It’s no surprise that the most common injury area for us runners is the lower leg. The shin or lower leg includes everything between the knee and ankle, and is a prime spot for aches and pains due to the high-impact nature of our favorite activity. But before we get into the most common lower leg injuries for runners, here’s a quick anatomy refresher.
The tibia is the large bone of the lower leg, and the fibula is the thin bone along the outer aspect of the lower leg. There are four compartments in the lower leg, each of which includes several muscles along with a nerve, artery, and vein. Each compartment is surrounded by a tissue known as fascia. The muscles in these compartments control motion of the foot and ankle. Many of the thigh muscles attach to the top of the tibia and fibula. Differentiating between specific causes of lower leg pain may be difficult due to overlapping symptoms.
Now that we know what we’re dealing with, here are six of the most common causes of lower leg pain and how to treat and prevent them so the next time you’re wondering, “Why does my leg hurt?” you’ll have some guidance in finding the root cause of the issue.
This term is used to describe pain along the medial (inner) side of the tibia. Typically, you’ll feel pain along a third or more of the bone. The pain develops while running and resolves afterward—it can improve with continued training. The medial side of the tibia will be tender to touch with no area more tender than another. There may be mild swelling in the lower leg, too.
Microscopic tears of the muscle away from the lining of the bone causes the pain. Predisposing factors include overpronation and running on hard surfaces, and shin splints are more common in novice runners. Treatments include icing after exercise, appropriate footwear or arch supports, and changing your running surface.
Improving the flexibility of your calf muscles and the strength of the muscles along the front and sides of your lower leg are important in treating and preventing this problem as well. To strengthen the muscles of the lower leg, we recommend placing a weighted ring on your foot and pointing your foot up, in, and out. Repeat for 10 reps. Perform three sets.
Also a source of bone pain, a stress fracture is an injury of the bone due to repetitive microtrauma. Bone responds to stress by becoming stronger. The stress causes bone resorption, which is followed by bone building, as long as the stress isn’t overwhelming. With excessive stress, resorption is greater than the building phase, leading to microscopic trauma and microfractures. Repetitive microfractures result in a stress fracture.
The typical presentation is bone pain with impact. Initially, the pain develops during the run but may even resolve during the course of the run. Over time, the pain is present throughout the run and may be present while walking. Mild swelling may be present in the affected area. Continued impact on a stress fracture can result in a complete fracture through the bone.
On clinical examination, there is a specific area of significant bone tenderness. There is pain or even inability to hop on the single leg. X-rays will not reveal abnormalities for at least two weeks and possibly much longer. MRI and three-phase bone scans can detect stress fractures much earlier.
Stress fractures in runners tend to occur in the lower aspect of the fibula and in the upper and lower aspects of the tibia. They can also—though less commonly—occur in the front of the tibia; this stress fracture can be problematic in healing due to the shape of the tibia.
Treatment begins with stopping all high-impact activities, but you may continue low-impact impact cross-training. If there is pain with walking, a boot, cast, or crutches may be needed. In some cases, a long air cast (a stirrup brace that covers the lower leg) may allow a more rapid return to running. Otherwise, most athletes can return to a gradual running program in six to eight weeks.
The reason for developing the stress fracture should be determined. Increasing training too quickly (intensity and/or distance) is the most common cause of this injury. Low bone density or low levels of vitamin D can predispose runners to stress fractures. Training schedules, diet, and for women, menstrual history, should be reviewed to find risk factors for the development of stress fractures and any problems detected should be corrected.
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During exercise, muscles swell, increasing in volume by up to 20 percent. If the fascia that surrounds one or more of the compartments is too tight to allow the swelling to occur, it acts like a tourniquet, restricting blood flow and putting pressure on the nerve. This causes pain and possibly numbness in the lower leg and foot, and the muscles may not function normally.
A runner with chronic exertional compartment syndrome complains of pain that develops at a certain point during the workout and becomes progressively worse, often to the point of having to slow or end the run. Slapping of the foot as it strikes the ground is another common complaint. The symptoms will resolve shortly after the exercise stops as the swelling resolves. Because of this, the runner’s leg usually seems normal when examined by a medical professional.
Compartment syndrome is diagnosed by measuring the pressure in each of the compartments in the involved legs before and immediately after a run. (The run is usually performed on a treadmill and is continued until significant symptoms develop.) The treatment for compartment syndrome is surgery, after which most athletes are able to return to full activities.
This is a common problem in the lower leg. Tendons attach the muscle to bone. Inflammation of the tendon causes pain when the muscle is stretched or contracted, and when the tendon swells, both strength and flexibility diminish. The posterior tibialis (the inner aspect of the ankle) and the peroneal (the outer aspect of the ankle) tendons may also be inflamed and tender to touch.
Common causes of Achilles tendinitis include a sudden increase in hill work or speed work. In addition, switching from training shoes to racing shoes without having worn the racing shoes in a long time may aggravate the Achilles tendon because of the racing flat’s lower heel. Overpronation may cause inflammation of the posterior tibialis tendon, while a stiff, underpronated gait may inflame the peroneal tendon.
Treatment for tendinitis includes icing the area for 15 to 20 minutes three to four times a day, adjusting training to decrease the offending stressors, and modifying footwear. The peroneal and posterior tibialis muscles can be strengthened with the exercises described in the section on shin splints (above). Stretching the Achilles tendon once you’ve warmed up with easy jogging is also recommended.
As flexibility improves, you should begin to strengthen your Achilles. One exercise involves hanging your heels off the back of a step, and lowering and raising them repeatedly. Do this slowly at first, then more quickly as your strength improves. You can then progress to single leg raises, starting slowly and gradually increasing speed over training sessions. Heel lifts can be added with shoes when the Achilles tendon is painful to alleviate some of the stress on the tendon.
Prolonged problems with the Achilles tendon may cause degenerative changes, known as tendinosis. The treatment is similar to tendinitis. Stubborn cases may be treated with deep tissue massage and manipulation (such as active release therapy), injections with platelet-rich plasma and similar substances, or surgery as a last resort. Cortisone injections shouldn’t be performed in the Achilles tendon due to the risk of rupture and weakening of the structure during the first 10 to 14 days following the injection.
The large calf muscles (gastrocnemius and soleus) can inflame due to a sudden injury in which the muscle tears. This most commonly occurs in the inner belly of the gastrocnemius at the junction of the muscle and the tendon. When this happens, you might feel a pop, and pushing off will be extremely painful.
There will be mild swelling and possibly some bruising in the leg. Treatment includes using a boot, crutches, or both, and ice should be used often. As the pain subsides, strength and flexibility exercises should be performed. When the runner is able to bear weight on the affected leg without pain, heel lifts should be added to the shoes. Lesser injuries, in which the muscle is inflamed, but not torn, may be treated like tendinitis.
Compression of the Popliteal Artery
Compression of this artery during exercise is an uncommon but potentially severe source of pain, which usually occurs at the level of the knee. With compression of the artery, blood flow to the leg muscles diminishes, causing significant pain until the exercise stops. The blood flow needs to be evaluated during exertion to diagnose this problem, and surgery is the treatment.
Treatment of Lower Leg Pain
With all of these injuries, medications should be used with caution. Short-term use (five to seven days) of non-steroidal anti-inflammatory medications (such as ibuprofen and naproxen) may help relieve pain, as long as there isn’t a contraindication to usage, such as gastrointestinal, liver, or kidney problems. Even then, these medications should be used with caution.
There is equivocal data in scientific literature on use of NSAIDs with stress fractures—several studies have suggested that these medications may impede the healing of fractures. Acetaminophen may be used for pain control if there are no medical contraindications to its usage. When in doubt, always seek care from a medical professional.
In the case of stress fractures, running should be discontinued until your health care provider gives the green light. Compartment syndrome will not resolve without treatment. When the symptoms are severe enough, options include surgery or eliminating running.
A torn gastrocnemius usually precludes running due to pain. For the other injuries, some degree of running can usually be continued. This involves decreasing the distance and intensity of workouts, with the amount of modification determined by the severity of the symptoms. The goal is to minimize symptoms while running—cross-training may be performed in addition to running if it doesn’t aggravate the problem. Training should be increased gradually, and ice should be used following the workout. Don’t forget to perform strength and flexibility exercises as training increases.
Prevention of Lower Leg Pain
Wear your racing shoes for at least half of your speed workouts and tempo runs. Before a marathon, do at least two long runs in the shoes you’ll wear on race day. Otherwise, you’re likely to get lower leg soreness immediately after or even during your race.
“When you consider that racing flats often have less than one inch of cushioning in the heels, it’s easy to see why suddenly subjecting your legs to such a large difference can strain the calf muscles,” says sport podiatrist Brian Fullem.
If you haven’t been wearing racing flats on a regular basis, introduce them slowly by wearing them on a series of post-run striders a couple of times a week. “Then gradually build up to a full workout, starting with shorter workouts,” Fullem says. “For example, if your track workout ends with 200- or 400-meter repeats, put on the flats for this portion of the workout.”