial duplex ultrasounds were performed; 10 were consistent with PAE (76.9%). An MR angiogram was performed in 8 (26.7%) and consistent with PAE in all. One computed tomography angiogram (3.3%) was completed and was normal. Overall, one or more tests were positive for PAE in all 30 with vascular evaluation.

CONCLUSIONS

The radiological prevalence of PAE and anterior leg CECS was 51.6%. All subjects with vascular studies (90.9%) had one or more tests confirming radiological PAE. These findings suggest that the coexistence of PAE and CECS is common, and the PAE protocol used has a high correlation with vascular studies.

Ultrasound-guided, minimally invasive looped thread fasciotomy for chronic exertional compartment syndrome of the lower leg: A cadaveric feasibility study

Background

- Chronic exertional compartment syndrome (CECS) is an exertional pain syndrome that typically affects the lower legs of participants involved in high-intensity running or marching activities. Surgical open fasciotomy is the standard treatment for recalcitrant cases of CECS. Alternative, minimally invasive fasciotomy techniques are emerging which may reduce rates of procedural complications and expedite recovery. The standard fasciotomy procedure for CECS may be improved by looped thread release with additional image guidance. The aim of this study was to describe and evaluate a novel technique of ultrasound-guided, minimally invasive looped thread fasciotomy for release of anterior and lateral compartments of the leg in a cadaveric model. We hypothesized that a fasciotomy of this type would be effective in achieving a target fasciotomy length of 80% of the length of a muscle compartment while avoiding injury to neurovascular structures.

Materials and methods

- We conducted a controlled laboratory study. Two proceduralists performed anterior and lateral compartment fasciotomies on ten lightly embalmed cadaveric legs. A total of twenty compartment releases were completed, using an ultrasound-guided, percutaneous looped cutting thread technique. The specimens were evaluated for length and completeness of fasciotomy, as well as any inadvertent injury to muscle, tendon, or neurovascular structures. Completeness of fasciotomy was compared between the anterior and lateral compartments.

Results

- Eighteen of twenty (90%) fasciotomies were continuous. Fasciotomy length was consistently under target (72% complete). Completeness of lateral compartment release was significantly more likely to be under target compared to anterior compartment release (65% vs. 79%, p ​= ​0.014). Sixteen of twenty (80%) fasciotomies incurred no iatrogenic soft tissue injury; no injuries to nerves or vessels were observed.

Discussion –

Ultrasound-guided, minimally invasive looped thread fasciotomy of the anterior and lateral leg compartments is feasible and can be successfully performed in a cadaveric model with low risk to neurovascular structures. However, further investigation is needed to improve completeness of release prior to recommendation for clinical use.

Familial Mediterranean Fever Patients may have Unmet Needs for the Treatments of Exertional Leg Pain and Enthesitis

INTRODUCTION

Exertional leg pain (ELP) and enthesitis are musculoskeletal findings in familial Mediterranean fever (FMF). They are not accepted as principal treatment targets. In this study, we assessed the effectiveness of treatments on ELP and enthesitis.

MATERIAL AND METHODS

We have included 218 FMF patients to the study. We retrospectively compared the FMF attacks' frequency, duration and intensity (FMF attack VAS score) and levels of ELP VAS and enthesitis VAS scores between pre-treatment stage and while patients were on treatment at the last visit.

RESULTS

Forty-nine (22.5%) and 52 (23.9%) of the patients had enthesitis and ELP respectively. All patients were on colchicine treatment. Serositis attacks respond the treatments significantly. Moreover, both ELP VAS scores (p=0.002) and enthesis VAS scores (p=0.17) were improved with treatment. But only improvement in ELP VAS scores was significant.

CONCLUSION

FMF treatments had favourable effect on ELP and enthesitis in FMF patients. However, the response rates would be inadequate. Therefore, there would be unmet need for treatment of both conditions.

Overuse-Related Injuries of the Musculoskeletal System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques

Overuse-related musculoskeletal injuries mostly affect athletes, especially if involved in preseason conditioning, and military populations; they may also occur, however, when pathological or biological conditions render the musculoskeletal system inadequate to cope with a mechanical load, even if moderate. Within the MOVIDA (Motor function and Vitamin D: toolkit for risk Assessment and prediction) Project, funded by the Italian Ministry of Defence, a systematic review of the literature was conducted to support the development of a transportable toolkit (instrumentation, protocols and reference/risk thresholds) to help characterize the risk of overuse-related musculoskeletal injury. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to analyze Review papers indexed in PubMed and published in the period 2010 to 2020. The search focused on stress (overuse) fracture or injuries, and muscle fatigue in the lower limbs in association with functional (biomechanical) or biological biomarkers. A total of 225 Review papers were retrieved: 115 were found eligible for full text analysis and led to another 141 research papers derived from a second-level search. A total of 183 papers were finally chosen for analysis: 74 were classified as introductory to the topics, 109 were analyzed in depth. Qualitative and, wherever possible, quantitative syntheses were carried out with respect to the literature review process and quality, injury epidemiology (type and location of injuries, and investigated populations), risk factors, assessment techniques and assessment protocols.

A Comparison of Two Models Predicting the Presence of Chronic Exertional Compartment Syndrome

Clinical history and physical examination are usually not sufficient to diagnose leg chronic exertional compartment syndrome (CECS). Two predictive clinical models have been proposed. The first model by De Bruijn et al. is displayed as a nomogram that predicts the probability of CECS according to a risk score. The second model by Fouasson-Chailloux et al. combines two signs (post-effort muscle hardness on palpation or hernia). To evaluate those models, we performed a prospective study on patients who were referred for possible CECS. 201 patients underwent intra-compartmental pressure at 1-min post-exercise (CECS if ≥ 30 mmHg) - 115 had CECS. For the De Bruijn et al. model, the risk score was 7.5±2.2 in the CECS group and 4.6±1.7 in the non-CECS group (p<0.001) with an area under the ROC curve of 0.85. The model accuracy was 80% with a sensitivity of 82% and a specificity of 78%. Concerning Fouasson-Chailloux et al. model, the accuracy was 86%; the sensitivity and the specificity were 75 and 98%, respectively. The De Bruijn et al. model was a good collective model but less efficient in individual application. In patients having both muscle hardness and hernia, we could clinically make the diagnosis of CECS.

The Role of Magnetic Resonance in the Diagnosis of Chronic Exertional Compartment Syndrome

Chronic compartment syndrome is a common and often underdiagnosed exercise-induced condition, accounting on average for a quarter of cases of chronic exertional pain in the leg, second only to the fracture/tibial stress syndrome spectrum. It traditionally occurs in young runner athletes, although more recent studies have demonstrated a considerable prevalence in low-performance practitioners of physical activity, even in middle-aged or elderly patients. The list of differential diagnoses is extensive, and sometimes it is difficult to distinguish them only by the clinical data, and subsidiary examinations are required. The diagnosis is classically made by the clinical picture, by exclusion of the differential diagnoses, and through the measurement of the intracompartmental pressure. Although needle manometry is considered the gold standard in the diagnosis, its use is not universally accepted, since there are some important limitations, apart from the restricted availability of the needle equipment in Brazil. New protocols of manometry have recently been proposed to overcome the deficiency of the traditional ones, and some of them recommend the systematic use of magnetic resonance imaging (MRI) in the exclusion of differential diagnoses. The use of post-effort liquid-sensitive MRI sequences is a good noninvasive option instead of needle manometry in the diagnosis of chronic compartment syndrome, since the increase in post-exercise signal intensity is statistically significant when compared with manometry pressure values in asymptomatic patients and in those with the syndrome; hence, the test can be used in the diagnostic criteria. The definitive treatment is fasciotomy, although there are less effective alternatives.

Ultrasound-Guided Fasciotomy for Chronic Exertional Compartment Syndrome: A Case Report

Chronic exertional compartment syndrome (CECS) is characterized by an excessive increase in intracompartmental muscle pressures after exercise. Athletes with CECS report pain, pressure, and occasionally neurologic symptoms in the affected compartment during exercise that abates with rest. Although many treatment options have been proposed, athletes often require a fasciotomy to return to unrestricted sports participation. Surgical success rates vary; complications are not uncommon; and after surgery, it usually takes athletes 6 or more weeks to return to unrestricted impact activities. This case report describes a new ultrasound-guided fasciotomy technique for the treatment of anterior leg compartment CECS. The procedure required a 3 mm incision, was performed in the office under local anesthesia, and allowed the athlete to resume running within 1 week of the procedure. Although the preliminary results of this study are promising, further translational research is required before the widespread adoption of this procedure is recommended.

Ultrasound-Guided Fasciotomies of the Deep and Superficial Posterior Leg Compartments for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation

BACKGROUND

Chronic exertional compartment syndrome (CECS) is a type of leg pain related to elevated intracompartmental pressure with activity in one or more of the four compartments of the leg. Open fasciotomy is the definitive treatment for CECS but has a reported complication rate of up to 15.7% and return to full activity reported up to 16 weeks. Ultrasound-guided (USG) fasciotomy of the anterior and lateral compartments has been translated into clinical practice.

OBJECTIVE

To determine the safety and feasibility of a USG fasciotomy of the deep posterior compartment (DPC) and superficial compartment (SPC) of the leg in a fresh-frozen cadaveric model.

DESIGN

Prospective, cadaveric laboratory investigation.

SETTING

Procedural skills laboratory at an academic institution.

CADAVERIC COHORT

Ten fresh-frozen cadaveric knee-ankle-foot specimens from five female and five male donors aged 58 to 93 years (mean 77.4 years) with body mass indexes of 18.1 to 33.5 kg/m² (mean 25.1 kg/m² ).

METHODS OR INTERVENTIONS

One experienced operator performed 10 USG DPC and SPC fasciotomies. A clinical anatomist performed dissections of each.

MAIN OUTCOME MEASURES

Achievement of target length and continuity of release was recorded. Target lengths of 10 cm for the superficial posterior compartment (SPC) and 15 cm for the deep posterior compartment (DPC) were established based on previous studies. Tendinous and neurovascular structures were assessed for damage.

RESULTS

No tendon or neurovascular injuries were observed. In the SPC, target length was achieved in 90% and continuous release was observed in 80%. In the DPC, target length was achieved in 60% and continuity observed in 30%.

CONCLUSIONS

These findings suggest that SPC USG fasciotomies using the technique described in this study are feasible, may be safe, and warrant further translational research; however, DPC USG fasciotomies are more challenging and require more technical refinement prior to clinical translation.

Isolated Lateral Chronic Exertional Compartment Syndrome of the Leg: A New Entity?

Background:

Chronic exertional compartment syndrome (CECS) mostly occurs in the anterior or deep posterior compartments (ant-CECS and dp-CECS, respectively) of the leg. It is generally accepted that CECS of the third or lateral compartment (lat-CECS) always occurs together with ant-CECS. However, whether exertional leg pain (ELP) can be caused by an isolated form of lat-CECS is unknown.

Purpose:

To determine the existence of isolated lat-CECS and study whether history taking and a physical examination aid in discriminating between different subtypes of CECS.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients were eligible for this single-center study, conducted between January 2013 and February 2018, if they reported anterolateral ELP and completed a questionnaire scoring the frequency and intensity of pain, tightness, cramps, muscle weakness, and paresthesia during rest and exercise. They were asked to mark areas of altered foot skin sensation, if present, on a drawing. All patients underwent a dynamic intracompartmental pressure (ICP) measurement of the anterior and lateral compartments simultaneously. The diagnosis of CECS was confirmed by elevated ICP (Pedowitz criteria). There were 3 patient groups: (1) isolated ant-CECS with elevated ICP in the anterior compartment and normal ICP in the lateral compartment, (2) isolated lat-CECS with elevated ICP in the lateral compartment but normal ICP in the anterior compartment, and (3) ant-/lat-CECS with elevated ICP in both the anterior and lateral compartments.

Results:

A total of 73 patients with anterolateral ELP fulfilled study criteria (isolated ant-CECS: n = 26; isolated lat-CECS: n = 5; ant-/lat-CECS: n = 42). Group differences were not observed regarding age (isolated ant-CECS: median, 26 years [range, 13-68 years]; isolated lat-CECS: median, 20 years [range, 17-63 years]; ant-/lat-CECS: median, 28 years [range, 17-57 years]; χ² (2) = 0.466; P = .79), sex (isolated ant-CECS: 50% male; isolated lat-CECS: 40% male; ant-/lat-CECS: 62% male; P = .49), or bilateral symptoms (isolated ant-CECS: 54%; isolated lat-CECS: 80%; ant-/lat-CECS: 69%; P = .40). However, cramps at rest were present in a portion of the patients with isolated ant-CECS (38%) and ant-/lat-CECS (57%) but not in those with isolated lat-CECS (P = .032). Patient drawings of altered foot skin sensation did not contribute to the diagnosis (P = .92). ICP values after provocation were all lower in patients with isolated ant-CECS and isolated lat-CECS compared with those with ant-/lat-CECS (P < .05).

Conclusion:

Seven percent of patients with CECS and anterolateral ELP who had symptoms due to isolated lat-CECS in the presence of normal muscle pressure in the anterior compartment.

Diagnosis and management of external iliac endofibrosis: A case report

External iliac artery endofibrosis is an uncommon, nonatherosclerotic disease seen in endurance cyclists. It is poorly identified by providers. These otherwise healthy patients usually present with symptoms of arterial insufficiency, such as thigh or buttock pain, loss of power, or weakness occurring during strenuous exercises. These symptoms subside rapidly with rest. As these patients lack traditional risk factors of peripheral artery disease, their symptoms are often overlooked or are attributed to other etiologies, resulting in mismanagement and delayed treatment. In this case study, we report our experience with the successful management of a 48-year-old male who is a longstanding, avid cyclist. He self-referred to our institution after extensive research of providers familiar with his problem and at the recommendation of other cyclists with similar experiences. The patient underwent a successful left external iliac to common femoral artery endarterectomy and patch angioplasty. Three months after operation, he returned to cycling and, for the most part, has remained without symptoms.

Common peripheral nerve injuries in sport: diagnosis and management

Peripheral nerve injuries are unusual in sport but impact an athlete's safe return to play. Nerve injuries result from either acute trauma (most commonly in contact/collision sports) or from repetitive microtrauma and overuse. Diagnosis of overuse nerve injuries includes nerve localization and surrounding soft-tissue anatomy, and must account for possible causes of repetitive microtrauma, including biomechanics, equipment, training schedule, and recovery. Prognosis is related to the type of nerve injury. Management should not simply be rest and gradual return to sport but should address biomechanical and training predispositions to injury. Understanding the type of injury and the tissues involved will guide appropriate rehabilitation decisions. Recognizing acute care considerations and implementing appropriate strategies can help minimize secondary trauma to an area following acute injury.