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The Lower Leg

If you are a runner or jogger and your shins hurt, check your feet. They are almost always the culprit behind shin pain and the key to recovery.

      Practically all of the pains that occur on the inner side of the shin bone (tibia) are due to improper foot strike, the way the foot hits the ground when you walk or run. These are overuse injuries, and the symptoms depend on the amount of stress you place on your legs and the problems you have with your foot strike. A sedentary person with a severe foot abnormality may have no leg pain, whereas a marathon runner with a mild foot abnormality may suffer severe shin pain.

      Pronation is the inward roll of the foot as it hits the ground. Two different foot problems cause excessive pronation. A person with a pronating foot has an overly mobile foot and ankle and loose ligaments. The foot rolls to the inside when weight is applied to it, as during walking or running. People with pronating feet may say they are flat-footed, and they may be, but often the arch of the foot appears to be rolled down because the ankle collapses inward. The feet and ankles naturally tip inward like those of a beginning ice skater.

      The other problem is Morton's foot, which is characterized by the second toe being longer than the big toe. If you have Morton's foot, your foot will roll to the inside when you come up on your toes to push off for the next step. (See Chapter 14 for more about specific foot problems.)

      Excessive pronation can lead to three lower leg injuries: shin splints, tibial stress syndrome, and tibial stress fracture.


"Shin splints" is a catch-all term used by coaches and runners for any pain on the inner side of the shin. A true shin splint injury is quite rare.

      What people call shin splints are actually pains in the muscles near the shin bone. They can be caused by running or jumping on hard surfaces or simple overuse. They usually occur in people unaccustomed to training, although they can also plague experienced athletes who switch to lighter shoes, harder surfaces, or more concentrated speed work.

      The pain is felt on the inner side of the middle third of the shin bone, which is where the muscle responsible for raising the arch of the foot attaches. When the arch collapses with each foot strike, it pulls on the tendon that comes from this muscle.

      The arch collapses to absorb the shock of the foot hitting the ground. As you come up on your toes for the next stride, the muscle attached to the arch fires and pulls the arch back up to ready it for the next impact. This muscle responds totally to the stretch of the tendon as the arch flattens.

      In the pronating foot, the arch stays down because the foot is rolled to the inside. Consequently, the muscle starts to fire while there is still weight on the foot, and it is unable to bring the arch up. Because of its multiple firings during each foot strike and its pull against great weight, the arch muscle tears some of its fibers loose from the shin bone. This causes small areas of bleeding around the lining of the bone and pain.

      The key element of treatment is an arch support to prevent excessive pronation and pull on the tendon. This usually solves the problem almost immediately. Many athletes do well with a simple commercial arch support. Those who have a more serious problem may need an orthotic device custom-made by a sports podiatrist.


Most runners with shin pain have tibial stress syndrome. Excessive pronation causes the shin bone to rotate inward with each step while the upper part of the leg remains almost fixed. This abnormal twist of the bone, coupled with the fact that you come down with two to four times your body weight on your leg when you run, puts stress on the shin bone and causes irritation and pain.

      Again, treatment is an arch support or orthotic device, depending on the degree of foot disability. This will support the foot and stop the rotation of the shin bone. As soon as the rotation stops, the soreness will begin to disappear, and you should be pain-free in two to three weeks.


If you overstress any substance repeatedly, it will become fatigued and crack. In the case of the leg, if the twisting of the tibia is severe and is repeated enough times, the bone will crack.

      Your body can compensate for this stress to some extent. X-ray studies of the shin bone show that the bone thickens in an attempt to strengthen itself. But if you continue to run and the bone fails to strengthen itself sufficiently, it can develop a minute, often microscopic, crack, or stress fracture.

      The problem with identifying a stress fracture is that the crack is so small that it typically cannot be seen on an x-ray until it begins to heal itself a few weeks later. If your leg x-ray is negative and you still feel shin pain, then you should have a bone scan. This is a simple, safe x-ray procedure that will reveal a stress fracture within 24 to 48 hours of injury.

      You should suspect a stress fracture if the pain level of bone stress syndrome suddenly increases. Also, if you previously felt pain only while running and you now feel it while walking, you should suspect a stress fracture.

      A tibial stress fracture requires rest. You cannot run through it; it will only get worse, and the crack in the bone will get larger. If the pain becomes severe, you may need crutches to walk. Otherwise, a break from running for six to eight weeks should be enough. You can cycle or swim for exercise, if this causes you no pain.

      As the fracture heals, treat the foot strike problem with one of the support devices mentioned earlier. If you don't correct your foot strike, you will likely fracture the bone again.

      For many years, shin splints and bone stress syndrome were treated with aspirin, ice, and wrapping of the calf muscle. I have found that propping up the foot is much more successful in correcting the excessive pronation. Many patients respond as well to commercial arch supports costing $15 to $40 as they do to orthotic devices that cost $200 to $300. Only if your foot deformity is severe or if pronation occurs mostly as you rise up on your toes will you need an orthotic.


Another type of pain occurs on the outer part of the lower leg and is due to stress on the small bone on the outside of the leg (fibula). This, however, is due to pounding and shock transmission up the outside of the leg rather than twisting.

      This type of pain occurs mostly among people with a supinating foot, which is a foot that rolls to the outside because the arch is too tight. This is a high-arched, rigid foot that will not collapse on impact. Look at your shoes and see if they are badly turned over to the outside. If they are, you are landing on the outside of your foot when you run. Since the arch of a supinated foot does not collapse to sustain the shock of the foot strike, the shock is transmitted up the outside of the lower leg and can result in bone pain and a possible stress fracture of the fibula.

      Treating this condition is much more difficult. You can prop up a loose arch, but you cannot make a tight arch collapse. The best treatment is to provide maximum padding for shock absorption at the outer side of the foot. An air-sole shoe or a very soft-soled shoe is not the answer because the outside of the sole soon collapses, increasing supination. If the padding is not effective, you may need an orthotic device to protect the foot.

      Fibula pain is less debilitating because the fibula is not a true weight-bearing bone. The pain should disappear in two to three weeks with proper padding under the foot.


The lower leg is unique in that the various muscles are contained in thick, fibrous tubes called compartments. The design of these compartments doesn't allow them to expand very much, so overdeveloped muscles will be somewhat compressed within the compartments.

      When you exercise the lower leg, the muscles become engorged with blood, and the pressure on the veins doesn't allow the blood to leave the muscle. Blood continues to enter the muscle from the arteries, where the pressure is higher than that inside the compartment. Blood continues to fill the compartment because it has no way to escape. This builds up until blood from the arteries can no longer get into the muscle. Without the oxygen carried through the arteries, the muscles can become damaged. Eventually, the muscle fibers die if the condition is not corrected.

      The pressure inside the compartment causes pain in the muscles in the outer front part of the shin. This area swells up and becomes very sensitive to any pressure.

      Treatment for compartment syndrome is to elevate the leg and ice it for several hours. The swelling should go down, and your leg will be less tender to the touch. If it does not respond within the first few hours, you must see a doctor. This is a surgical emergency. If the compartment is not opened up to relieve the pressure within, the muscles will die and you will have total, permanent loss of function of these leg muscles.

      Compartment surgery is also done in athletes who have recurrent, milder episodes. A good example is long-distance runner Mary Decker-Slaney, who had both legs treated surgically at age 15 because of recurrent problems with compartment syndrome.

      This is probably the most dangerous of all overuse injuries that I see. Luckily, it is quite rare.


Muscle pulls and tears commonly occur in the major muscles of the calf, the gastronemius and the soleus. These muscles make up the large bulge in the back of the lower leg and are responsible for lifting the heel and driving you forward as you run.

      Pulls and tears represent different degrees of the same injury as muscles are suddenly over-stretched beyond their limits. The degree of overstretching determines whether the muscle is pulled or actually torn.

      Treatment depends on the severity of the injury. You should rest for a few days to begin with and then begin a gentle, gradual stretching program. Calf stretches are best done with the Wall Push-up. Once the muscle is adequately restretched, it should be restrengthened. Toe Raises are the easiest way to do this.

      Do the Wall Push-up one leg at a time. If you stretch both legs at the same time and one calf is tighter than the other, which is likely if you have a pulled muscle, you are limiting the stretch in the good leg to what you can do with the bad leg.

      As always, adequately stretching the muscle is also the best way to prevent a pull or tear.


Calf cramps are dangerous because the sudden muscle pain can be so severe that a runner falls and risks other injury. No one has pinpointed the exact cause of muscle cramps. A number of factors may be at work, including dehydration, electrolyte imbalance in the blood, physical conditioning, and improper diet.

      Calf cramps usually occur after periods of repeated heavy exercise. I see plenty of muscle cramps during the first two weeks of football practice. Some of the players sweat profusely or are on low-salt diets, and the cramping may be related to these factors. Or it could just be a matter of getting the calf muscle accustomed to working hard again. I tell the players to drink more water before, during, and after practice, and this generally limits the cramping.

      Many people assume that a nutritional deficiency is the main cause of muscle cramps, but that's not the case. Over-exercise, fatigue, poor conditioning, and water loss should first be eliminated as causes before you check for any nutritional deficiencies.

      The calf muscle often twitches uncontrollably, which is a signal that it may go into spasm. When the muscle does cramp, stretch it out gently by doing Wall Push-ups. Then massage the muscle with your thumbs and forefingers from the top down toward your feet until the pain passes.


The Achilles tendon, the largest tendon in the body, connects the gastrocnemius and soleus muscles to the heel and transfers the force of their contractions to lift the heel.

      Achilles tendinitis is an inflammation of the tendon and is a prime symptom of an overuse injury. The most common cause is excessive pronation of the ankle and foot, which cause the Achilles tendon to pull off-center. This condition may also be due to over-stress from frequent jumping.

      The treatment for Achilles tendinitis is to rest until it feels better and to ice the tendon several times a day during this time. You can use anti-inflammatory agents to relieve swelling and pain. Stretch the tendon as well with Wall Push-ups or Heel Drops. Heel Drops can be done from a stair, a telephone book, or a 2 × 4 board. Or you can lean forward on an inclined plane.

      An arch support or orthotic device may help correct the pronation that caused the tendinitis. Whether you need an arch support or an orthotic depends on the severity and complexity of your foot disability, not on the severity of your tendinitis. A severely pronating foot with lax ligaments will probably respond well to an arch support. A foot that pronates less but has a variety of other problems may not benefit as much from a simple arch. I suggest that everyone try an arch first and, if that doesn't work, then go on to an orthotic.


The classic case of a ruptured Achilles tendon is a person stepping or lunging and then feeling a snap at the back of the calf. Athletes often report that it felt as if someone had kicked them in the back of the heel or had thrown a rock and hit them in the heel. The snap of the tendon may sound like a bone breaking.

      A complete tear of the Achilles tendon is thought to be due to an accumulation of frequent, small tears or inflammations that have weakened the tendon. Scar tissue may build up around the tendon, and swelling may be apparent above the heel. Once rupture occurs, you can often feel a hole between the tendon's severed ends.

      One sign of an Achilles rupture is the inability to stand on your toes. However, this test is not completely reliable. Also, when you walk, your foot may turn out to the side.

      A ruptured Achilles tendon can be confused with a partial rupture because it may cause little pain at first. In fact, an Achilles rupture is quite often misdiagnosed. In one survey of European primary care doctors, less than half of them made the correct diagnosis. Most of these doctors diagnosed the injury as a sprained ankle. Thus, the initial minimal pain can lead both doctors and patients to regard this very serious injury as trivial.

      The only foolproof way to know if you have ruptured this tendon is to lie on your stomach with your foot off the end of a bed, toes pointing down, and have someone squeeze your calf. The front of the foot normally will move down. If there is no flex in the foot, then the tendon is torn. You can also compare the two legs. Squeeze the uninjured leg first to observe the flexing movement, and then squeeze the injured leg to see whether it moves.

      The best treatment for an athlete is surgical repair. (There is a method used for the elderly in which the tendon is placed in a cast, but this is not adequate for an athlete.) Ideally, you should have the operation within two weeks of the injury. You will be in a cast for six to eight weeks. For the first few weeks the cast will extend above the knee, and then it will be reduced to below the knee.

      After eight weeks you can start range-of-motion and stretching exercises. These will be difficult and should always be done with a physical therapist. It may be six months or more until you can return to athletic activity. Coming back from a ruptured Achilles tendon is one of the most difficult recoveries for an athlete.


A small tendon, the popliteus tendon, runs parallel to the Achilles tendon on the inside of the leg. It probably no longer has any function, and there is some argument over whether everyone has this tendon. But if you have it and you over-stress it suddenly, it can snap.

      A popliteus rupture usually is seen in a tennis player and occurs as he or she makes the first, hard step toward the nethence the name "tennis leg." It is also referred to as a disease of the aging athlete because it becomes more common with advancing age. Young athletes almost never rupture the popliteus tendon.

      The symptoms of a popliteus rupture are similar to those of an Achilles rupture. The victim may complain of being hit in the back of the calf with a tennis ball, and the blow can feel as severe as when the Achilles tendon snaps. You also may not be able to stand on your toes and may have a similar gait as someone with an Achilles tendon rupture. The base of the bulging muscle on the inner side of the calf will be quite tender, and you may see a small black and blue spot there.

      The treatment is to ice the calf intermittently for the first few days and to rest it. You may need to walk with a cane or crutches during this time. A shoe with an elevated heel also helps to prevent stress. As soon as you can tolerate it, start a gentle stretching program. As the pain diminishes, you can increase your intensity until you attain full flexibility.

      Normally, the tendon will heal with this routine in 10 to 21 days. However, I tell my patients not to go back to athletics until they can stretch the affected side without pain as far as they can stretch the good side. If you go back too soon, you are likely to rupture the tendon again.

      As usual, the best prevention is to warm up and stretch properly. This injury is most prevalent among tennis players probably because they are notoriously bad at stretching. This injury should be examined by a physician to differentiate it from an Achilles rupture.


Giants offensive lineman John (Jumbo) Elliott missed a major part of the 1990 season because of a fibula fracture. He was out of action longer than most people who suffer this injury because, as he weighs in at 300-plus pounds, every bone in his body is weight-bearing. In his first game back, against Buffalo, Jumbo gave up a sack for a safety to All-Pro defensive lineman Bruce Smith. But he played well against him for the rest of the game. In the locker room after the game, as he was icing his leg, he told me that his leg had been sore and he couldn't move the way he usually did. I asked him how he had handled Smith so well. This behemoth of a man looked at me and coyly said, "Cunning, sheer cunning."

      Breaking either the tibia or fibula is a traumatic injury that requires medical treatment. A fracture of the tibia is serious because this bone heals slowly and sometimes poorly because of the sparse blood supply in some areas of the bone. Commonly seen among skiers, this fracture is called a boot-top fracture since the leg breaks right at the top of the rigid ski boot. Before the advent of rigid boots, skiers used to fracture their ankles. Now their ankles are protected, so they fracture the tibia.

      A fracture of the fibula is less serious because the fibula is not a true weight-bearing bone. Normally, an athlete can return to activity within four or five weeks of a fibula fracture with padding to protect the leg from further damage.

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