How To Diagnose And Treat Exercise-Induced Leg Pain

Meagan M. Jennings, DPM, FACFAS

   Diagnostic imaging can include duplex ultrasonography, computed tomography (CT) with contrast, digital subtraction angiography and conventional arteriography, all of which one performs with dynamization of the limb. For a patient with popliteal artery entrapment syndrome, this allows visualization of popliteal artery occlusion when the knee is hyperextended and the foot is plantarflexed.

   Treatment typically requires consultation with a vascular surgeon and surgical intervention. In the early stages, surgical decompression of the popliteal artery can often alleviate symptoms. However, in the late stages, use of a saphenous vein bypass graft is appropriate.

Pertinent Pointers On Diagnosing And Treating MTSS And Tibial Stress Fractures

Medial tibial stress syndrome and tibial stress fracture can both be correlated with biomechanical and structural conditions such as hindfoot varus, excessive forefoot pronation, genu valgum, excessive femoral anteversion and external tibial torsion. The pathomechanics for MTSS typically involve two proposed theories: tibial bending and fascial traction.

   In regard to MTSS, Bouche and Johnson concluded in a cadaver study that fascial tension increased with increased strain on the posterior tibial, flexor digitorum longus and soleus tendons, possibly giving some merit to the fascial traction theory.9

   Both MTSS and stress fracture occur often in athletes partaking in high impact activities such as running or jumping sports. Both conditions are rare in adolescents under 15 years of age.

   One would make the diagnosis of MTSS via a clinical exam with patients experiencing diffuse tenderness to palpation along the posteromedial border of the mid- to distal one-third of the tibia. Trace to mild edema may be present as well.

   Stress fractures tend to have more focal pain on exam. When it comes to imaging, one should begin with radiographs, which are usually normal for MTSS but may show periosteal reaction for a stress fracture. Physicians can obtain a three-phase Tc-99 bone scan as well. This scan may demonstrate linear streaking for MTSS versus a “hot spot” and focal uptake that occur in a stress fracture. Magnetic resonance imaging (MRI), although more expensive, can be more specific and is also an option for differentiating MTSS from a stress fracture.

   Treatment for both conditions includes cessation of high impact activities until symptoms resolve and this can take up to 12 weeks. Patients should substitute non-impact activities such as biking, swimming and aqua jogging for running during the recovery period. Ice massage for 20 minutes twice daily and nonsteroidal anti-inflammatory (NSAID) use can decrease symptoms as well. Use of a compression leg sleeve or taping for MTSS can allow relief of symptoms during impact activity if it were necessary for one to compete or continue an activity.

   Upon the return to activity, it is important to evaluate the biomechanics of the patient and his or her shoe gear, and consider custom orthotics. Encourage cross training with low to no impact activities such as swimming and biking as well as a gradual return to a walk/jog program.

In Conclusion

In determining a patient’s etiology of exercise-induced leg pain, it is important for the clinician to take a thorough history and physical to uncover all potential etiologies. It is important to remember that certain medications such as statin drugs or drugs such as diuretics that cause electrolyte imbalance can lead to myofascial pain and cramping.

   Additionally, being aware of the patient’s diet as well as his or her family and social history can lend insight to diagnosis. Lower extremity specialists should be aware of the multiple pathologies that can cause exercise-induced leg pain. They should also be well versed in the diagnosis and treatment of these conditions, or ensure a proper referral when appropriate.

   Dr. Jennings is affiliated with the Department of Orthopedics and Podiatry at the Palo Alto Medical Foundation in Mountain View, Calif.

   Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.


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