ACSM Sports Medicine Basics

Exercise-Induced Leg Pain

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Introduction forms of exercise-induced leg pain are (excessive flattening of the arch of the foot
Anatomically speaking, the leg is the region described below. during locomotion) and tibialis posterior
between the knee and the ankle. Repetitive tendinopathy.
weight bearing exercise commonly causes Muscle Strain • Region most affected: Tibialis posterior.
painful injuries in this region. The sources • W hat is it? Muscle fiber damage However, tibialis anterior, achilles and
of leg pain are varied, but the cause is often •H  ow does it occur? Over-stretching a peroneal tendinopathy can also occur
the same. In the modern day, the pursuit muscle following micro-tears.
of athletic excellence has reached such •R  egion most affected: Tibialis anterior • Signs and symptoms: Pain, swelling and
phenomenal extremes, the human body is muscle (front of the leg, beside the shin palpable crepitance (crunchy feeling) along
often subjected to degrees of physical work it bone) often following chronic downhill the tendon during muscle contraction and
is not able to tolerate. While most body tissues running. stretch. For tibialis posterior tendinopathy,
have the capacity to adapt and strengthen in •S  igns and symptoms: Acute, focal (site this can be mainly felt behind the medial
response to increased loading, overuse injuries of the tear) pain within the muscle during malleolus (inside ankle bone.) Pain is
result when loading increases occur too quickly contraction and stretch. May be swollen and likely to occur primarily at the start of and
for adequate adaptation to take place. warm. following exercise.
•P  revention: Attain good muscle flexibility, • Prevention: Gradual increases in training.
Types of Leg Pain warm up, introduce training modifications Leg (tibialis posterior and tibialis anterior)
“Shin splints” is a lay term that has gradually, vary training. and foot muscle strengthening to support the
been associated with a large number of • Treatment: After the swelling has subsided, arch of the foot when not injured. Orthotic
fundamentally different exercise-induced leg stretch and strengthen the affected muscle inserts in the shoes to reduce chronic per
injuries. Initially, shin splints was thought within the limits of pain. planus (flat foot) or hyperpronation during
to be caused by tibialis posterior tendon exercise, if necessary.
injury. Later, other conditions associated with Tendinopathy • Treatment: Initially, take anti-inflammatory
chronic exercise, including compartment • W hat is it? Micro-tears in tendon that medication and minimize painful activities.
syndrome, tibialis anterior strain, tibial may cause inflammation in the surrounding Complete rest is not advised as tendon heals
periostitis and tibial stress fracture were tissue. Often incorrectly referred to as better when given mild, normal loading.
indiscriminately referred to as shin splints. tendinitis. Once inflammation and pain has subsided,
Given the very different pathologies of those •H  ow does it occur? Over-training stretch and strengthen the muscle associated
conditions, use of the term “shin splints” in repetitive movements, particularly with the tendon.
is clearly inappropriate for the purposes of over-stretching and eccentric loading
diagnosing and managing exercise-induced (muscle contracting while being forced to
leg pain. Instead, specific conditions must be lengthen). There may be a relationship
identified and addressed. The most common between repetitive hyperpronation
MEDIAL TIBIAL STRESS SYNDROME
-MTSS (APERIOSTITIS)
• W hat is it? Over-stimulation or
inflammation of the medial tibial periosteum
(membrane surrounding bone) - the most
common leg injury.
• How does it occur? Bone bending is a
natural consequence of weight bearing.
Wider bones resist bending better than
narrower ones and are, therefore, less
prone to injury. Chronic repetitive bending
stimulates a long bone to widen its cross
section by activating bone cells in its
periosteum to lay down new bone. If
increases in training intensity continue to
occur during this process of adaptation, the
bone cells cannot keep up, micro-damage
occurs and the region becomes inflamed and
painful. The injury may be compounded by
simultaneous, repetitive muscle or fascial pull positive within 48 hours of injury. Edema is • Signs and symptoms: Deep, diffuse, aching,
on the periosteum. visible on MRI. cramping leg pain, swelling and tightness,
• Region most affected: Inside border of the • Prevention: Gradual increases in training leg muscle weakness, numbness in the leg
distal half to third of the tibia (shin bone), in intensity. Same as for MTSS. and/or foot, reduced pulse at the front of the
the region of the narrowest cross section. • Treatment: A period of complete rest (15 ankle, occasional muscle herniations through
• Signs and symptoms: Pain during weight days minimum) from painful weight-bearing fascial defects. Initially, pain develops around
bearing (particularly running and jumping). activity is vital. Although uncommon, 30 minutes into a moderate exercise bout
Tenderness on palpation. Sometimes spontaneous complete fractures may occur at but, with time, pain occurs earlier. If the
swelling, redness and warmth. the site of the stress fracture with continued activity is promptly ceased, pain resolves
• Prevention: Gradual training increases (<10 loading. Typical tibial stress fractures within 10 to 15 minutes. The diagnosis
percent per week). Attaining good dorsi will heal within four to eight weeks with may be confirmed by compartment pressure
flexion flexibility (moving the top of the foot modified rest. An important exception is testing during or immediately following
toward the shin) and leg muscle strength stress fractures on the anterior (foremost) exercise. Unlike muscle strain, tendinopathy,
preseason, wearing appropriate footwear, border of the tibia that can take many MTSS or stress fracture, symptoms are
varying the training surface and consuming months to heal and may require extrinsic absent between exercise bouts.
1000 mg/day dietary calcium. stimulation (pulsed electromagnetic field or • Prevention: Nothing known to be effective.
• Treatment: Rest (7 to 10 days minimum) low-intensity pulsed ultrasound) or surgery. • Treatment: Acutely, immediate rest and leg
from painful activities. Pool, run and cycle to It is not uncommon for tibial stress fractures elevation. Fasciotomy (a minimally invasive
maintain aerobic fitness. Return to training to recur. If so, further rest is necessary and surgical procedure involving the cutting of
very gradually. Do not stretch or strengthen the return to training must be at a much fascia in the leg to release the compartments)
muscles while symptomatic. While there is slower rate than previously. A diet, hormone is the only effective long-term solution if
little scientific evidence that lower extremity and bone density evaluation is recommended a patient is to remain active. Rest, anti-
alignment anomalies (e.g. flat feet or to rule out underlying factors that may be inflammatories and stretching are ineffective
hyperpronation) cause MTSS, for a small predisposing the individual to stress fracture. treatments. Exercises that increase muscle
proportion of people, orthotics prevent bulk will compound the problem.
injury and/or reduce symptoms. CHRONIC COMPARTMENT
SYNDROME CONCLUSION
TIBIAL STRESS FRACTURE • W hat is it? A condition of leg muscle For most exercise-induced painful leg
• W hat is it? An incomplete crack or cracks in ischemia (lack of blood) induced by exercise. conditions, prevention is the most effective
the tibia following repetitive impact loading. It is relatively rare. form of management. The recurring
• How does it occur? May follow MTSS if • How does it occur? Normally, during preventive theme is gradual increases in
training is continued at, or higher than, exercise, an elevated demand for oxygen training intensity. Such gradation is necessary
the intensity at which periostitis occurred. induces increased flow of blood to the in order to avoid overloading the body’s
Stress fractures, however, are likely preceded muscles, causing them to swell about adaptive mechanisms.
by a greater degree of bone remodelling 20 percent. If the sheaths of connective
(bone resorption followed in due course tissue (fascia) surrounding the muscles are About the Author
by formation) than MTSS, with resultant unusually inelastic, this expansion is limited, Written for the American College of Sports Medicine by
Belinda R. Beck, Ph.D., FACSM.
temporary bone porosity and weakness. and the increase in blood flow is prevented. Suggested Citation: Beck BR. Exercise-Induced Leg Pain.
• Region most affected: As for MTSS. Less Muscles starved of oxygen produce cramping Indianapolis, IN: American College of Sports Medicine; 2016.
commonly, below the knee, medially. pain. Nerves and arteries passing through ACSM Sports Medicine Basics are official statements by the
• Signs and symptoms: Profound, localized the compartment will be impinged. American College of Sports Medicine concerning topics of interest
to the public at large. ACSM grants permission to reproduce this fact
pain during running and jumping. In • Region most affected: The anterior sheet if it is reproduced in its entirety without alteration. The text
severe cases, pain may occur when walking compartment. However, the deep posterior may be reproduced in another publication if it is used in its entirety
without alteration and the following statement is added: Reprinted
and nonweight bearing at night. Focal and peroneal compartments may also be with permission of the American College of Sports Medicine.
tenderness and swelling on palpation. A affected. The condition occurs in both legs Copyright ©2016 American College of Sports Medicine. Visit
triple-phase 99mTc bone scan may be ACSM online at www.acsm.org.
in 90 percent of cases.