Member Case Study: Lower Leg Pain

author : AMSSM

comments : 1

After the Marine Corps Marathon, I started developing left lower/lateral leg pain late in my marathon training and pushed through it.

Member Question

I'm having a problem with my left lower leg. I completed my first half Iron distance race in June without too much trouble and no injuries. I trained for and completed the Marine Corps Marathon in late October. I started developing left lower/lateral leg pain late in my marathon training and (stupidly) pushed through it and finished my (first) marathon. The pain is located along the lateral aspect of my mid left lower leg. It's actually, specifically, located along the posterior border of my fibula and spans approximately the upper half of of my fibula.

Most of the time it feels "tight" almost like a muscle strain or pull. However, during the race and with running since then it gradually worsens to become very intense, like a stabbing pain. The pain is around and "under" my fibula if I had to try and locate it. The pain makes me stop running. I cannot run through it. I used to run trails and running on uneven pavement during the race really, really made it worse. It's tender to touch if you push fairly hard right along the posterior border of my fibula just below the head of the fibula. I've had an X-ray that didn't show any stress fracture.

Since the race I have not run much. I've tried a couple one minute intervals on the treadmill after walking and it still feels 'tight.' It's been three months and I've been pretty good at resting it. Biking doesn't seem to bother it if it's quieted down. Right after the marathon I couldn't even bike without it hurting. This has been a perplexing problem for the 2-3 sports doctors that I have seen. I would certainly appreciate any help you could offer.

Answer by Trish Palmer, MD

Member AMSSM

Lower leg pain in a runner has many causes.  These can include simple things like a muscle imbalance or poor biomechanics, to more complicated problems including:  stress fracture, muscle tear, popliteal artery entrapment, and exertional compartment syndrome.

Muscle imbalance and biomechanical issues may be evident on examination, but sometimes require a video gait analysis to diagnose.  Treatment is usually through physical therapy, sometimes with specific orthotics, or change in running shoe.

Stress fracture often does not show up on x-ray.  Runners can develop a stress reaction or stress fracture of the fibula, which appears to be near the area of pain for you.  Other forms of imaging may be helpful to establish this diagnosis.  Treatment consists of only performing pain-free activity (not “running through it”).  Then most people can GRADUALLY return to running activity.  I usually also have the runner assessed for their biomechanics to try to prevent this from happening again.  Nutrition is also part of the treatment and prevention for a stress fracture.

A tear of the lateral head of the gastrocnemius could be the source of pain in the area in question.  This may be evident on examination, sometimes on MRI.  This problem usually responds to pain-free activity restriction while the muscle heals.  Specific physical therapy modalities and exercises may promote faster return to running, but it may take several weeks, sometimes months for complete healing.

Popliteal artery entrapment is an uncommon reason for exercise-induced calf pain, yet it does happen.  The problem is a blood vessel that gets squeezed during exercise, thereby causing symptoms.  There are several ways to diagnose this problem, which frequently requires surgery to treat.

Exertional compartment syndrome is also a cause of leg pain.  This happens when a compartment (for you the lateral) becomes more engorged with blood than previous, for reasons we do not always understand.  Diagnosis can be difficult, unless symptoms are reproducible and you have the equipment.  I often have the athlete run to the point of symptoms (usually on a treadmill near my office), then immediately do the testing when symptoms are present. Treatment starts with pain-free activity, with extremely slow progression (only if pain-free) back to activity.  Sometimes this problem requires surgical release of the compartment. 

There are also several other causes.  I think the key is getting to a point of pain-free activity (which may mean a complete break from running) while possibly additional evaluation is contemplated.  Another possible issue is something I see quite often-athletes will go for one visit to several different doctors hoping for an easy answer rather than seeing one sports medicine physician repeatedly to go through the process of eliminating certain diagnoses and trying certain treatments and reassessing.  Often there is not an immediate easy answer in medicine, but every physician has a plan B and C and D, if plan A was not helpful.

Trish Palmer, MD

Rating

Click on star to vote

19272 Total Views  |  41 Views last 30 days  |  10 Views last 7 days

date: April 22, 2009