Lower leg pain

Lower leg pain is a common complaint in athletes who have recently changed their footware or have increased the intensity of their training. The main diagnoses to be considered are stress fracture of the tibia, chronic compartment syndrome, medial tibial periostitis and tibialis anterior syndrome. The term ‘shin splints’ is unhelpful and should be avoided.

  Stress fracture of the tibia

Stress fractures are not uncommon in the tibia, particularly in long-distance runners. The patient initially complains of pain during exercise, then pain during arid after exercise, and finally pain at all times. On examination there may be little to find except that the tibia may he tender to percussion. Initially the X-ray may he normal but after some weeks a faint haze of callous may form locally over the site of the invisible fracture. This X-ray picture, if combined with a history of continuous pain, is also characteristic for osteosarcoma. Careful imaging with MRI or CT scan should be able to distinguish between these two diagnoses.

This condition can prove very difficult to manage. It may occur at a crucial phase in an athlete’s training programme and at some stage, preferably sooner rather than later, it is going to become clear that training for the next few months or indeed that season is over. This can be very difficult for an athlete to accept, but until it is the condition is unlikely to settle. As the fracture is incomplete it should not require any extra protection, and a modification of activity is usually all that is required for healing.

Chronic compartment syndrome

The anterior and deep posterior compartment is most commonly involved. Physicial examination is generally unhelpful and a diagnosis is made from the history and intracompart­mental pressure monitoring whilst the athlete exercises. Subcutaneous fasciotomies of the affected compartment provides good relief of symptoms.

Tibialis anterior syndrome

Acute inflammation in the tendon sheath of the tibialis anterior muscle often arises from over-use of the ankle joint, especially running and jumping on hard surfaces. Tenderness is localised to the tibialis anterior tendon with pain on resisted dorsiflexion of the ankle. Increased temperature, swelling and crepitus may be palpated over the tendon sheath. Resolution is usually swift with a short period of nonweight-bearing and rest.

Medial tibial periostitis

The attachment of the investing muscle fascia into the periosteum of the posteromedial order of the tibia may become inflamed. The pain is often poorly localised by the athlete but tenderness is well localised over the distal medial margin of the tibia, particularly over the lower half of the bone. Resisted plantar flexion aggravates the pain and radiographs should be performed to exclude a stress fracture.