Recently I saw a very interesting case of lower extremity pain with exercise where I was able to help this patient find a diagnosis and treatment plan after several years of symptoms, several medical professionals and many many tests and scans had not provided answers. Lower extremity pain that occurs with exercise can have a variety of causes and is an excellent reason to see a sports medicine physician. Foot, ankle, leg, knee, thigh or hip pain with exercise is frequently experienced by runners and cyclists, but can be an issue for all active people, regardless of their sport of choice. While some causes are common are easily diagnosed, others are rare, require special testing (usually immediately after exercise) and are rare enough that many physicians may not have even heard of the diagnosis, much less know how to diagnose or treat it. In this blog, we will discuss some of the various and interesting reasons an athlete’s legs might hurt during exercise.
The most common cause is stress reaction or stress fracture of the tibia. Stress reactions are common running injuries and could be caused by training errors, inadequate nutrition, improper or over worn footwear. Examination, x-rays and sometimes an MRI or Bone scan will confirm the diagnosis. Treatment may include rest, nutritional optimization, activity modification and in rare cases surgery.
Tendonopathy or tendonosis is also seen commonly in runners and other athletes. This condition used to be called “tendonitis” but inflammation usually doesn’t play a significant role, so that term has fallen out of vogue among clinicians familiar with the more recent research. Examination, ultrasound and MRI are all helpful in making the diagnosis. X-rays may help rule out bone injuries or find variations that can make tendonopathy more likely. Rehab exercises to stimulate healing the tendon is the mainstay of treatment, while activity is modified to stop ongoing injury. Occasionally injections or rarely surgery can be helfpul.
Nerves can become entrapped in tissue, compressed by an injury/spinal disc or anatomic variation. During exercise the nerve gets irritated through friction or compression and symptoms increase. These can be quite tricky to diagnose. A detailed exam, MRI or an EMG nerve test can identify the problem. Treatments include physical therapy, injections around the nerve, long acting nerve blocks, or surgery.
Whenever a person exercises, there is some swelling of the muscles that occurs. This is a normal response to exercise. However, in some patients the swelling is excessive and the thick fascia layers around the muscle don’t stretch enough to accommodate the swelling. In these patients, this restricted swelling causes severe pain in the effected muscles and poor circulation. Called Chronic Exertional Compartment Syndrome (CECS), the pain and circulation get better with rest, but the condition doesn’t seem to get better without treatment. CECS is definitively diagnosed by measuring the pressure in the muscles with a needle attached to a special meter, but clues can be found on exam or MRI. While major surgery used to be the only option, newer treatments include minimally invasive procedures and injections with botox.
A large supply of blood flow to working muscles is essential to sustain exercise. In some patients, particularly masters class or older athletes, persons who smoke, have diabetes or problematic cholesterol levels, plaque can build up in the arteries and restric blood flow. This is the general cause of most heart attacks and strokes, and can be a cause for leg pain with activity, typically for patients with the risk factors just mentioned. In healthy, young, athletic patients, there are some uncommon conditions where the arteries can become restricted during exercise. Popliteal Artery Entrapment Syndrome (PAES) is usually associated with one of 6 anatomy variations in the muscle and/or artery behind the knee which becomes pinched during ankle movements. PAES can be diagnosed with examination, ultrasound or arteriogram with the patient in certain positions. Studies that are done with the patient in the normal relaxed position will miss the problem. Another vessel problem seen in healthy athletes (usually cyclists) is Iliac Endofibrosis. In this condition a major artery kinks causing the blood flow to become very fast and turbulent. This fast abnormal blood flow causes scaring inside the artery which makes the kinking worse. Iliac Endofibrosis is progressive and can be expected to get worse without treatment. For both PAES and Iliac Endofibrosis, surgery is usually the needed treatment.
Because of the diverse number of causes, most physicians are not familiar with diagnosing the full range of causes for exertion lower extremity pain. If you aren’t able to exercise to your potential because you get pain in your lower extremities, seek out a sports medicine physician to get the answers you need.