Lower leg injuries | North Vancouver

Lower Leg Injuries and Rehabilitation

By Dr. Jenn Turner

As triathletes and runners, we continually put our bodies at risk for a high number of different injuries. As more research is done into these various disorders, yet another reason is discovered as to why endurance athletes are great candidates for injury. Injuries to the lower leg and calf are no exception. The lower leg muscles are left fatigued and worn from the demands of the swim and bike portions when it comes time for the running component of a triathlon. Unfortunately it is the run where the greatest demand is placed on the lower leg muscles thus putting these muscles at risk for injury.

Anatomy of the Lower Leg

The lower leg encompasses all of the structures of the leg below the knee. It is further divided into four compartments that contain the various muscles of the lower leg. The anterior compartment (the front of the shin) is made up of 4 muscles that pull the toes up. This compartment is the usual spot for “shin splints” or compartment syndrome. The lateral compartment is along the outside of the lower leg and is made of 2 muscles which turn the toes out and up. The posterior compartment is at the back of the leg and holds the large muscles that are most commonly known as the calf muscles (the gastrocnemius and soleus). The gastrocnemius is shorter, thicker and has two attachments (inner and outer). It is the most visible of the calf muscles. The soleus lies underneath the gastrocnemius and in a small percentage of the population there is another muscle called the plantaris which is located in the posterior compartment as well. The tendons of these three muscles combine to make up the achilles tendon. The role of this muscle group is to point the toes. The deep posterior compartment is deep within the back of the lower leg and contains three muscles which help also with pointing the toes down but also have more specific roles within the foot.

TYPES OF LOWER LEG INJURIES

Gastrocnemius/Soleus strain or rupture
Posterior Shin Splints (deep posterior compartment) (also referred to as MTSS- medial tibial stress syndrome)
Anterior Shin Splints (anterior compartment)
Posterior or Anterior compartment syndrome
Achillies tendinopathy or rupture
Gastrocnemius/Soleus cramping
Various tendinopathies of muscles in other compartments
Tennis Leg (tear of the inside head of the gastrocnemius muscle)

Treatment and Rehabilitation

With any of the above injuries, in the earliest stages of injury, RICE (rest, ice, compression and elevation) is the best treatment and can be administered immediately. With all of the injuries listed above, inflammation is inevitable. The degree of inflammation will vary depending on the extent of the damage to the tissue. Tears or ruptures tend to have more inflammation due to the often “traumatic” nature of the injury. Tendinopathies are more likely to develop over time thus inflammation is not as noticeable. In the acute stage of injury anti-inflammatories may be of benefit if the swelling is severe. Crutches may be necessary to reduce weightbearing, especially in the case of a severe tear or rupture. Ice massage or light friction massage and gentle stretching to prevent adhesion formation is also beneficial for both types of injury and should be done to patient tolerance. In the case of a tendinosis, an early proprioception or balance program is a key for quick recovery (see photo). With a tendon injury, basic strengthening can be started right away as well, using what is called- isometric exercises. Isometric is defined as “same length of the muscle” which means that the muscle is gently contracted against a fixed resistance. This kind of exercise allows for strengthening the muscle without further inducing strain.

The next stage of injury is called the sub-acute stage. The pain and swelling has subsided but not completely resolved in this stage, and although function has improved, is still compromised. Practitioners can address adhesion formation more aggressively in this stage using Active Release Technique® or another soft tissue technique. Range of motion exercises should become a priority in the sub-acute stage. These are best done non-weight bearing using a towel to begin and progressing to standing stretches as shown in the pictures. Range of motion can also be incorporated in strengthening protocols which will include both concentric (shortening) and eccentric (lengthening) contractions of the calf muscles as shown. Eccentric strengthening is essentially the “negative” or “down” phase of the exercise. So in the case of a posterior leg tear or tendinopathy, the athlete will go up on two feet on to their toes, and then slowly come back down so the weight is distributed evenly on the toe and heel. To increase the difficulty of this exercise, after the up phase one foot can be lifted and the athlete must come down slow and controlled on one foot. Researchers have been examining the effects of eccentric exercises, and if done correctly, can help to restore the tendons to better than pre- injury status. Increasingly difficult proprioception and balance exercises and balance should be continued in this stage as this type of rehabilitation has also been shown to speed recovery with injury.

During the acute and sub-acute phase activity modification is a must to promote healing. This means that the athlete should not be running but can still swim or do water running which is gravity assisted. This will put less stress on the healing structures, but still allow the athlete to stay conditioned. Moderate intensity cycling may be beneficial to increase blood flow, increase range of motion and prevent de-conditioning as well.

The final stage of rehabilitation expands on the previous levels. This stage requires all the care of the previous stages of injury with an increase in the complexity of most of the exercises. In this stage “return-to-play” and more functional exercises are done to prepare the athlete for the increased demands of the swim/bike/run. A biomechanical analysis is good to do in this stage, especially in the case of long term or recurring injuries. Orthotics may be required to alter foot and lower leg mechanics and the strengthening program may expand to address muscular imbalances above and below the actual point of injury. Return to activity must be monitored to prevent increasing the intensity, duration and frequency of training too quickly. In the case of prolonged pain or complete rupture, further steps should be taken for advanced imaging studies to rule out stress fracture or for surgical repair.

Using a towel or strap can be of assistance for increasing range of motion in non-weight bearing positions. To include both the gastroc and soleus, do one stretch with the leg straight and then bend the knee and repeat the stretch. Hold each stretch for 30 seconds.

Non weight bearing exercises on a wobble board or rocker board in the first stages is essential in preventing injuries from recurring. Once weight bearing is not painful these exercises can progress to standing.

ECCENTRIC TRAINING

Standing, the athlete goes up on both toes. Then lifting one foot, the athlete very slow and controlled comes back down with the load on the other foot. This exercise should be done only when weight bearing is not painful. Just a few reps should be done per set as eccentric exercise is associated with Delayed Onset Muscle Soreness (DOMS), which can inhibit recovery if excessive load is put on the tendons and muscles.

In the later stages of injury, advanced proprioception exercises can be a focus for rehabilitation. Using a bosu ball or unstable surface for doing exercises such as squats and lunges can help to develop better stability to the entire kinetic chain including the lower leg.

Dr. Jenn Turner is a triathlete and chiropractor. She is currently completing a residency program to be a Chiropractic Sports Specialist and is a director of Moveo Sport and Rehabilitation Centre, a partner with North Shore Athletics. Contact her at jenn@moveo.ca.

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