LEG PAIN (IT'S NOT ALWAYS SHIN SPLINTS)
By: Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S.
Pain in the lower leg must be evaluated thoroughly in order to determine the exact problem. There are four common injuries that can lead to leg pain.
I. STRESS FRACTURES
Stress fractures are micro fractures that can occur in any bone in the lower extremity or spine. The most common area is the metatarsal bones in the foot but they are also seen in the leg bones. The most common presentation is a patient who presents with a sudden alteration in their training regimen (i.e. more sprinting, increased mileage or increased intensity) that develops pinpoint pain and localized swelling over bone. This type of injury is more common in women with menstrual irregularities and lower calcium intake. They are also very common in teenage girls who are very active in sports and who are very thin framed.
- Stress fractures are overuse injuries that cause stress to the bone that exceeds the bone's ability to repair itself.
- Repetitive stress to the bone over a short period of time.
- May occur at the beginning of a sports season in an unconditioned athlete.
- Commonly associated with an increased incidence in people with osteopenia or osteoporosis.
- A new job or activity requiring the patient to be on his/her feet for a long period of time.
- Structural abnormalities (high arched foot, bowleggedness, knock-knees, flatfoot) may predispose people to stress fractures.
- Rarely bone tumors may cause pathologic stress fractures.
- Pinpoint tenderness to any bone of the lower extremity.
- Localized swelling over the area.
- Pain may be minimal in the morning but as the day goes on the pain gets worse and more swelling becomes apparent to the involved region.
- Inability to participate in sporting activities due to the level of pain that worsens with the activity.
- An athlete will not be able to play a sport with a stress fracture due to the pain that will stop them during the activity.
X-RAYS: X-rays may be negative for a stress fracture for three weeks. Bone scans and MRis are rarely necessary.
TREATMENT: The type of treatment instituted depends on the bone involved and the length of time that the patient has had the condition.
- A change in a person's job may be necessary for a short period of time to rest the affected bone.
- Rest from the activity precipitating the problem. Cross training to activities that do not stress or overload the bones (i.e. swimming, cycling, Stairmaster).
- A change to a softer running athletic surface and the use of cushioned shock absorbing custom molded orthotics (insoles for the shoes).
- Occasionally immobilizing the extremity in a hard cast or removable boot may be necessary if weightbearing is painful.
- Surgery, if the bone fails to heal, may be necessary but it is rarely needed.
- Calcium and vitamin D supplementation.
- In females with menstrual irregularities follow-up with their physician is imperative.
Tendons connect muscle to bone and are responsible for movement of the joints. When the covering of the tendon is inflamed it is referred to as tendinitis. When the injury becomes more chronic and it affects the main body of the tendon it is called tendinosis.
CAUSES: Athletes or workers in high force and/or high repetition activities may be predisposed to tendinitis. It is more common in people who are unaccustomed to these types of activities. It is common in a athlete at the beginning of a training season when training intensity is increased. This sudden alteration to a training program coupled with biomechanical faults (flatfeet, bowleggedness, knock-kneed) and tight or weak muscles may play a role.
SYMPTOMS: Pain with movement of the foot, ankle or leg. Occasionally swelling and a crackling sensation may be felt with movement. Tenderness is always present over the involved tendon. Stiffness is usually present upon first arising in the morning while getting up to walk. The stiffness and soreness will often diminish allowing for use of the injured area. Later on in the day or with activity there is a recurrence of the pain due to inflammation over the area.
TREATMENT: It is most important to.determine why the person has developed the problem.
- Rest. Resting the body part will almost cause immediate benefit to the patient as the injured tendon would not be moving.
- Ice assists in decreasing the inflammation over the tendon.
- Physical therapy to decrease inflammation over the tendon and the improve muscle strength and flexibility.
- Medication to help reduce the inflammation may be necessary. It will assist in healing of the tendon and weakening it, which could predispose it to rupture.
- Orthotics are extremely beneficial for faulty biomechanics (flatfoot) that may predispose the patient to these injuries.
- Immobilization may be necessary in a cast or boot in order to provide complete rest to the injured tendon.
- Immobilization may last from 2-6 weeks depending on the degree of damage.
PROGNOSIS: Prognosis is usually excellent when identifying the major factor that caused the problem. If untreated chronic inflammation can develop, which can be more difficult to treat. In rare cases surgery is necessary to completely heal the inflamed tendon.
Ill. CHRONIC COMPARTMENT SYNDROME
The muscles of the lower leg are grouped into four compartments. The compartments are formed by borders of bones and tight ligament-like (fascial) structures. Blood vessels and nerves run in these compartments.
During exercise the muscles engorge with blood, causing them to enlarge. The compartments may not accommodate the muscle expansion, causing an increased pressure within the compartment. This diminishes blood supply to the muscles and nerves.
- Tight fascial bands that do not expand during activity.
- Herniation of muscle through the fascia.
- Enlarged calf muscles.
- Biomechanical abnormalities including excessively low or high arched feet.
- Associated with low blood pressure.
SYMPTOMS: A deep ache and soreness in the muscle. Numbness and tingling in the foot and weakness in the muscle may develop. These symptoms will usually develop at a specific time or distance during the exercise. The leg will feel tense when touched. A drop foot or foot slap may also be experienced and the athlete cannot run through this condition.
DIAGNOSIS: Usually made by a thorough history and evaluation of the patient. Checking the compartment pressure at rest and immediately after exercise, then 5 minutes later all help to determine the level of the problem. This pressure is always compared to the patient's diastolic blood pressure. The closer those pressures become the more indicative of a problem it is.
- May be as simple as exercising until the pain develops, then stopping.
- Orthotics will correct any biomechanical faults that may predispose the patient to this problem.
- Activity modification may be necessary temporarily and changing the playing or running surface may play a positive roll.
- Physical therapy may be necessary to decrease muscle tightness and improve overall muscle strength.
- Surgery is the definitive treatment to relieve the pressure in the compartment if the condition is unresponsive to conservative care. If the runner or athlete decides to continue the activity, it may be impossible for them to run through it. Surgery is successful in a vast majority of the cases. Within one week patient can get on an exercise bike and start to cross train. Running can usually resume within 3-4 weeks.
IV. SHIN SPLINTS (PERIOSTITIS)
Pain in the front or on the inside of the shinbone is one of the most commonly seen problems in the sports medicine practice. The muscles in the leg pull on the bone, causing inflammation and soreness to the bone-muscle junction. Shin splints may occur on the front or inside of the leg. The pain may progress to a point where stress fractures (small cracks in the bone) may occur.
- Pain in the front of the shin is usually caused by tight calf muscles and weak shin muscles.
- Pain on the inside of the leg is most common in sprinters and people who may be flatfooted or pronated (feet and ankles roll in). It is made worse by weakness to the muscle group on the inside of the leg, which may limit a person's ability to participate in sports. It is also commonly associated with tight calf muscles.
- Walking barefooted or running in very flat or worn out shoes may cause or aggravate the condition.
- An alteration in a person's training regimen may also precipitate shin splints.
- Pain is diffuse in the shin (over a one to four inch area).
- Swelling is usually not seen in early stages. If swelling does occur, shin splints may have progressed to stress fractures.
- Pain is usually present early on in the activity, the pain may lessen and then return during the latter part of the activity. Athletes can generally run through the pain. If it has progressed to a stress fracture, they cannot.
- It is most important to identify the cause of the injury so that the appropriate treatment can be rendered.
- A rehabilitation program emphasizing stretching and strengthening is necessary.
- Rest and ice will also help to diminish the pain during the acute process.
- Shin splint sleeves help to keep the muscle warm and compress the muscle against the bone, lessening the pain.
- An evaluation of the foot, ankle and leg are necessary to look for problems that may predispose a person to these injuries.
- Orthotics which are custom molded to the patient's foot may be indispensable in the treatment of shin splints and the prevention of their recurrence.
- If not improving, immobilization may be necessary in a cast or boot.
- Surgery for people who fail to respond to conservative care may be needed although rarely necessary.