Exercise related leg pain
● Exercise-related leg pain (ERLP)
encompasses several disorders
characterized by diffuse pain along the
tibia caused by exertional or overuse
activities.
● Pathologies progress from tendonitis ,
periostitis, stress fracture to full blown
fracture
Medial tibial stress syndrome
● Medial tibial stress syndrome (MTSS), a
common overuse syndrome, is a
periostitis or stress reaction
characterized by diffuse pain along the
posteromedial border of the tibia and
associated with the tendon of the soleus.
● Shin splints
● MTSS typically is exacerbated by
weight-bearing activities, such as
walking, running, jumping, or standing
for prolonged periods.
● Overpronation of the foot
● Suggestions of pain in MTSS include
the proximal tendon of the tibialis
posterior tendon, the proximal tendon of
the soleus, and the tibial periosteum.
● MTSS can be differentiated from stress
fracture through bone scan.
● It is important to emphasize that
abnormal pronation is a dynamic issue
that occurs during landing during
walking, running or jumping. Many
static malalignments, such as pes planus,
hypermobile first ray, excessive forefoot
varus, excessive rearfoot valgus,
excessive lateral tibial torsion, excessive
genu valgum, and excessive femoral
anteversion.
● Management of this patient is foot
orthotic devices.
● Self limiting
● Management includes pain meds and
trigger point mobilization
● Once symptoms reduced, strengthening
of dynamically control pronation (i.e.,
tibialis posterior tibialis anterior and
peroneus longus) and the soleus.
● Start controlled weight bearing exercises
Tibial stress fracture
● Stress fractures are a result of overuse
that result in failure of the bone along a
continuum of failed adaptation from
accelerated osteoclastic remodeling to a
complete fracture.
● Commonly in distal 3rd of tibia
● Commonly seen in female with Hx of
disordered eating, secondary
amenorrhea, and resultant osteopenia
(female athlete triad) are particularly at
risk
● Red Flags: night pain, focal pain, tender
area sensitive to US
● The treatment of uncomplicated stress
fractures involves modified rest with
non–weight bearing, pool running,
swimming, or cycling until the patient
can perform pain-free hopping.
Modified rest last at least 3 weeks from
the confirmation of the stress fracture,
and all symptoms must subside before a
 graduated return to activity program can
be initiated.
● As weight-bearing activity is gradually
increased, emphasis must
● be placed on​ pain-free ​activity
Tibial exertional compartment syndrome
● Chronic exertional compartment
syndrome (CECS) must be considered
as a cause of lower leg pain in athletes,
especially those in endurance sports.
The lower leg usually is divided into
four discrete compartments (anterior,
lateral, superficial posterior, and deep
posterior)
● CECS is characterized by severe
cramping, diffuse pain, and tightness in
one or more of the leg compartments.
The patient will report compartment
tightness that occurs during and/ or after
exercise, which is often more intense the
next day.
● A treadmill stress test with
measurement of intracompartmental
pressures may be necessary for a
definitive diagnosis of CECS because
this is considered the gold standard.
● Treatment of CECS may involve both
conservative and surgical measures.
● Fasciotomy is the definitive treatment,
but in some cases, the condition resolves
with activity modifications such as
reduction in training volume or
intensity. Other conservative treatment
involves icing, stretching, muscle
strengthening, proper footwear, and
orthotic intervention, when appropriate.
Recently evidence from a case series of
two runners suggests that modifications
in heel strike pattern may be successful
in reducing symptoms.
Fractures of tibia and fibula
● Fractures of the tibia may require
internal fixation for stabilization and
long periods of immobilization because
the tibia is the primary weight bearing
bone in the lower leg. Prolonged
immobilization can lead to severe disuse
atrophy of the entire lower extremity if
not properly managed during the
immobilization phase. It is crucial to
maintain strength and mobility of the
muscles surrounding the more proximal
knee and hip joints as well as the joints
of the foot. Some fractures of the fibula
may require internal fixation, but
immobilization time is shorter compared
with the time required for tibial
fractures.
Gastrocnemius strain
● Gastrocnemius strains, sometimes
referred to as “tennis leg,” are frequently
seen in explosive sports that require
quick movements in multiple directions.
● Sports such as tennis require the athlete
to bear weight on the forefoot (i.e., balls
of the feet) and make powerful
movements in different directions.
● The common mechanism for this injury
is forced dorsiflexion while the knee is
extended or forced knee extension while
the foot is dorsiflexed
 ● Common in medial gastrocnemius
● For acute strains, treatment should
follow the RICE protocol; weight
bearing to tolerance is allowed in the
first weeks after injury. A compression
wrap applied from the foot to a point
just distal to the knee can be used to
provide external pressure to the injured
limb.
● The patient will have difficulty with
push-off during gait, and bilateral heel
lifts may be temporarily helpful
Achilles tendinopathy (Sever’s disease)
● The Achilles tendon is the most
common site of tendon pathology (i.e.,
tendinopathy) in the lower leg, ankle,
and foot. Injuries can range from
peritendinitis (i.e., inflammation of the
peritenon sheath surrounding the
Achilles tendon), tendinosis (i.e.,
degeneration of the tendon without
inflammation), partial and complete
ruptures, and insertional lesions, such as
bursitis.
● The tendon itself has an area of relative
avascularity about 2 cm (1 inch) above
its insertion. This is the area where
partial tears with secondary nodule
formation and degenerative cysts are
seen in tendinosis
● Common symptoms of Achilles
tendinopathy are stiffness, pain with
elongation or stretching, pain under load
(e.g., going up onto the toes), and pain
with running. The clinical examination
may reveal signs of local tenderness,
crepitus, palpable nodules in the tendon
or peritenon, and limited dorsiflexion
ROM. Limited power at push off is
commonly noted as a result of pain and
subsequent disuse atrophy
● Tx: Arch Taping, CKC , Eccentric
strengthening, wobble board exercise,
carioca and side steps exercises
Peroneal tendinopathy
● Peroneal tendinopathy is a result of
overuse of either the peroneus longus or
peroneus brevis tendons
● Seen in conjunction with lateral ankle
sprains and may be the cause or the
result of lateral ankle instability.
● Isolated peroneal tendinopathies are
somewhat rare
● Peroneus brevis involvement is more
commonly associated with supination
overuse as it is stressed in the inverted
position of the foot and ankle. A slightly
different mechanism is usually
attributed to brevis, the peroneus longus
plantar flexes and everts the foot
running beneath the plantar surface of
the foot to attach to the first metatarsal.
● Tenderness to palpation distal and
posterior to the lateral malleolus is most
common in peroneal tendinopathy.
● Pain with resisted plantar flexion and
eversion
● Passive inversion and dorsiflexion may
be painful for the peroneus brevis and
likely the peroneus longus.
● Passive first metatarsal dorsiflexion also
may be painful if the peroneus longus is
involved
● Eccentric strengthening
Plantar Fasciitis
● Stress injury to the plantar fascia and
typically causes symptoms near its
calcaneal origin.
● The plantar fascia normally stabilizes
and locks the foot in supination before
push-off. The plantar fascia is put under
strain by the “windlass mechanism,”
 which occurs during push-off when the
metatarsophalangeal joints are
hyperextended.
● Stressed by hyperpronation of the foot,
as the medial longitudinal arch
collapses. The condition is found in both
rigid and hypermobile feet.
● Decreased flexibility in the
gastrocnemius–soleus especially if the
condition is seen in the cavus foot.
● A periosteal reaction at its origin can
result in hemorrhage and, ultimately, a
heel spur. In many cases, heel spurs are
asymptomatic, but if present, they are a
sign of stress overload to the plantar
fascia.
● Excessive pronation and the resulting
stretch and wringing of the plantar
fascia during the stance phase can lead
to straining of these tissues.
● If tight posterior muscles limit
dorsiflexion, they may force the rear
foot into pronation or the midfoot into
dorsiflexion about the oblique midtarsal
joint axis. These pathomechanics result
in excessive stress on and subsequent
injury to the plantar fascia.
● Tx includes local corticosteroid
injection, arch taping, low-dye taping,
and/ or off-the-shelf orthotics can help
hold the foot in a neutral position and
protect the plantar tissues from constant
irritation during the early stages of
rehabilitation.
● Gastrocnemius and soleus muscle
stretching is important
● Heel lifts, heel cups, modified arch
taping, massage of the plantar fascia,
joint play mobilizations, and assessment
for proper footwear all are important in
the management of plantar fasciitis.
● If morning stiffness persists, a night
splint to maintain dorsiflexion of the
plantar fascia may be useful with the
rare persistent case, surgical
consultation is required.
● Spring ligament is affected
Navicular fracture
● Rare but can be very difficult to
diagnose and treat
● Injuries include complete fractures,
stress fractures, and in skeletally
immature patients, traction apophysitis.
● Fractures and stress fractures of the
navicular are notorious for being
nonunion fractures.
● Prolonged immobilization (not modified
rest) and bone stimulators are often
needed to aid the healing of these
fractures. Once the fracture has healed,
rehabilitation should emphasize the
restoration of ankle and foot ROM,
strength, and endurance, as well as
normal gait mechanics.
Kohler’s disease
● Avascular necrosis of the navicular bone
that occurs in children, especially boys
● Rest is the most important treatment for
Kohler’s disease, although a long leg
cast sometimes is needed to accomplish
this in an active child. This condition
typically resolves on its own, with no
lasting effects.
Metatarsal fracture
● The most common fractures of the
metatarsals involve the second or third
metatarsal (march fracture) and the shaft
of the fifth metatarsal just proximal to
the styloid process (Jones fracture)
● Metatarsal stress fractures occur most
often in the second and third metatarsals
and are common in those who engage in
running and jumping
 ● Training errors, changes in exposure to
different surfaces, strength/ flexibility
dysfunction, poor shoes, and
biomechanical variants
● Second metatarsal is the most prone to
stress fracture because the base of the
second metatarsal extends proximally
into the distal row of tarsal bones and is
held rigid and stable by the bony
architecture and ligament support.
● Stress fractures heal well when treated
for 4 to 6 weeks with modified rest and
non–weight-bearing exercise (e.g.,
cycling, swimming, running in water),
which maintain the patient’s
cardiovascular fitness.
Metataesalgia
● Metatarsalgia is a general term for
forefoot pain in the area of the lesser
metatarsal heads. However, this
common term is nondescript and does
not identify the specific source of
pathology. Two common causes of
metatarsalgia are transverse metatarsal
arch sprains and Freiberg’s infarction.
Transverse Metatarsal arch sprain
● Transverse metatarsal arch sprains may
be caused by an acute or chronic
mechanism of injury.
● The plantar ligaments supporting the
arch are injured, allowing the adjacent
metatarsal heads to excessively plantar
flex or drop and can lead to clawing of
the toes. This can irritate metatarsal
heads and the subcutaneous tissues on
the plantar aspect of the foot.
● A metatarsal felt pad placed just over
the second to fourth metatarsal heads
can be used to support the injured
structures.
Freiberg’s infarction
● Freiberg’s infarction is a painful
avascular necrosis of the second
or, rarely, the third metatarsal
head
● It typically is seen in
adolescents or young adults,
who often are involved in
running and jumping activities.
● Early radiographs may be
normal, with later development
of flattening of the involved
metatarsal head. If the condition
is caught early, deformity of the
metatarsal head, which leads to
early degenerative changes, can
be prevented.
● Early treatment consists of
exercise modification to
eliminate excessive running and
jumping plus orthotic foot
support with a metatarsal pad or
bar to unload the involved
metatarsal head. A rocker bar on
the shoe may also be required. If
pain persists and deformity
develops with degenerative
osteophytes, surgical
consultation is appropriate.
First ray injuries
● Injuries to the first ray (big toe) are
particularly problematic because the
center of force distribution goes through
the first ray during the terminal parts of
stance and push off in the gait cycle.
Specific injuries include sesamoiditis,
hallux valgus, hallux rigidus, and turf
toe.
Sesamoiditis
● Involves trauma to the sesamoid bones
in the tendons of the flexor hallucis
 brevis at its attachments to the base of
the proximal phalanx of the hallux on
the plantar aspect of the foot. This
trauma can include a stress fracture,
contusion, osteonecrosis,
chondromalacia, or osteoarthritis of the
sesamoid bones as they slide over and
articulate with the head of the first
metatarsal.
● The patient reports localized tenderness
to the medial (tibial) or lateral (fibular)
sesamoid, with localized swelling and
pain on weight bearing that increases
when on the toes. The diagnosis
typically is confirmed with a bone scan.
● The sesamoid bones are embedded
within the tendon of the flexor hallucis
brevis. Sesamoiditis does not refer to the
direct inflammation of the bones
themselves but rather the soft tissue
surrounding the bones. Most individuals
with sesamoid pain are those with a
cavus foot.
● Medial sesamoid is most often involved,
radiographs is inconclusive
● Tenderness to palpation over the
involved sesamoid is most often present
and may also present with a thickening
or swelling of the tendinous sheath. The
patient will be painful upon weight
bearing, especially with the shoes off.
● Management of sesamoiditis is usually
handled with orthoses or shoe inserts
● A metatarsal pad under the first ray may
be enough to support the medial column.
● However, in more severe cases, a full
custom-molded orthotic device with
significant medial midfoot support may
be necessary
Hallux Valgus
● Condition that has a hereditary factor
and is often familial.
● It is usually seen in patients with
excessive foot pronation who use
narrow footwear
● Hallux valgus may occur with widening
of the forefoot on weight bearing,
resulting in increased laxity of the
ligaments of the forefoot, particularly of
the first and fifth metatarsal heads.
● Metatarsal angle increases with hallux
valgus from 1° to 2° to approximately
12°, resulting in increased valgus
deviation of the great toe toward the
second toe
● Treatment is directed at controlled foot
pronation using an orthotic and motion
control footwear with adequate forefoot
width. The callus can be trimmed, and
icing and other modalities (e.g.,
ultrasound) can be used to treat the
bursitis. If not treated adequately, hallux
valgus will continue to progress and
often is treated surgically if severe and
painful.
Hallux rigidus
● Hallux rigidus is a disabling condition
associated with decreased ROM at the
first metatarsophalangeal joint
accompanied by degenerative changes
in the joint.
● Hallux rigidus is most frequently the
result of repeated trauma, but it also can
be seen after joint immobilization for a
single traumatic episode or infection.
The condition progresses, with
increasing restriction of joint motion.
● Radiographic films confirm the
hypertrophic degenerative features, such
as joint space narrowing, often dorsal
osteophytes, transverse joint space
widening, and subchondral bone
sclerosis.
Turf toe
● “Turf toe” is a sprain of the first
metatarsophalangeal joint that typically
occurs when the great toe is forced into
hyperextension.
● It is often associated with sports played
on artificial turf when a player catches
the toe in a seam, but the condition also
is common in those in the performing
arts, such as ballet.
● Treatment is aimed at reducing the
inflammation, protection, and
restoration of normal ROM
● Mx is combined with taping of the big
toe to prevent hyperextension.
● If normal ROM cannot be achieved, an
orthotic with a rocker bar or a stiff-soled
shoe with a rocker bar may be used to
allow a pain-free gait
● When the individual returns to activity,
a properly fitted shoe with a stiffer sole
should be used. The shoe can be
combined with taping or a stiff insert to
prevent hyperextension at the
metatarsophalangeal joint.
● If an orthotic or shoe modification fails
to provide relief, surgical consultation is
needed. Cheilectomy is the usual
procedure because it improves ROM
without sacrificing joint stability.
●