Different types of leg pain in athletes

A variety of conditions can cause acute or chronic leg pain in athletes. Some are temporary and will get better with conservative measures, but others are potentially dangerous and have to be managed with surgical intervention. Fortunately, the former are much more common and will likely be experienced at some time in an athlete’s career. The latter includes stress fractures and chronic compartment syndrome.

All of us at one time or another have had pain in our shins after exercising or playing a sport. It usually comes after a period of inactivity or when we’re starting a new exercise program. We know these as “shin splints.” What happens in this case is that all this new or accelerated activity causes a phase of inflammation in the area of the bone where a calf muscle originates. The outer layer of bone is called the periosteum and this is the tissue in which the muscle fibers anchor themselves to the bone. Forceful contractions of the muscle in this area leads to inflammation.

With shin splints the clinical symptoms are fairly consistent. It is an area of up to a hand’s breadth and is located on the big toe side and toward the back of the shin bone. The area itself remains painful even after the exercise is over and can remain tender for up to a week. There is rarely any swelling of the soft tissues and no redness or increased skin temperature is noted. This will help distinguish it from other causes of leg pain. Diagnostic tests include plain x-rays that are usually normal. A bone scan may be positive but will show a thin line of activity along the length of the shin bone rather than a discrete, concentrated area of intense uptake seen in a tibial stress fracture.

Treatment includes rest and reducing activities, ice massaging and nonsteroidal anti-inflammatory drugs. Once asymptomatic, an athlete can gradually increase his or her activities as long as they are not having any pain.

Stress fractures occur when there are forces applied to a bone which, in and of themselves, are not enough to cause the bone to break. But when they are applied over a period of time, the accumulative effect will cause a fracture. Just as if you straightened out a paper clip, you could not cause the metal to break by bending it. However, if you bend that paperclip back and forth enough times, the metal would fatigue and subsequently break. That’s the physics involved with a stress fracture. These can occur in either bone of the leg depending on where the stresses are concentrated.

The clinical picture usually is pain that occurs with activity, sometimes just with weight bearing. It may hurt just to walk, and running and jumping are intolerable. Patients describe the pain as a deep ache and can usually be localized to a fingertip spot over the front of the bone. If you squeeze the bones of the leg together, pain at the site of the stress fracture will result. Plain x-rays may show a stress fracture but if they are normal and the pain lasts more than a week, the bone scan is the next step and will show the marked uptake at the site of the stress fracture.

Treatment includes crutches if weight bearing is too painful. Often a cast boot is helpful for ambulation. Athletics are suspended for six to eight weeks. Cross training can be started to include no impact activities such as “running” in a pool with a floatation vest, swimming or cycling if there is no associated pain. Sometimes your doctor may recommend an electrical bone stimulator for cases not responding to the previous treatments. Only in rare circumstances is surgery used to place a rod down the shaft of the bone to alleviate the stress area and allow bone healing.

Chronic compartment syndrome is a situation in which the envelope surrounding the muscles does not allow room for the muscles to expand as they fill with blood during activity. Patients typically begin to experience pain in the front or back of the leg (depending on which compartment is involved) after 5-10 minutes of exercising. The pain intensifies and can last anywhere from several minutes to hours after the activity is stopped.

A physical exam may show a tense, tight compartment in the leg if seen immediately following onset of the pain. X-rays will typically be normal in these cases and “exercise induced compartment syndrome” can only be diagnosed by using a transducer to demonstrate elevated compartment pressure while exercising along with a delayed return to normal levels post exercise. Treatment for EICS usually requires surgery. In this treatment, the tight fascia that makes up the boundaries of the compartment is surgically released through small incisions in the skin and the confining structures are eliminated to allow the muscles to expand as they work. Results are almost always good with this treatment.

This story was originally published April 8, 2017 at 1:14 PM with the headline "Different types of leg pain in athletes."