Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment

Abstract

Context: Chronic lower leg pain in athletes can be a frustrating problem for patients and a difficult diagnosis for clinicians. Myriad approaches have been suggested to evaluate these conditions. With the continued evolution of diagnostic studies, evidence-based guidance for a standard approach is unfortunately sparse.

Evidence acquisition: PubMed was searched from January 1980 to May 2011 to identify publications regarding chronic lower leg pain in athletes (excluding conditions related to the foot), including differential diagnosis, clinical presentation, physical examination, history, diagnostic workup, and treatment.

Results: Leg pain in athletes can be caused by many conditions, with the most frequent being medial tibial stress syndrome; chronic exertional compartment syndrome, stress fracture, nerve entrapment, and popliteal artery entrapment syndrome are also considerations. Conservative management is the mainstay of care for the majority of causes of chronic lower leg pain; however, surgical intervention may be necessary.

Conclusion: Chronic lower extremity pain in athletes includes a wide differential and can pose diagnostic dilemmas for clinicians.

Keywords: chronic exertional compartment syndrome; chronic leg pain; medial tibial stress syndrome; nerve entrapment; popliteal artery entrapment syndrome.

Figure 1.

Cross-section of the lower left leg showing its 4 compartments: anterior at upper left; lateral at center left; deep posterior at center; superficial posterior at bottom right. Used with permission from: Fraipont MJ, Adamson GJ. Chronic exertional compartment syndrome. J Am Acad Orthop Surg. 2003;11:268-276.

Figure 2.

Drawing shows the common peroneal nerve and its branches at the knee. The common peroneal nerve wraps around the fibular neck and under the peroneus longus muscle to trifurcate into the recurrent articular branch to the knee capsule, the superficial peroneal nerve, and the dorsal peroneal nerve. Used with permission from: Donavan A, et al. MR imaging of entrapment neuropathies of the lower extremity. Radiographics. 2010;30:1001-1019.

Figure 3.

Normal anatomy of the tibial, common peroneal, and saphenous nerves at the level of the knee. Axial magnetic resonance image shows the tibial nerve (white arrowhead) between the lateral head (LG) and medial head (MG) of the gastrocnemius muscle. The common peroneal nerve (black arrowhead) is seen between the lateral gastrocnemius muscle and biceps femoris muscle (B). The saphenous nerve branches (white arrow) are seen lateral to the sartorius muscle (black arrow). Used with permission from: Donavan A, et al. MR imaging of entrapment neuropathies of the lower extremity. Radiographics. 2010;30:1001-1019.

Figure 4.

Common peroneal neuropathy secondary to a ganglion of the proximal tibiofibular joint. Sagittal magnetic resonance image shows a ganglion arising from the proximal tibiofibular joint (arrow) with associated denervation-related increased signal intensity of the anterior tibial and extensor digitorum longus muscles (arrowheads). Used with permission from: Donavan A, et al. MR imaging of entrapment neuropathies of the lower extremity. Radiographics. 2010;30:1001-1019.

Figure 5.

Lateral plain radiograph of the tibia showing an anterolateral stress fracture. This high-risk tension-sided stress fracture may be associated with prolonged nonunion.

Figure 6.

Coronal magnetic resonance imaging of bilateral lower extremities demonstrating an early stress reaction of the left tibia as evidenced by the development of edema in the proximal tibia.

Figure 7.

Magnetic resonance angiogram demonstrating occlusion of the left popliteal artery due to popliteal artery entrapment syndrome.