Athlete's with Leg Pain: What's Wrong and What to Do About ItIt's pretty hard to run, twist, jump, and compete as an athlete when you have chronic lower leg (below the knee) pain. And that condition accounts for more leg problems than anything else (other than knee pain) in both competitive and recreational athletes.
With all the improvements in diagnostic testing and available evidence out there, the authors of this article (two physicians from Vanderbilt Orthopaedic Institute in Nashville, Tennessee) decided to do a literature search on chronic lower leg pain. They hoped to find evidence to support and guide a standard diagnostic and treatment approach to this problem.
Their search extended from January 1980 to May 2011 and uncovered five common causes of lower leg pain in athletes. These conditions include 1) medial tibial stress syndrome (shin splints), 2) chronic exertional compartment syndrome, 3) stress fracture, 4) nerve entrapment, and 5) popliteal artery entrapment syndrome. Long-distance runners and military personnel seem to have the most lower leg injuries.
The authors provide a brief review of each of these five conditions, the most common causes of these injuries, and current recommendations for treatment. They state at the beginning of the article that the evidence for a standard approach to these problems in athletes is "sparse."
All five of these chronic lower leg pain problems are caused by weight bearing, repetitive or compressive forces, and overexertion or overuse from activities such as running. Continuing activities that bring on leg pain or make leg pain worse is an important risk factor for acute pain becoming chronic (long-term).
Other risk factors for these conditions include female sex, anatomy (e.g., flat feet, hip internal rotation), and previous injuries. Eating disorders and loss of bone density are additional risk factors for bone fractures. And being overweight contributes to delays in recovery. Continued exercise and overtraining resulting in increased muscle bulk can lead to impingement (pinching) of a nerve or blood vessel (entrapment).
Before treatment can be determined, an accurate diagnosis must be made. The physician starts with a good patient history including training history (number of sessions per week, length of each session, intensity of sporting activity), training surface, and footwear. Any recent changes in any of these variables may be an important part of the history.
Depending on the patient's symptoms, diagnostic imaging can include X-rays, bone scans, and/or MRIs. For more specific identification of problems involving compartment syndromes, pressure testing can be done. To test for nerve compression, electrodiagnostic studies can be ordered. The diagnosis helps direct treatment.
Most often, conservative (nonoperative) care is the first line of treatment. Recommendations for conservative care include rest, the use of ice, antiinflammatory medications, and possibly taping, splinting or casting the lower leg.
Physical therapy is an important part of the recovery and rehabilitation for these athletes. The therapist will address posture and alignment, flexibility and stretching, activity modification, and strengthening. The therapist is also integral in guiding the athlete in selecting proper shoe wear and getting back into an appropriate and effective training schedule.
Some conditions such as stress fractures, requires rest before rehab. The athlete is put on crutches and a nonweight-bearing status. Load is taken off the bone until healing can take place. This means no sports or recreational activities until cleared by the physician.
Other problems such as entrapment syndromes affecting blood vessels require more immediate surgical attention. Surgery may also be needed for athletes with some of these other problems that do not respond to conservative care. The athlete who requires surgery can expect a longer period of recovery and gradual return-to-sports through rehabilitation. Impact and sports-specific training is essential following surgery for any of these conditions.
The authors conclude that chronic leg pain in competitive and recreational athletes is common, often develops slowly over time, and is ignored too long before diagnosis and treatment. The diagnosis can be difficult and requires patience in taking a complete history and performing the clinical examination. Right now, there is no evidence-based standard of care for these problems. More studies are needed to provide evidence to guide physicians in these cases.
Rachel Biber Brewer, MD, and Andrew J. M.Gregory, MD. Chronic Lower Leg Pain in Athletes: A Guide for the Differential Diagnosis, Evaluation, and Treatment. In Sports Health. March/April 2012. Vol. 4. No. 2. Pp. 121-127.
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