Leg pain

Calf tears

Calf tears of one sort or another are really common in all sports, but particularly sprinting sports and activities involving a rapid change of direction (football, rugby and racquet sports). They are common across all age groups but can be a bit more problematic in older athletes. The group I see them in most are the people who used to be really sporty as youngsters, then had several years off (perhaps because of family or work), then returned to sport. 

The calf is actually made up of a number of important muscles in two main groups, the gastrocnemius and the soleus, and it’s possible to tear either or both, but treatment is not too different between the two.

There is usually a fairly sudden dramatic tearing sensation during sports which will stop you in your tracks. Often the calf will be swollen and you may see some bruising developing over the following days. It’s painful to limp around on the leg. 

These injuries normally respond well to rest, ice, elevation and compression as well as anti-inflammatory tablets, and will usually settle down of their own accord. At the more severe end of the spectrum, they sometimes need a boot and crutches for a period of time and it is important to consider whether you are at risk of getting a blood clot while you are not using the leg as normal. 

When I see people with a calf tear, I usually arrange either an ultrasound scan or an MRI scan depending on what I find after examining them. The benefit of this is it allows me to determine how serious it is, what physiotherapy is required and how long somebody needs to stay off sport. The right treatment early on is really important or it can become a problem that keeps coming back again and again. 

Shin pain

I see quite a lot of people with shin pain coming from far and wide to see me and I have run a regional service for this down in Dorset.

There are three common causes of shin pain in sports people: stress fractures, tibial periostitis (also called MTSS) and compartment syndrome. Sometimes people refer to these as shin splints but this is a coverall term which is not really very scientific!

Stress fractures

Stress fractures are a common cause of shin pain in sports people, especially runners. It usually starts with pain after sport, then often with pain at night, eventually, there can be pain with sport.

The shin bone or tibia is an incredibly strong bone, but despite this, it can still fracture from the repetitive impact of running. I tend to see tibial stress fractures when people are increasing their weekly amount of sport rapidly and the body can’t strengthen up quickly enough to compensate. I see a few of these every marathon season and I see them in military recruits as well as ordinary day to day people.  

Sometimes the problem can have been brought on because of training errors, and sometimes there can be factors in the shape of your body (biomechanical factors) that make some people more likely to have stress fractures than others. Weight can also be an issue, so can bone health, diet and hormones.

Tibial stress fractures can be serious and there are plenty of videos on the internet of people’s legs literally breaking during marathons when they have ignored the pain and tried to carry on. This is an important reason why you should take shin pain associated with sports seriously. If I can identify a stress fracture before it completely snaps then the treatment is fairly straight forward, but once it has snapped major surgery may be the only option. 

By listening to your story about your shin pain I can usually tell whether this is a possibility. A careful clinical examination helps narrow down the options and probably the best test to look for stress fractures and stress reactions is an MRI scan. Importantly, a normal x-ray does not completely rule out an impending stress fracture.

Shin splints / tibial periostitis / MTSS

This troublesome cause of shin pain goes under a lot of different names. It can be quite a miserable condition and I’ve certainly suffered from this myself during my marathon years. It is inflammation where the muscles that support the arch of your foot join onto your shin bone. It’s caused by a combination of overuse, tight muscles and certain foot shapes (more common in people with a flatter arch to the foot). I see it a lot in runners, but also in other running sports.

There is typically a burning pain on the inner border of the shin bone with activity. It can be painful at the start of a training session but as your endorphins get going it can feel okay once you’re warmed up. The pain often then comes back after the end of the session. It may be tender to touch down the inner edge of the shin bone. It can be one leg or both legs though they are rarely a matching pair. It can be associated with a change in shoe use or doing more sport than you are used to.

By carefully listening to your symptoms and gently examining you I can usually make the diagnosis, though we often choose to get an MRI scan to make sure there is not a stress fracture. The treatment often centres around correcting any biomechanical problems, making sure you are running in the right shoes and sometimes using insoles to help support the arch so the muscles don’t have to work so hard.

Shockwave therapy is also a brilliant non-invasive treatment option for this condition which can help settle things down.

If nothing else works then sometimes I do surgery for this problem. Because it can be confused with a stress fracture it is really important to get this checked out and not to ignore it and keep training on sore shins.

Compartment syndrome 

Compartment syndrome is a confusing term but a potent cause of leg pain. The muscles in your legs are all contained in tight fibrous bags which we call the compartments. In some people, as the muscles grow they can become too big for the compartments that they are in. Then with sport, as more blood rushes into the muscles they can strangle themselves and give you a horrible cramping pain. The pain typically comes on a short way into a run and is fairly predictable. The more you try to carry on the worse the pain gets and you can’t beat it. When you sit and rest usually as the situation relaxes within a few minutes the pain settles down but if you then try and run again it all starts up again quite quickly. 

There are four main compartments in the leg and it can affect any or all of them, and one leg or both legs. There can often be a dull aching pain at rest but usually it is sport that brings the problem on. Sometimes there can be tingling sensations associated with the cramping pain or pins and needles – this happens as the blood supply is cut off from the nerves.

The way to confirm the diagnosis is a little bit involved but starts with an appointment where I will listen to your symptoms and examine you. We then usually get an MRI scan before and after exercise to see whether this shows inflammation in the muscles. The real way to know for sure is to measure the pressures in the muscles before exercise then immediately after exercise when you are in pain. This involves a pressure gauge and a needle!

If you do have compartment syndrome then the only options are to cut back on sport or to have surgery to open up the fibrous bags around the muscles so there is room for the muscles to expand!

It just so happens that I ran the regional compartment syndrome service for the NHS. I have seen lots and lots of people with this condition. We can usually get really good results by following a tried and tested method for confirming the diagnosis and doing careful gentle surgery.