“Just push through it.”
These four words have probably caused more setbacks to training plans, than any injury itself. As a specialist lower limb physiotherapist , I’ve seen countless runners hobble into my clinic, their faces etched with a mixture of pain and frustration, each telling a similar story of how they tried to “run it off” or “work through it.”
Exercise-induced leg pain (EILP) isn’t just a simple inconvenience – it’s a challenging condition that affects everyone from elite athletes to weekend warriors. Recent research suggests that up to 82.4% of athletes experience some form of EILP during their careers, yet it remains one of the most misunderstood and frequently misdiagnosed conditions.
Why? Because EILP isn’t just one condition – it could be one of nine distinct problems, each with its own unique fingerprint of symptoms and required treatments. Getting it wrong doesn’t just mean prolonged pain; it could mean the difference between a quick return to activity and a season-ending injury.
In this comprehensive guide, we’ll explore the various causes of EILP, exploring each condition in detail, from the common medial tibial stress syndrome (MTSS) to the rare but significant McArdle’s syndrome. As a healthcare professional, understanding these distinctions could be the key to early diagnosis and successful management for EILP.
A recent scoping review by Bosnina et al. (2023) presents a comprehensive diagnostic framework for EILP in the athletic population. The study identified and analysed nine distinct conditions that commonly cause EILP, establishing clear diagnostic criteria for each.
In this comprehensive guide, we’ll explore the various causes of EILP, exploring each condition in detail, from the common medial tibial stress syndrome (MTSS) to the rare but significant McArdle’s syndrome. As a healthcare professional, understanding these distinctions could be the key to early diagnosis and successful management for EILP.
A recent scoping review by Bosnina et al. (2023) presents a comprehensive diagnostic framework for EILP in the athletic population. The study identified and analysed nine distinct conditions that commonly cause EILP, establishing clear diagnostic criteria for each.
Key Findings:
- The diagnostic process requires a systematic combination of patient history, physical examination, and investigative tools
- Each condition presents with unique patterns, though some symptoms overlap
- Differential diagnosis is crucial for appropriate treatment planning
Clinical Implications
The research emphasises the importance of accurate differential diagnosis and suggests that EILP diagnosis is often one of exclusion. The findings support the need for standardised diagnostic criteria to improve care consistency and patient outcomes. This framework provides clinicians with a structured approach to EILP diagnosis, potentially reducing diagnostic variability and improving treatment efficacy.
Let us explore the nine conditions outlined in the review:
- Chronic Exertional Compartment Syndrome (CECS): An overuse condition characterised by increased pressure within muscle compartments, causing severe pain and tightness during exercise. Typically affects the anterior compartment and presents bilaterally. Symptoms build during activity until exercise cessation is necessary, then quickly subside with rest. Diagnosis is confirmed through compartment pressure testing and is common in young male athletes.
- Medial Tibial Stress Syndrome (MTSS): Presents as diffuse pain along the posteromedial tibial border, commonly known as ‘shin splints’. Pain persists for hours to days after activity cessation. Particularly prevalent in runners, dancers, and military recruits. Diagnosis relies on clinical history and palpation findings, with MRI sometimes used to exclude other conditions. Pain can significantly impact training capability.
- Tibial Stress Fracture: It manifests as localised, excruciating pain in the tibia, often accompanied by nocturnal pain. Usually occurs in the middle to lower third of the tibia. Requires minimum 6-8 weeks healing time with immobilisation. It’s most common in young runners aged 10-30. Diagnosis is confirmed through localised tenderness and specific tests, often requiring imaging for confirmation.
- Superficial Peroneal Nerve Entrapment Syndrome (SPNES): Involves mechanical compression of the superficial peroneal nerve, causing moderate to severe pain and neurological symptoms in the anterior leg compartment. Symptoms include paraesthesia, numbness, and ‘restless leg’ sensation. Typically unilateral and affects young active adults. Diagnostic local anaesthetic testing can confirm the condition.
- Myofascial Tears: Presents as acute or chronic muscle tissue damage at the interface between aponeurosis and muscle fibres. Can be severely disabling and results from direct or indirect trauma. Pain occurs with activity and improves with rest. Diagnosis typically requires dynamic ultrasound or MRI, particularly for deep tears.
- Lumbar Radiculopathy: Characterised by sharp, radiating leg pain due to nerve root compression at the spinal cord level. Symptoms include paraesthesia, numbness, and spontaneous cramping. Typically affects males aged 30-50 years. Can cause restricted movement and disturbed sleep. MRI and nerve conduction studies assist in diagnosis.
- Popliteal Artery Entrapment Syndrome (PAES): A vascular condition causing arterial insufficiency in the affected limb. Presents with leg pain, poikilothermia, and intermittent claudication in the posterior compartment. Usually unilateral and affects young runners. Diagnosis involves various imaging techniques including MRI, CT angiogram, and ultrasound after exercise provocation.
- McArdle’s Syndrome: An autosomal recessive metabolic myopathy causing pain, tightness, and lethargy in multiple muscle compartments. Leads to exercise-induced rhabdomyolysis due to muscle phosphorylase deficiency. Diagnosis confirmed through genetic testing, blood screening, and muscle biopsy. A long-term condition requiring careful management.
- Accessory/Low-lying Soleus Muscle Syndrome (ALLSMS): A rare anatomical variant causing soft tissue swelling and potential nerve compression. Can mimic tarsal tunnel syndrome and compartment syndrome. Symptoms include pain during activity and neurological symptoms affecting the foot. Diagnosis confirmed through MRI and ultrasound scans. Common in young active adults.
Conclusion
Exercise-induced leg pain represents far more than just a simple training niggle or temporary discomfort. As we’ve explored, it encompasses nine distinct conditions, each with its own unique presentation, diagnostic criteria, and treatment pathway. This complexity underscores why the “just push through it” mentality can lead to devastating consequences for athletes and active individuals alike.
To learn more about the management of runners with injuries, including initial rehab, load management, strength training, and running re-training, check our comprehensive online Running Rehab Course with access to all information related to the rehab of running injuries.
I cover the management of Exercise-related leg pain (including MTSS) and other difficult running-related injuries in detail on my ONLINE RUNNING COURSE with runners and also on getting back to running, following lower limb injuries.
Thanks a lot for reading!
Cheers,
Benoy
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