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Chronic Leg Pain: Putting the Diagnostic Pieces Together

Mark R. Hutchinson, MD; Scott Cahoon, MD; Thomas Atkins, MD


In Brief: Chronic pain in the calf, tibia, fibula, or muscle compartments of the leg must be carefully evaluated to make the proper diagnosis and define the most appropriate course of treatment. The most common overuse leg injuries are stress fractures, chronic exertional compartment syndrome, medial tibial stress syndrome, and strains and sprains. The history is the key component of the evaluation. Targeted questions can suggest which ancillary tests can confirm the working diagnosis. Infection, tumors, radiculopathy, and vascular compromise other than compartment syndrome are rare but must be considered in the differential.

Chronic leg pain is a common source of discomfort in running and other activities that involve impact on the lower extremities (see "How Common Is Leg Pain?" page 41). By definition, the leg runs from the knee to the ankle; it contains four muscle compartments supported by the tibia and fibula (figure 1). The neurovascular structures travel inside and outside the fascial layers that define these compartments. Sports-related leg pain can stem from any of these areas (table 1) or be referred to the leg from distal or proximal pathology.


Table 1. Differential Diagnosis of Chronic Leg Pain in Active Patients

Stress fracture
Chronic exertional compartment syndrome
Medial tibial stress syndrome ("shin splints")
Muscle-tendon injury
   Complete rupture
   Partial rupture
Neurovascular condition
   Blood clots
   Nerve entrapment
   Spinal radiculopathy

Key Questions for the History

Patients reporting chronic leg pain will rarely provide all the information necessary to arrive at a proper diagnosis without careful guidance and focused questions. Frequently, an athlete will have minimal symptoms or clinical signs at the time of the evaluation. For this reason it is imperative to obtain a thorough history.

Did the pain start acutely or gradually? Acute injuries, such as fractures, contusions, abrasions, lacerations, and muscle tears, are typically structural. Gradual onset, however, tends to indicate overuse and inflammation. Progressive complaints at rest could also be a sign of infection or tumor.

Is the pain only in the leg? Pain due to nerve-root impingement will frequently be associated with pain in the back or at the site of impingement. Multiple pain sites in other extremities may lead to a systemic diagnosis. Associated paresthesias or muscle weakness distal to the patient's leg may indicate nerve impingement within the leg or chronic exertional compartment syndrome (CECS).

Is the pain localized or diffuse? A focal, isolated site of pain on the bone is consistent with a stress fracture. A focal, isolated site of pain along a muscle-tendon unit (commonly at the musculotendinous junction) frequently indicates a strain or partial rupture. Pain along the entire shin is more likely from periostitis or medial tibial stress syndrome ("shin splints"). Pain involving an entire muscle group could stem from a contusion, myositis, CECS, infection, blood clot, or other neurovascular disorder.

Is the pain associated with activities? Pain that is mild at rest but is exacerbated on first loading of the limb is consistent with a stress fracture or a muscle-tendon injury. Pain that is exacerbated with non-weight-bearing, passive range of motion may indicate tendinitis or muscle-tendon pathology in the motor unit being put in tension. Pain with active or resisted muscle firing may indicate injury in the muscle-tendon unit being tested. Pain that is absent at rest but develops and gradually increases in intensity during activity, such as halfway through a 10-mile run, is common with CECS.

Is the pain worse at night? Pain that is particularly worse at night suggests the possibility of a tumor.

Does anything relieve the pain? The deep ache associated with CECS generally resolves with 20 to 30 minutes of rest. The pain associated with stress fractures and muscle-tendon strains may improve with cryotherapy and anti-inflammatory medications but rarely resolves completely. The pain of osteoid osteoma, a benign bone tumor, may be significantly reduced with nonsteroidals, especially salicylates.

What was the mechanism of injury? Certain sports or activities increase the risk partly because of the repetitive movements involved. In chronic cases, athletes frequently cannot isolate an event that caused their complaint. If they can, it will frequently point directly to the lesion.

Has training recently changed? Overuse injuries such as stress fractures or tendinitis are frequently associated with a rapid increase in intensity or a change in training patterns.

Has equipment been modified, and is it in good repair? In particular, a thorough history should include questions about shoes. Avid runners should change their shoes every 3 to 4 months to take advantage of the shock absorption capability of the shoes.

Has the training surface recently changed? Like shoes, the training surface plays an important role in the amount of stress on the lower leg. Athletes changing from a soft playing surface to a harder one are more likely to sustain overuse injuries such as stress fractures or stress reactions of the bone.

Is the diet adequate for the energy demands? A brief nutrition evaluation should be performed on all athletes who have leg pain. Eating disorders may lead to osteopenia and stress fractures. Insufficient energy intake increases the risk of stress fractures and muscle-tendon injuries. Patients should be asked to recite their intake for the past 48 to 72 hours. Rarely will the examiner receive a negative response to the question "Do you eat OK?"

Are there hormonal imbalances? All female athletes should be screened for menstrual irregularities. Absent or infrequent menses implies estrogen imbalance. Estrogen is an important factor enabling women to retain and lay down bone. Menstrual irregularities may lead to stress fractures or osteoporosis.

Thorough Physical Exam

The physical examination for leg pain begins with observation as the patient walks into the training room or clinic. Is there a limp? Is the patient using crutches or other assistance devices? Are shoes adequately cushioned or particularly worn? An antalgic gait or the use of assistance devices is uncommon in CECS, which is generally exacerbated with activities.

Complete inspection of both lower extremities including the knee, ankle, and lumbar spine can indicate any focal area of deformity, swelling, or redness. Red streaks above an area of swelling with associated warmth and adenopathy point to infection; inspection of the foot and leg for areas of broken skin may identify the source of contamination. Screening of the ankle, knee, hip, and lumbar spine should include range of motion and a distal neurologic examination to uncover contributing or associated causes of leg pain.

Abnormal findings by inspection should be carefully palpated and examined. The examiner should palpate along the anteromedial and anterolateral border of the patient's tibia and fibula to identify diffuse or focal pain. Stress fractures are usually so focal that the point of maximal tenderness can be covered by a single finger. Multiple sites of stress fractures are possible in the same limb. Medial tibial stress syndrome or periostitis typically involves a more diffuse pain pattern along the tibia.

Each of the four compartments (anterior, lateral, deep posterior, and superficial posterior) should be palpated for tenderness and tenseness. It is difficult to isolate the deep posterior compartment, but with deep compartment involvement, pain is generally more severe at the posterior medial border of the tibia than in the superficial gastrocnemius-soleus complex. Significant tenseness, especially after exercise, should raise the concern of CECS. Ankle plantar flexors, dorsiflexors, and evertors should be placed in tension and palpated along their course. A defect indicates a complete tear. Diffuse pain along the course of the tendon sheath may herald tendinitis or synovitis.

Additional Tests

Confirming or isolating a specific diagnosis of chronic leg pain in athletes may require more specialized testing. For most athletes, requesting that they re-create the pain is the simplest and least expensive test. Pain that is absent at rest but triggered by exertion is consistent with CECS. We frequently take athletes to the gym or track and have them perform their sport until the pain appears.

Another helpful and inexpensive test is the tuning fork test. Sliding a vibrating tuning fork along the skin should severely exacerbate the pain in a focused area at the site of a stress fracture.

Additional diagnostic studies should be guided by the clinical diagnosis. Occasionally, the diagnosis is so clear that no additional studies are necessary. Ordering anteroposterior, lateral, and oblique plain radiographs is usually the initial step to rule out underlying bony pathology. Osteomyelitis, bone tumors, periosteal reaction, and stress fractures may be seen; with a stress fracture, however, plain radiographs may not be positive until a few weeks after the initial presentation.

If stress fractures, medial tibial stress syndrome, or bone tumors are the primary focus of the working diagnosis, a bone scan may be indicated. For athletes, we prefer to use tomographic bone scans (SPECT), which can better identify subtle lesions. If CECS is the primary working diagnosis, compartment pressure should be measured before and after exercise to confirm the diagnosis. Magnetic resonance imaging (MRI) can provide high-resolution views and in-depth information regarding musculotendinous injuries and stress fractures; however, its routine use is debatable because of its cost.

Stress Fracture

Stress fractures are a result of repetitive abnormal or excessive loading of bone. They were first described in 1855 after being noted in the metatarsals of Prussian soldiers (1). Bone undergoes remodeling in response to stress (Wolff's law). Jones et al (2) graded this stress reaction from normal remodeling (grade 0) to stress fracture (grade 4), with mild, moderate, and severe stress reaction in between. Stress fractures represent an imbalance of bone resorption over bone formation.

Incidence. Stress fractures are most common in runners, although specific incidence is poorly documented. A prospective study (3) in track-and-field athletes found a 21% overall 1-year incidence of stress fractures. Forty-six percent of the fractures were in the tibia, and 12% were in the fibula. They are also frequent in basketball, soccer, volleyball, ballet, and aerobics. One retrospective study (4) of approximately 3,000 athletes found an overall annual incidence of 1.9%. A prospective study (1) of almost 300 military recruits found a rate of 31%.

Many risk factors have been suggested. Women have been shown to be at risk for stress fracture (5). Age may also be a risk factor. Giladi et al (6), in a prospective analysis of military recruits, found only two independent predictors of stress fracture: greater passive hip range of motion and a narrower tibia.

Diagnosis. The history usually includes a gradual onset of pain, usually first noted during or after strenuous exercise. The pain gradually progresses to occur during nonsports activity or at rest and eventually leads to reduced activity. Typically, patients will report a recent change in their training regimen with increased mileage or intensity. In a study (7) of 131 patients who had 169 stress fractures, the mean interval between the start of hard training and the onset of symptoms was 2.7 months.

Physical examination will reveal localized tenderness to palpation or percussion over the anterior tibia or lateral fibula. There may be erythema or edema over the area of tenderness. A palpable bump may indicate periosteal reaction. Patients will often have an antalgic gait. The tibia is the most common site of any stress fracture. The fracture normally occurs at the junction of the middle and distal thirds, but proximal metaphyseal involvement is not uncommon. Fibular stress fractures normally occur in the distal third. Anterior tibial stress fractures most commonly involve the push-off or landing leg in athletes (8).

After a thorough history and physical exam, plain radiographs are the initial diagnostic test (figure 2). Although they have a high specificity, plain x-rays lack sensitivity. The typical radiographic finding is faint sclerosis in a horizontal or linear pattern (9) Sometimes a linear radiolucency (the "dreaded black line," figure 2) or surrounding periostitis is seen. Less common is an overt fracture. Although initial radiographs may be negative, follow-up x-rays will often demonstrate the fracture line.


Bone scans are the "gold standard" diagnostic test (figures 3 and 4). Sensitivity approaches 100%, but the specificity is poor. Findings can be diagnostic early in the course of the disease. Triple-phase bone scans are also useful in differentiating stress fractures from medial tibial stress syndrome (10). Stress fractures will have a focal area of increased uptake, while medial tibial stress syndrome will be more diffuse. MRI has excellent sensitivity and greater specificity than bone scans, but it is more costly.


Treatment. The most important measure in managing stress fractures is limiting impact loading across the fracture by splinting or a reduction in activities. Functional splinting can be provided with a pneumatic ankle brace for activities of daily living. The splint must extend well past the fracture site, and a knee-high brace is therefore preferable for most mid- and lower-tibial stress fractures.


When impact activities can be performed in the brace without pain, a gradual return to sports is permitted (11). If the pain recurs or the fracture is resistant to healing, casting or complete abstinence from impact activities may be necessary, but we find this to be rare. Nonetheless, if required, casting or bracing is continued until radiographic healing occurs.

Patients can resume unprotected impact activities in 2 to 3 months or after the season has ended if adequate healing has been allowed. Resumption of unprotected impact activities should progress gradually, beginning in the pool, then on cushioned surfaces, and finally on the normal playing surface.

Pain control with acetaminophen, icing, stretching, and cross-training is emphasized throughout the rehabilitation period. Nonsteroidal anti-inflammatory drugs (NSAIDs) may slow the bone healing response and should be avoided. Ultrasound and electromagnetic bone stimulation devices may speed the healing of stress fractures in selected athletes. These modalities are, however, expensive and have not yet been definitively proven effective in athletes who have stress fractures.

Calcium supplementation is rarely needed to speed healing but is a wise adjuvant preventive measure for athletes who have poor nutrition. We encourage all at-risk female athletes to take a multivitamin with vitamin D and supplement their daily calcium intake with 500 mg of calcium. Athletic women who have abnormal or no menses should also be monitored and regulated because estrogen is an important factor in laying down healthy bone.

Chronic Exertional Compartment Syndrome

CECS is a result of increased pressure within leg compartments that occurs during or shortly after exercise. The increased pressure compromises circulation within the microvasculature (12). Symptoms of CECS usually resolve with rest but may progress to an acute form if exercise is continued (13).

The anterior compartment of the leg is most commonly involved with CECS, but the syndrome has been described in all four compartments. Each compartment is bounded by bone and a thick fascial covering that limits its ability to expand. Exercise can produce a 20% increase in muscle volume (14), which is thought to result from intracellular and extracellular fluid accumulation. With the increased pressure, a venous and lymphatic occlusion occurs that further increases pressure and vascular occlusion (12).

Diagnosis. Typically, the patient will report pain over the involved compartment during or immediately following exercise. Often the patient will report a recent increase in training time or intensity. The pain will usually occur at a predictable point in the exercise regimen (14) and usually begins as a dull or crampy ache and increases in intensity if training persists. The pain will usually continue after the exercise has stopped but will completely resolve with rest in the earlier stages of involvement (15).

Associated but less common symptoms include shooting pain, numbness, tingling, or burning caused by involvement of the nerves traversing the affected compartment. More specifically, the anterior compartment contains the deep peroneal nerve and the anterior tibial artery; the lateral compartment contains the superficial peroneal nerve; the superficial posterior compartment contains the sural nerve; and the deep posterior compartment contains the tibial nerve and artery. Bilateral symptoms are common, but one leg is usually more severely affected.

Examination may be entirely normal, but if the patient has recently exercised, the clinician may elicit tenderness and increased tension directly over the involved compartment. Passive stretching of the involved compartment may also elicit pain.

Occasionally, the patient has muscle herniation through fascial defects (12). These may be secondary to CECS or the source of chronic pain in themselves. Examination for compressive neuropathies of the superficial and deep peroneal nerves should also be done.

The diagnosis of CECS is primarily clinical. However, documentation of increased compartment pressures helps to confirm the diagnosis. Typically, preexercise and postexercise compartment pressures are required. The reliable measurement of compartment pressures has become more achievable with new devices, including wick catheters, slit catheters, and the solid-state transducer intracompartment catheter (12). Intracompartment pressure is considered abnormal if it is greater than 20 mm Hg at rest or greater than 25 to 30 mm Hg postexercise, or if it does not normalize 5 minutes postexercise.

Radiologic exam is important to rule out associated conditions. If the history and physical exam are consistent, plain films and pressure measurements will suffice, but bone scan, computed tomography (CT), or MRI may need to be ordered, depending on the clinical scenario.

Bone scans are indicated if the presentation is less clear-cut and a stress fracture is possible. For elite athletes, bone scans may be necessary to confirm even a strong clinical suspicion to provide documentation to the athlete, team, and coaches that time loss from the sport or activity modification is actually necessary. CT is an excellent imaging technique for bone pathology but is rarely used for most athletes who have leg pain. If additional imaging studies are necessary, MRI can be helpful in evaluating soft-tissue tumors and injuries, bone edema, and stress-related injuries. MRI scans are safe but expensive and therefore should be used only when further clarification of the diagnosis is necessary.

Treatment. Conservative treatment usually consists of reducing the frequency and duration of stressful activities, stretching the involved compartment, using soft orthotic inserts, providing adequate hydration, and using NSAIDs and icing after activity. If symptoms persist for more than 6 months, fasciotomy can provide significant relief (13). Recurrence of symptoms following conservative treatment is common unless the patient gives up the precipitating activity. Athletes unwilling to give up their level of activity will require surgery.

Medial Tibial Stress Syndrome

In medial tibial stress syndrome, many structures have been implicated as the source of pain (16,17). It is thought to be an overuse syndrome involving the fascia of the soleus as the fascia inserts on the posterior medial tibia or the periosteum underneath the tibialis posterior muscle (12).

Diagnosis. Whether thought of as a fasciitis or a periostitis, the diagnosis requires excluding other causes of leg pain, such as stress fracture, CECS of the deep posterior compartment, contusion, and strain. As in the previously discussed syndromes, runners—especially those who run on hard surfaces—are affected more than other athletes (18).

Radiographs of the leg are usually negative, but a bone scan can help in making the diagnosis. A positive bone scan typically shows a moderate increase of linear activity along the posteromedial border of the tibia, involving as much as one third of its length.

Treatment. Most patients respond to conservative treatment. This involves rest followed by a gradual return to precipitating activities after symptoms subside. Rest is defined as a relative decrease in the exacerbating activity to a level that no longer produces pain. A gradual return includes running on soft surfaces before running on hard surfaces.

Symptomatic treatment may include moist heat, bracing, local steroid injection, and taping but does not change the overall course. Custom orthoses may benefit patients who have excessive pronation or subtalar mobility. Fasciotomy of the deep posterior compartment, release of the attachment of the soleus from the medial tibia, or cauterization of the periosteum is warranted when conservative treatment fails.

Muscle-Tendon Injury

Although stress fractures, CECS, and medial tibial stress syndrome are important, the most common cause of leg pain in athletes is musculotendinous strain. Poor conditioning or overuse in a high-demand activity can lead to tendinitis or partial tears of the muscle-tendon unit, usually at the muscle-tendon junction.

Diagnosis. Acute musculotendinous injuries may be related to poor preparticipation stretching or conditioning. Athletes often can define the specific mechanism of injury that initiated the pain. For example, an explosive leap or quick stop implies a gastrocnemius-soleus injury, an inward ankle roll often leads to peroneus or ankle sprain, and kicking a ball can cause anterior tibialis strain. The pain is usually focal and most frequently is at the musculotendinous junction.

In chronic injuries, however, the cause may be less defined and more a matter of repetitive overuse. While pain may still be located at the musculotendinous junction, the presentation tends to be more diffuse. Pain along the tendon may indicate tendinitis or peritendinitis.

In both chronic and acute cases, pain with resistance of the specific motor group and pain when the inflamed tendons are stretched are the most common findings. Swelling and crepitation may also be present.

"Tennis leg" is a strain of the medial gastrocnemius. Unlike Achilles tendinitis, which occurs distally over the Achilles tendon just proximal to the calcaneus, tennis leg is more proximal, in the medial belly of the gastrocnemius. Named by Miller (19) for its prevalence in middle-aged tennis players, this strain or rupture may also be seen in other racket sports, basketball, running, and skiing.

The injury usually occurs with eccentric loading of the contracted gastrocnemius and soleus. Patients will report sudden pain in the posterior leg and occasionally relate a popping sensation. Swelling and ecchymosis in the posterior leg may follow. The duration of discomfort depends on the severity of injury.

Treatment. Treatment for muscle-tendon injuries depends on the severity of injury. The RICE protocol (rest, ice, compression, elevation) usually works well for mild strains. Following the acute phase, passive stretching and active strengthening are initiated before a return to activities. Restriction of activities may be required for several weeks or months. More severe strains may require immobilization with a cast or splint to allow healing of the injured muscle-tendon unit in anatomic position.

If a defect is palpated, the muscle and tendon should be placed at optimum relaxation to allow the torn ends to reapproximate. Intrasubstance tendon injuries may be treated surgically; however, injuries in the muscle belly must be treated conservatively because the muscle tissue will not hold a suture. Once severe injuries have healed (4 to 8 weeks), patients must undergo rehabilitation to regain motion and optimize motor strength.

From Common to Rare

Whether the cause of chronic leg pain is one of the common conditions discussed above or a rarer condition like tumor, infection, referred nerve pain, vascular claudication, or thrombophlebitis, a thorough history and physical examination with associated tests are essential. Fortunately, accurate diagnosis and appropriate treatment will return most patients to full sports participation.


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How Common Is Leg Pain?

The incidence of leg pain depends on a variety of factors, including sport, gender, intensity of training, playing surface, shoes, and nutrition. According to National Collegiate Athletic Association (NCAA) Surveillance System statistics (1), the incidence of acute or chronic leg complaints ranges from 0.10 (ice hockey) to 0.93 (women's field hockey) per 1,000 athletic exposures (table A). The number of leg injuries as a percentage of total injuries in each sport ranges from 1.4% (ice hockey) to 7.9% (women's soccer). In gymnastics, softball, and soccer, women have a higher rate of acute and chronic leg injuries than men do in comparable sports (softball is compared with baseball).

It should be emphasized that the NCAA Surveillance System statistics include both acute and chronic injuries and a very specific competitive collegiate population. The data and findings may not apply to other groups or sports. The exact incidence of chronic leg complaints in competitive or recreational athletes is not currently available in the literature. Stress fractures alone have been reported to occur in 1.9% of college freshman athletes (2) and 31% of military recruits (3).


  1. National Collegiate Athletic Association (NCAA): NCAA Injury Surveillance System, Overland Park, KS, 1996
  2. Goldberg B, Pecora C: Stress fractures: a risk of increased training in freshmen. Phys Sportsmed 1994;22(3):68-78
  3. Milgrom C, Giladi M, Stein M, et al: Stress fractures in military recruits: a prospective study showing unusually high incidence. J Bone Joint Surg (Br) 1985;67(5):732-735

Dr Hutchinson is director of Sports Medicine Services and attending orthopedic surgeon in the Department of Orthopaedics at the University of Illinois at Chicago. He serves as team physician at the university and for the USA Gymnastics National Rhythmic Team and is an editorial board member of The Physician and Sportsmedicine. Drs Cahoon and Atkins are residents in the Department of Orthopaedics at the University of Illinois at Chicago. Address correspondence to Mark R. Hutchinson, MD, University of Illinois at Chicago, Dept of Orthopaedics, 209 Medical Science South (M/C 844), 901 S Wolcott, Chicago, IL 60612-7342; e-mail to [email protected].




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