Exertional Leg Pain: Long Overdue for Some Respect!
Exertional leg pain remains a difficult problem that continues to plague athletes and those who exercise (and the clinicians that attempt to manage it). Unfortunately it is often overlooked as a trivial problem, and many athletes are dismissed, and told to either rest or use anti-inflammatory medication, without even bothering to establish a diagnosis. Rightly or wrongly, ‘shin pain’ is often not deemed as debilitating as the knee and ankle joints surrounding it.
The reality is that exertional leg pain can be quite debilitating- affecting the ability to exercise, and in some cases restricting even activities of daily living such as walking at a moderate pace. In rare instances, missed lower limb pathology can lead to limb or life threatening conditions that should not be missed.
Exertional leg pain can present a number of differential diagnoses, and confusing the issue is the fact that more than one (and sometimes multiple) causes can co-exist at the same time. Unfortunately unhelpful umbrella terms such as ‘shin splints’ are still used by both lay people and clinicians, leading to confusion and misdiagnosis.
Often one must treat one cause of exertional leg pain and manage this as best as possible, before it is possible to determine whether other problems are co-existing. For example debilitating medial tibial stress syndrome may mean that an athlete cannot run long or far enough to exhibit signs of a co-existing chronic exertional compartment syndrome (CECS). In this case it is best to optimize control of the medial shin pain with directed rehabilitation, followed by a graded return to running to identify whether the more classic crescendo-decrescendo pattern of CECS is present.
The Sports and Exercise Medicine Physician is often best suited to examine and interpret particularly recalcitrant exertional leg pain. This involves taking a thorough history, examining the patient (often at rest and after exercise when symptoms have been provoked) and interpreting a number of investigations. Always the aim is to establish a specific anatomical cause for the pain, and with a diagnosis (or diagnoses) embark on a directed and individualized treatment plan.
The Australasian College of Sports Physicians have established a working group with the aim of developing protocols for the work-up, investigation, and treatment of exertional leg pain. This is an area in dire need of further research and study, as much evidence is anecdotal. Once evidenced based protocols for the work-up and diagnosis are developed and accepted, maybe exertional leg pain will get some of the respect it deserves!