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 refers to pain in the lower legs that can be from various causes but that typically is caused by running or vigorous walking.
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.
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.
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.
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.
An ankle sprain is an injury to the ligaments (the tough elastic tissue that connects bone to bone) in the ankle.
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:
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).
The severity of the sprain depends on how much the ligaments are stretched or torn.
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 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.
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).
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.
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.
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