Show Notes
With cases from Dr James Noake In musculoskeletal medicine, we are trained to recognise patterns. Most of the time, the answer sits comfortably within the familiar: overload, strain, tendinopathy. But every so often, something doesn’t quite fit. The story is slightly off, the response to treatment unexpected, or the clinical picture just a little too inconsistent. This is where the ‘Zebra Farm’ comes in. Each time, we explore a trio of real-world cases as written up by Dr James Noake (Consultant in Musculoskeletal, Sport and Exercise Medicine) in his upcoming book ‘Real World Sports Medicine and Musculoskeletal Case Studies : Knee and Lower Leg’. The cases challenge diagnostic instinct; presentations that look routine on the surface but reveal something far less obvious underneath. These are not just rare conditions for rarity’s sake; they are reminders of the cognitive traps we all fall into: anchoring, pattern recognition bias, and premature closure. Because sometimes, when you hear hoofbeats, it isn’t a horse. This is the Zebra Farm. Case 1: The ‘Compartment Syndrome’ That Wasn’t - Myotonia Congenita A runner and footballer in their late 20s had endured a 10-year history of bilateral lower leg pain, described as ‘crampy’ and ‘bursting’. Everything pointed toward chronic exertional compartment syndrome (CECS): * Rapid symptom onset with running * Involvement of multiple compartments (anterior worst) * Stiffness and subjective weakness after activity They had even undergone bilateral fasciotomies with no improvement. Something didn’t add up On reassessment: * Muscles felt ‘woody’ and rigid post-exercise * There was increased muscle tone noted and delayed muscle relaxation * Power improved paradoxically with repeated effort * MRI showed diffuse calf oedema bilaterally, but nothing focal The crucial clue came from EMG: * Myotonic discharges producing a classic ‘dive-bomber’ sound * Further testing showed mild changes in the deltoid too Diagnosis: Myotonia Congenita A non-dystrophic neuromuscular disorder - not a compartment problem at all. Why it fooled everyone * The patient looked ‘muscular’ (due to doing isometrics 24/7 for 10 years…) * Imaging looked ‘consistent’ with exertional pathology * Long history reinforced diagnostic anchoring Key sign ➡️Symptoms didn’t fully settle after stopping exercise and they improved with repetition (warm-up phenomenon). Note though that this warm up phenomenon is short lived! Transition: When ‘muscle pain’ isn’t muscle at all The first case teaches us that abnormal muscle physiology can masquerade as mechanical overload. The next case pushes this even further: when the pain isn’t muscular at all, but vascular. Case 2: The ‘Nerve Entrapment’ That Was a Clot - Peroneal Vein Thrombosis A patient in their 40s presented with 3 months of deep lateral calf aching: * Worse with activity—but now present at rest and at night * Localised toward the lateral calf * Referred as possible superficial peroneal nerve entrapment They also had a significant history: * Prior contralateral DVT * Avascular necrosis of the hip The imaging changed everything MRI neurography revealed: * Marked oedema in the flexor hallucis longus region * Oedema centred around the peroneal vessels This raised suspicion of something non-mechanical. ➡️ Duplex ultrasound confirmed a peroneal vein thrombosis Diagnosis: Deep vein thrombosis mimicking MSK pain Why it fooled clinicians * Localised lateral calf pain suggested nerve pathology * Gradual onset, not acute Key sign ➡️ Pain that progresses from activity-related to constant, especially with night pain, should raise suspicion Bigger picture This case also highlights underlying systemic risk: * With recurrent thrombosis and AVN, consider possible antiphospholipid syndrome / Systemic lupus erythematosus (SLE) Transition: When imaging is subtle - but the symptoms are loud The first case was metabolic.The second was vascular. The third returns to muscle but challenges our understanding
More from MSKMag OutLoud
It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com