Shin splints, ankle sprains, Achilles tendinitis, rupture of the Achilles tendon, and stress fractures of the foot are common injuries to the lower leg.

Shin Splints

Shin splints refers to pain in the lower legs that can be from various causes but that typically is caused by running or vigorous walking.

• Pain can occur in the front or back of the leg below the knee.
• Ice, analgesics, rest, and stretching exercises can help.

Repetitive impact forces in the legs during running or vigorous walking (such as hiking) can overload the muscles and tendons in the legs and cause shin pain. Excessive outward rotation of the foot on the leg (supination) may also cause or exacerbate shin splints.

Symptoms and Diagnosis

Pain can be in the front outer aspect of the leg or the back inner part of the leg. Shin splint pain typically begins at the start of activity but then lessens as activity continues. At first, the pain is felt only immediately after the heel strikes the ground during running or walking. If the person continues to run, the pain occurs throughout each step, eventually becoming constant. Pain usually disappears with rest.

Doctors diagnose shin splints based on symptoms and the results of a physical examination.

Treatment

Running must be stopped until it causes no pain. Applying ice and using nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain. Conditioning can be maintained with alternative exercises, such as swimming.

Once shin pain starts to subside, exercises to stretch and strengthen the muscles in the legs, such as the bucket-handle exercise, can be done. The exercises are important to avoid recurrence. Wearing supportive shoes with rigid heel counters and arch supports and avoiding constant running on banked or hard surfaces may help prevent shin splints from recurring.

Shin Splints Shin splints may develop in the muscles in the front and outer parts of the shin (anterolateral shin splints) or in the muscles in the back and inner parts (posteromedial shin splints). Pain is felt in different areas, depending on which muscles are affected.

Achilles Tendinitis

Achilles tendinitis is inflammation of the Achilles tendon, the tough band extending from the calf muscles to the heel.

Achilles tendinitis is very common in runners. During running, the calf muscles help with the lift-off phase of gait (raising up on the toes from the foot being flat on the ground). Repetitive forces from running combined with insufficient recovery time from exercise can inflame the Achilles tendon.

Pain in the lower calf and back of the heel is usually the first symptom of tendinitis. Doctors diagnose Achilles tendinitis based on the symptoms and results of an examination.

Strengthening the Shin Muscles
Bucket-handle exercise Wrap a towel around the handle of an empty water bucket. Sit on a table or other surface high enough to prevent the feet from touching the floor. Place the bucket handle over the front part of one shoe. Slowly raise and lower the bucket by bending the foot up and down. Do not move the lower leg, just lift with the foot. Repeat 10 times, then rest for a few seconds. Do 2 more sets of 10. To increase resistance, add water to the bucket—but not so much that the exercise is painful. Toe raises Stand up. Slowly rise up on the toes, then slowly lower the heels to the floor. Repeat 10 times, then rest for 1 minute. Do 2 more sets of 10. When this exercise becomes easy, do it while holding progressively heavier weights. Outward rolls Stand up. Slowly roll the ankle out so that the inner part of the sole is raised off the floor. Slowly lower the sole back to the floor. Do 3 sets of 10.

Ice and NSAIDs relieve pain and inflammation. Refraining from running and from pedaling a bicycle as long as the pain persists is important. Exercises to stretch and strengthen the hamstring muscles can be started as soon as they can be done without pain. Other measures depend on what conditions are causing tendinitis. Measures may include wearing shoes with flexible soles or placing heel lifts in running shoes to reduce tension on the tendon and stabilize the heel. People should return to running gradually, stretch the tendon before running, and, at the beginning, apply ice after running.

Achilles tendon rupture

Athletic activity can cause a complete tear of the Achilles tendon, the tough band extending from the calf muscles to the heel.

Complete tears of the Achilles tendon are more common in middle-aged than in young athletes. It is particularly common among people who begin intense activity without sufficient conditioning, stretching, or both. Often rupture occurs during sudden cutting movements.

Symptoms are severe calf pain and inability to walk normally on the leg. Doctors can usually make the diagnosis based on an examination. Sometimes magnetic resonance imaging (MRI) is required. Surgical repair is usually recommended.

Ankle Sprain

An ankle sprain is an injury to the ligaments (the tough elastic tissue that connects bone to bone) in the ankle.

• Usually, ankle sprains occur when people walk or run on uneven ground and the foot rolls inward, causing the ligaments of the ankle to stretch beyond their limits.
• Usually, the ankle is swollen, and walking is painful.
• Diagnosis is by examination and sometimes x-rays.
• Treatment includes rest, ice, compression with a bandage, and elevation of the leg (RICE) and often protection of the ankle with a brace or removable boot.

There are 25,000 ankle sprains reported a day in the United States. Sprains usually occur when the foot rolls inward, causing the sole of the foot to face the other foot. This type of movement is called inversion of the foot or sometimes rolling out of the ankle. This injury (sometimes called an inversion sprain) usually damages the ligaments on the outside of the ankle. It occurs when people walk on uneven ground, especially when they step on a rock or off the edge of a curb. The following tend to cause the ankle to roll outward and thus increase the risk of a sprain:

• Loose ligaments in the ankle from prior sprains
• Weakness or nerve damage in the leg muscles
• Certain types of shoes, such as spiked heels

Other ankle ligaments can be injured, and injuries are likely to be more severe than with a common inversion sprain. For example, the large, strong ligament on the inside of the ankle may be sprained, or the ligament that holds the two leg bones together above the ankle may be sprained (called a high ankle sprain).

Spraining an Ankle An ankle sprain may occur when the ankle rolls outward and the foot rolls inward (inversion), tearing the ligament along the outside of the ankle.

Symptoms

The severity of the sprain depends on how much the ligaments are stretched or torn.

• Mild: The ligaments may stretch, but they do not actually tear, except microscopically. The ankle usually does not hurt or swell very much, but a mild sprain increases the risk of a repeat injury. Recovery can take hours to days.
• Moderate: A ligament tears partially. Obvious swelling and bruising are common, and walking is usually painful and difficult. Healing takes days to weeks. Moderate and severe sprains can impair proprioception (the ability of the brain to sense where the foot and ankle are without seeing them).
• Severe: A ligament tears completely, causing severe swelling and bruising. The ankle is unstable and unable to bear weight. Healing usually takes 6 to 8 weeks. When athletes return to unrestricted activity before healing is complete, they risk future injuries and difficulty walking on uneven surfaces. Also, in severe ankle sprains, damage to the smooth cartilaginous surfaces of the bones of the ankle joint (articular cartilage) can result in long-term pain, swelling, and occasionally catching (becoming stuck), giving way (involuntary buckling of the joint), and possibly arthritis of the ankle at an young age.

Diagnosis

Physical examination of the ankle can give clues to the extent of ligament damage. X-rays are often taken to determine whether a bone is broken, but they do not enable doctors to evaluate the ligaments. X-rays taken with the ankle in positions that stretch the ligaments (stress x-rays) may indicate the extent of ligament damage, as can MRI, but these tests are not necessary in most ankle sprains. Arthroscopy (use of a fiberoptic viewing tube to view inside the joint) sometimes is done if doctors suspect that the smooth surface of the ends of the bones in the ankle have been damaged, as when a sprain is very severe or fails to heal.

Treatment

Treatment consists of NSAIDs for pain control and RICE (rest, ice, compression, and elevation). Other treatments depend on how severe the sprain is.

Usually, mild sprains are treated by applying ice packs to the area, wrapping the ankle and foot with an elastic bandage or tape, elevating the ankle, and, as the sprain heals, gradually increasing the amount of walking and exercise. For many people with mild sprains, walking and exercise can begin immediately as long as supportive footwear is worn.

For moderate sprains, a removable cast boot or ankle brace can be used initially. Physical therapy is important to help minimize swelling, maintain range of motion, maintain proprioception, and gradually increase the strength of the muscles around the ankle to prevent future ankle instability and recurrent sprains.

Severe sprains require immediate medical attention. Without treatment, they may result in long-term ankle instability and pain. The ankle should be immobilized in a brace or removable cast boot. Usually, people need crutches and are referred to a specialist. Whether surgery should be done is controversial. Most experts believe that surgically reconstructing torn ligaments is no better than treatment without surgery. Physical therapy to restore movement, strengthen muscles, and improve balance is necessary before people resume strenuous activity and can hasten recovery.

Stress Fractures of the Foot

Stress fractures are small, incomplete fractures (breaks) in bones that result from repeated stress rather than a distinct injury.

• Pain occurs with weight-bearing and worsens gradually.
• X-rays or a bone scan is done.
• The fractured part should not bear weight for at least 6 to 12 weeks.

Stress fractures develop when repetitive weight-bearing exceeds the ability of the supporting muscles and tendons to absorb the stress and cushion the bones. Stress fractures can involve the thigh bone, pelvis, or shin. More than half of all stress fractures involve the lower leg, most often the bones of the mid foot (metatarsals).

Stress fractures do not result from a distinct injury (for example, a fall or a blow) but occur after repeated stress and overuse. Stress fractures of the metatarsal bones (march fractures) usually occur in runners who too quickly change the intensity or length of work outs and in poorly conditioned people who walk long distances carrying a load (for example, newly recruited soldiers). Other risk factors include a high foot arch, shoes with inadequate shock-absorbing qualities, and thinning bones (osteoporosis).

Women and girls who exercise strenuously and do not eat an adequate diet (for example, some long distance runners and some athletes in sports that emphasize appearance) may be at risk of stress fractures. They may stop having menstrual periods (amenorrhea) and develop osteoporosis. This condition is known as the female athlete triad (amenorrhea, disordered eating habits, and osteoporosis).

Did You Know... Stress fractures of the bones of the foot are sometimes called march fractures because they commonly occur among newly recruited soldiers who have recently started marching long distances.

Symptoms

With metatarsal stress fractures, forefoot pain most often occurs after a long or intense workout, and then disappears shortly after stopping exercise. With subsequent exercise, onset of pain is earlier and may become so severe that it prevents exercise and persists even when not bearing weight.

Diagnosis

Standard x-rays are usually done but may be normal until about 2 to 3 weeks after the injury, when x-rays show that the bone is healing from the fracture. Earlier diagnosis is often possible by doing a bone scan. Women who have stress fractures should talk with their doctors about whether they should be tested for osteoporosis.

What Is a Stress Fracture? Stress fractures are small cracks in a bone caused by repetitive impact. They commonly occur in the bones of the midfoot—the metatarsals.

Treatment

Treatment includes reduction of weight-bearing on the involved foot. For a while, the person uses crutches and a wooden shoe or other commercially available supportive shoe or boot. Casts are sometimes needed. Healing can take up to 12 weeks. As with other injuries, people can maintain aerobic fitness by doing non-weight–bearing exercises (for example, swimming) until recovery is complete.

Last full review/revision February 2009 by Paul L. Liebert, MD