Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered.
Purpose/Questions
We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes.
Methods
A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations.
Results
Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary.
Conclusions
Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.
AbousayedMMTartaglioneJPRosenbaumAJDipretaJAClassifications in Brief: Johnson and Strom classification of adult-acquired flatfoot deformityClin Orthop Relat Res20164742588–59310.1007/s11999-015-4581-6
2.
AokiYYasudaKTohyamaHItoHMinamiAMagnetic resonance imaging in stress fractures and shin splintsClin Orthop Relat Res2004421260–26710.1097/01.blo.0000126333.13806.87
3.
BeckBRTibial stress injuries. An aetiological review for the purposes of guiding managementSports Med1998264265–27910.2165/00007256-199826040-00005
BonasiaDERossoFCottinoURossiRExercise-induced leg painAsia Pac J Sports Med Arthrosc Rehabil Technol.20152373–845730650
6.
BraverRTChronic exertional compartment syndromeClin Podiatr Med Surg2016332219–23310.1016/j.cpm.2015.12.002
7.
BrennanFHJrKaneSFDiagnosis, treatment options, and rehabilitation of chronic lower leg exertional compartment syndromeCurr Sports Med Rep200325247–25010.1249/00149619-200310000-00003
8.
BubraPSKeighleyGRateeshSCarmodyDPosterior tibial tendon dysfunction: an overlooked cause of foot deformityJ Family Med Prim Care20154126–29436700110.4103/2249-4863.152245
9.
BurneSGKhanKMBoudvillePBMalletRJNewmanPMSteinmanLJRisk factors associated with exertional medial tibial pain: a 12 month prospective clinical studyBr J Sports Med2004384441–445172490410.1136/bjsm.2002.004499
10.
BurrusMTWernerBCStarmanJSGwathmeyFWCarsonEWWilderRPChronic leg pain in athletesAm J Sports Med20154361538–154710.1177/0363546514545859
11.
CampbellRSGraingerAJCurrent concepts in imaging of tendinopathyClin Radiol2001564253–26710.1053/crad.2000.0653
12.
ChaudhryZSRaikinSMHarwoodMIBishopMECiccottiMGHammoudSOutcomes of surgical treatment for anterior tibial stress fractures in athletes: a systematic reviewAm J Sports Med20171363546517741137
13.
Clanton TOSolcherBWChronic leg pain in the athleteClin Sports Med1994134743–759
14.
CollinsPSMcDonaldPTLimRCPopliteal artery entrapment: an evolving syndromeJ Vasc Surg1989105484–48910.1016/0741-5214(89)90129-8
15.
ContiSFPosterior tibial tendon problems in athletesOrthop Clin North Am1994251109–12110.1016/j.ocl.2019.08.005
16.
CounselPCominJDavenportMConnellDPattern of Fascicular involvement in midportion achilles tendinopathy at ultrasoundSports Health201575424–428454711910.1177/1941738115595226
17.
DamareyBDemondionXWavreilleGPansiniVBalbiVCottenAImaging of the nerves of the knee regionEur J Radiol201382127–3710.1016/j.ejrad.2011.04.035
18.
DavdaKMalhotraKO'donnellPSinghDCullenNPeroneal tendon disordersEFORT Open Rev201726281–292550885810.1302/2058-5241.2.160047
19.
De Carvalho JuniorAEBittarCKSalomaoOMirandaJBNinomiyaASilvaDBTendinopathy of the anterior compartment of the ankleRev Bras Ortop2010452141–14710.1590/S0102-36162010000200006
20.
De MaeseneerMMadaniHLenchikLNormal anatomy and compression areas of nerves of the foot and ankle: us and mr imaging with anatomic correlationRadiographics20153551469–148210.1148/rg.2015150028
21.
DetmerDEChronic leg painAm J Sports Med198082141–14410.1177/036354658000800221
22.
EdwardsPHJrWrightMLHartmanJFA practical approach for the differential diagnosis of chronic leg pain in the athleteAm J Sports Med20053381241–124910.1177/0363546505278305
23.
ErolKKarahanAYKerimoğluÜAn important cause of pes planus: the posterior tibial tendon dysfunctionClin Pract201551699438734110.4081/cp.2015.699
24.
FarookiSTheodorouDJSokoloffRMTheodorouSJTrudellDJResnickDMRI of the medial and lateral plantar nervesJ Comput Assist Tomogr2001253412–41610.1097/00004728-200105000-00014
25.
FeldmanJJBowmanENPhillipsBBWeinleinJCTibial stress fractures in athletesOrthop Clin North Am2016474733–74110.1016/j.ocl.2016.05.015
26.
FerkelEDavisWHEllingtonJKEntrapment neuropathies of the foot and ankleClin Sports Med2015344791–80110.1016/j.csm.2015.06.002
27.
FlaniganRMDiGiovanniBFPeripheral nerve entrapments of the lower leg, ankle, and footFoot Ankle Clin2011162255–27410.1016/j.fcl.2011.01.006
28.
FraipontMJAdamsonGJChronic exertional compartment syndromeJ Am Acad Orthop Surg2003114268–27610.5435/00124635-200307000-00006
29.
FredericsonMJenningsFBeaulieuCMathesonGOStress fractures in athletesTop Magn Reson Imaging2006175309–32510.1097/RMR.0b013e3180421c8c
30.
FrinkMHildebrandFKrettekCBrandJHankemeierSCompartment syndrome of the lower leg and footClin Orthop Relat Res20104684940–95010.1007/s11999-009-0891-x
31.
GaetaMMinutoliFScribanoECT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalitiesRadiology20052352553–56110.1148/radiol.2352040406
32.
GatenbyGHaysomSTwaddleBWalshSFunctional outcomes after the surgical management of isolated anterolateral leg chronic exertional compartment syndromeOrthop J Sports Med2017511568258710.1177/2325967117737020
33.
GourgiotisSAggelakasJSalemisNEliasCGeorgiouCDiagnosis and surgical approach of popliteal artery entrapment syndrome: a retrospective studyVasc Health Risk Manag20084183–88246475710.2147/vhrm.2008.04.01.83
34.
GrassetWMercierNChaussardCCarpentierEAldridgeSSaragagliaDThe surgical treatment of peroneal tendinopathy (excluding subluxations): a series of 17 patientsJ Foot Ankle Surg201251113–1910.1053/j.jfas.2011.10.010
35.
GreenwoodLHYrizarryJMHallettJWJrPopliteal artery entrapment: importance of the stress runoff for diagnosisCardiovasc Intervent Radiol19869293–9910.1007/BF02577908
36.
GuralnikJMFerrucciLPieperCFLower extremity function and subsequent disability: consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance batteryJ Gerontol A Biol Sci Med Sci2000554M221–23110.1093/gerona/55.4.M221
37.
HaentjensPAutierPCollinsJVelkeniersBVanderschuerenDBoonenSColles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysisJ Bone Joint Surg Am200385-A101936–194310.2106/00004623-200310000-00011
38.
HaiZGuangruiSYuanZZhuodongXChengLJingminLCT angiography and MRI in patients with popliteal artery entrapment syndromeAJR Am J Roentgenol200819161760–176610.2214/AJR.07.4012
39.
HarkinEPinzurMSchiffATreatment of acute and chronic tibialis anterior tendon rupture and tendinopathyFoot Ankle Clin2017224819–83110.1016/j.fcl.2017.07.009
40.
HubbardTJCarpenterEMCordovaMLContributing factors to medial tibial stress syndrome: a prospective investigationMed Sci Sports Exerc2009413490–49610.1249/MSS.0b013e31818b98e6
41.
HumphreysDBNovakCBMackinnonSEPatient outcome after common peroneal nerve decompressionJ Neurosurg20071072314–31810.3171/JNS-07/08/0314
42.
HutchisonAMEvansRBodgerOWhat is the best clinical test for Achilles tendinopathy?Foot Ankle Surg2013192112–11710.1016/j.fas.2012.12.006
43.
KhanKMCookJLTauntonJEBonarFOveruse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problemPhys Sportsmed200028538–4810.3810/psm.2000.05.890
44.
KhouryNJel-KhouryGYSaltzmanCLKatholMHPeroneus longus and brevis tendon tears: MR imaging evaluationRadiology19962003833–84110.1148/radiology.200.3.8756941
45.
KorkolaMAmendolaAExercise-induced leg pain: sifting through a broad differentialPhys Sportsmed200129635–5010.1080/00913847.2001.11439710
KuligKReischlSFPomrantzABBurnfieldJMMais-RequejoSThordarsonDBNonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trialPhys Ther200989126–3710.2522/ptj.20070242
48.
LevienLJVellerMGPopliteal artery entrapment syndrome: more common than previously recognizedJ Vasc Surg1999304587–59810.1016/S0741-5214(99)70098-4
49.
LiberatiAAltmanDGTetzlaffJThe PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaborationBMJ2009339b2700271467210.1136/bmj.b2700
50.
LiuBBarrazuetaGRuchelsmanDEChronic exertional compartment syndrome in athletesJ Hand Surg Am20174211917–92310.1016/j.jhsa.2017.09.009
51.
LuiTHEndoscopic decompression of the first branch of the lateral plantar nerve and release of the plantar aponeurosis for chronic heel painArthrosc Tech201653e589–594502154110.1016/j.eats.2016.02.018
52.
MaffulliNViaAGOlivaFChronic Achilles tendon disorders: tendinopathy and chronic ruptureClin Sports Med2015344607–6242640958610.1016/j.csm.2015.06.010
53.
MagnanBBondiMPierantoniSSamailaEThe pathogenesis of Achilles tendinopathy: a systematic reviewFoot Ankle Surg2014203154–15910.1016/j.fas.2014.02.010
54.
MaquirriainJSurgical treatment of chronic achilles tendinopathy: long-term results of the endoscopic techniqueJ Foot Ankle Surg2013524451–45510.1053/j.jfas.2013.03.031
55.
MasakadoYKawakamiMSuzukiKAbeLOtaTKimuraAClinical neurophysiology in the diagnosis of peroneal nerve palsyKeio J Med200857284–8910.2302/kjm.57.84
56.
MathesonGOClementDBMcKenzieDCTauntonJELloyd-SmithDRMacIntyreJGStress fractures in athletes. A study of 320 casesAm J Sports Med198715146–5810.1177/036354658701500107
57.
MeyerSASaltzmanCLAlbrightJPStress fractures of the foot and legClin Sports Med1993122395–413
58.
MorgantiCMMcFarlandEGCosgareaAJSaphenous neuritis: a poorly understood cause of medial knee painJ Am Acad Orthop Surg2002102130–13710.5435/00124635-200203000-00008
59.
MorimotoDIsuTKimKSugawaraAYamazakiKChibaYMicrosurgical decompression for peroneal nerve entrapment neuropathyNeurol Med Chir (Tokyo)2015558669–67310.2176/nmc.oa.2014-0454
ParkHJChaSDKimHSReliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instabilityClin Orthop Surg201024237–243298178110.4055/cios.2010.2.4.237
62.
PeaceKAHillierJCHulmeAHealyJCMRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 casesClin Radiol200459111025–103310.1016/j.crad.2004.02.010
63.
PedowitzRAHargensARMubarakSJGershuniDHModified criteria for the objective diagnosis of chronic compartment syndrome of the legAm J Sports Med199018135–4010.1177/036354659001800106
64.
PillaiJLevienLJHaagensenMCandyGCluverMDVellerMGAssessment of the medial head of the gastrocnemius muscle in functional compression of the popliteal arteryJ Vasc Surg20084851189–119610.1016/j.jvs.2008.06.057
65.
PliskyMSRauhMJHeiderscheitBUnderwoodFBTankRTMedial tibial stress syndrome in high school cross-country runners: incidence and risk factorsJ Orthop Sports Phys Ther200737240–4710.2519/jospt.2007.2343
66.
PremkumarAPerryMBDwyerAJSonography and MR imaging of posterior tibial tendinopathyAJR Am J Roentgenol20021781223–23210.2214/ajr.178.1.1780223
67.
ReinkingMFAustinTMRichterRRKriegerMMMedial Tibial stress syndrome in active individuals: a systematic review and meta-analysis of risk factorsSports Health201793252–26110.1177/1941738116673299
68.
RettigACShelbourneKDMcCarrollJRBisesiMWattsJThe natural history and treatment of delayed union stress fractures of the anterior cortex of the tibiaAm J Sports Med1988163250–25510.1177/036354658801600309
69.
RFtPKhanujaHSCooleyGRLeg pain in the running athleteJ Am Acad Orthop Surg2004126396–40410.5435/00124635-200411000-00004
70.
RietveldABMBHagemansFMTOperative treatment of posterior ankle impingement syndrome and flexor hallucis longus tendinopathy in dancers open versus endoscopic approachJ Dance Med Sci201822111–1810.12678/1089-313X.22.1.11
71.
RietveldABMBHagemansFMTHaitjemaSVissersTNelissenRGHHResults of treatment of posterior ankle impingement syndrome and flexor hallucis longus tendinopathy in dancers: a systematic reviewJ Dance Med Sci201822119–3210.12678/1089-313X.22.1.19
72.
RodriguesRNLopesAATorresJMMundimMFSilvaLLSilvaBRCompressive neuropathy of the first branch of the lateral plantar nerve: a study by magnetic resonance imagingRadiol Bras2015486368–372472539810.1590/0100-3984.2013.0028
73.
RosenbergZSCheungYJahssMHNotoAMNormanALeedsNERupture of posterior tibial tendon: CT and MR imaging with surgical correlationRadiology19881691229–23510.1148/radiology.169.1.3420263
74.
RossetEHartungOBrunetCPopliteal artery entrapment syndrome. Anatomic and embryologic bases, diagnostic and therapeutic considerations following a series of 15 cases with a review of the literatureSurg Radiol Anat1995172161–16910.1007/BF01627578
RowleyKMJarvisDNKuriharaTChangYJFietzerALKuligKToe Flexor strength, flexibility and function and flexor hallucis longus tendon morphology in dancers and non-dancersMed Probl Perform Art2015303152–15610.21091/mppa.2015.3029
77.
SchubertRMRI of peroneal tendinopathies resulting from trauma or overuseBr J Radiol201386102120110750465107010.1259/bjr.20110750
SterlingJCEdelsteinDWCalvoRDWebbR2ndStress fractures in the athlete. Diagnosis and managementSports Med1992145336–34610.2165/00007256-199214050-00005
80.
StyfJRKornerLMDiagnosis of chronic anterior compartment syndrome in the lower legActa Orthop Scand1987582139–14410.3109/17453678709146460
81.
TaljanovicMSAlcalaJNGimberLHRiekeJDChilversMMLattLDHigh-resolution US and MR imaging of peroneal tendon injuriesRadiographics2015351179–19910.1148/rg.351130062
82.
TellisiNLoboMO'malleyMKennedyJGElliottAJDelandJTFunctional outcome after surgical reconstruction of posterior tibial tendon insufficiency in patients under 50 yearsFoot Ankle Int200829121179–118310.3113/FAI.2008.1179
83.
TouliopolousSHershmanEBLower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the legSports Med1999273193–20410.2165/00007256-199927030-00005
84.
TrnkaHJDysfunction of the tendon of tibialis posteriorJ Bone Joint Surg Br2004867939–94610.1302/0301-620X.86B7.15084
85.
van den BrandJGNelsonTVerleisdonkEJvan der WerkenCThe diagnostic value of intracompartmental pressure measurement, magnetic resonance imaging, and near-infrared spectroscopy in chronic exertional compartment syndrome: a prospective study in 50 patientsAm J Sports Med2005335699–70410.1177/0363546504270565
86.
VargheseABianchiSUltrasound of tibialis anterior muscle and tendon: anatomy, technique of examination, normal and pathologic appearanceJ Ultrasound2014172113–12310.1007/s40477-013-0060-7
87.
VerleisdonkEJvan GilsAvan der WerkenCThe diagnostic value of MRI scans for the diagnosis of chronic exertional compartment syndrome of the lower legSkeletal Radiol2001306321–32510.1007/s002560100361
88.
VermaRBShermanOAthletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis, and treatmentAm J Orthop (Belle Mead NJ)20013011798–806
89.
WaizyHGoedeFPlaassCStukenborg-ColsmanCTendinopathy of the tibialis anterior tendon: surgical managementOrthopade2011407630–63210.1007/s00132-010-1703-4
90.
WiegerinckJIKerkhoffsGMvan SterkenburgMNSiereveltINvan DijkCNTreatment for insertional Achilles tendinopathy: a systematic reviewKnee Surg Sports Traumatol Arthrosc20132161345–135510.1007/s00167-012-2219-8
91.
WorthRMKettelkampDBDefalqueRJDuaneKUSaphenous nerve entrapment. A cause of medial knee painAm J Sports Med198412180–8110.1177/036354658401200114
92.
YatesBWhiteSThe incidence and risk factors in the development of medial tibial stress syndrome among naval recruitsAm J Sports Med.2004323772–78010.1177/0095399703258776
93.
ZiaiPBencaEWenzelFPeroneal tendinosis as a predisposing factor for the acute lateral ankle sprain in runnersKnee Surg Sports Traumatol Arthrosc20162441175–117910.1007/s00167-015-3562-3
