Often dismissed as trivial, exertional leg pain (ELP) continues to be a difficult problem that plagues athletes, those who exercise, and the clinicians who attempt to manage it.
Roughly defined as any problem that limits or prevents an individual completing their desired exercise program, ELP encompasses muscle tears or strains, bone pathology (including stress fractures and periostitis), exertional compartment syndromes, and neural and/or vascular entrapment syndromes.
Rightly or wrongly, ‘shin pain’ is often deemed not as debilitating as the knee and ankle joints surrounding it; as a result, lay people and even medical practitioners often wave off shin pain as “shin splints”, leading to confusion and misdiagnosis. Many are then told to either rest or use anti-inflammatory medication –without even bothering to establish a diagnosis.
The reality is that exertional leg pain can be quite debilitating, affecting the ability to exercise, and in some cases, restricting even activities of daily living such as walking at a moderate pace. In rare instances, missed lower limb pathology can lead to limb or life-threatening conditions, such as a bone tumours, deep vein thrombosis, or popliteal artery entrapment syndrome.
As mentioned, exertional leg pain can present a number of differential diagnoses, and further confusing the issue is the fact that multiple causes can co-exist. Often one must treat one source of exertional leg pain and manage it as best as possible, before one can determine concurrent problems.
For example, debilitating medial tibial stress syndrome may mean that an athlete cannot run long or far enough to exhibit signs of a co-existing chronic exertional compartment syndrome (CECS). In this case it is best to optimize control of the medial shin pain with directed rehabilitation, followed by a graded return to running to identify whether the more classic crescendo-decrescendo pattern of CECS is present.
For recalcitrant exertional leg pain not responding to treatment the sports and exercise medicine physician is often best suited to examine and interpret particularly recalcitrant exertional leg pain. This involves taking a thorough history, examining the patient (often at rest and after exercise when symptoms have been provoked), and interpreting a number of investigations. Always the aim is to establish a specific anatomical cause for the pain and with a diagnosis (or diagnoses) embark on a directed and individualized treatment plan.
Chapters 35 and 36 in Clinical Sports Medicine provide a good starting point for the clinician interested in developing a better grasp of exertional leg pain.
Exertional leg pain is an area in dire need of further research and study as much of the current evidence is anecdotal. The Australasian College of Sports Physicians have established a working group with the aim of developing protocols for the work-up, investigation, and treatment of exertional leg pain.
Once evidence-based protocols for the work-up and diagnosis are developed and accepted maybe exertional leg pain will get some of the respect it deserves!
Dr Matthew Hislop is a Sports and Exercise Medicine Physician working at Brisbane Sports and Exercise Medicine Specialists in Brisbane. He has a special interest in exertional leg pain, and has published a number of papers on Chronic Exertional Compartment Syndrome.