The Anatomy of a Runner: lower leg

The sixth in a series of posts about the anatomy of a runner. A runner’s most common injuries in the lower leg include fractures or stress fractures of the bones, strains, ruptures or tears of the muscles, a Charley horse or cramps, shin splints, and to a lesser degree deep vein thrombosis in athletes, and the dislocation of the fibula head. Each of these injuries are discussed in this post, including why it hurts, where it hurts, treatment options and prevention.

FUNCTIONAL OVERVIEW

Located between the knee and ankle, the lower leg consists of four compartments that contains muscles, nerves and blood vessels separate from their neighbors. Each compartment is surrounded by tissue known as fascia. Muscles in these compartments control the motion of the foot and ankle while the two bones of the lower leg provide attachments to thigh muscles, and bears most of the body’s weight.

F374E56D-5BC2-477E-A9CA-892AB3EEE6CAThe human legs are exceptionally long and powerful as a result of their exclusive specialization to support and locomotion — in orangutans the leg length is 111% of the trunk; in chimpanzees 128%, and in humans 171%. Humans also use 75 percent less energy walking upright than chimps use walking on all fours primarily because chimps use large hip muscles while humans use smaller muscles, like those in our lower legs. (Wikipedia)

Note: For the purposes of this discussion, the ankle and Achilles’ tendon will be covered in a future post.

MAJOR PLAYERS:

BONES

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Tibia: a Latin word meaning both shinbone and flute (flutes were once fashioned from the tibia of animals).

Fibula: a Latin word that designates a clasp or brooch. The fibula was likened by the ancients to a clasp attaching it to the tibia to form a brooch.


The two bones of the lower leg, the tibia and fibula, are two of the body’s long bones, given this name because they are longer than they are wide, they are the major bones of the limbs, and are responsible for the bulk of our height as adults.

The tibia, the larger of the two bones, is familiarly known as the shinbone, and bears most of the body’s weight. The fibula runs alongside the tibia on the outer side, and swells into a bony knob on the outside of the ankle known as the lateral malleolus. (The medial malleolus, felt on the inside of the ankle, and the posterior malleolus, felt on the back of the ankle, is part of the tibia.)

The fibula, also known as the calf bone, is mainly a muscle attachment point and plays a significant role in maintaining balance, stabilizing the ankle, and supporting the muscles of the lower leg. Compared to the tibia, the fibula is about the same length, but is considerably thinner.

A cavity is found in the center of the bone that serves as a storage area for bone marrow used to store energy in the form of lipids. The overall mass and thickness of the bone increases under stress, such as from lifting weights or supporting body weight.

BONE FRACTURE

Why it hurts: A tibial fracture is the most common injury of all long bone fractures resulting from automobile collisions, sports injuries, or falls from a height.

Where it hurts: Symptoms may include tenderness directly over the shin bone, deformity of the leg, swelling and bruising, an inability to bear weight. If a fracture is suspected, seek medical advice immediately.

Treatment depends on the location and severity of the fracture, but usually includes immobilization and limitations in weight-bearing activities. Because there is less blood supply to the mid and lower parts of the tibia they tend to heal more slowly. Some fractures may require surgery.

STRESS FRACTURE

Overuse stress fractures are more common among runners and endurance athletes and account for up to half the injuries sustained by military recruits; causes include 1) insufficiency: when osteoporotic bone is subjected to normal stress, and 2) stress: when normal bone is subjected to excessive load.

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Jointessential.com

Why it hurts: Stress fractures (also called hairline fractures) are overuse injuries of bone: a result of repetitive sub-threshold loading that, over time, exceeds the bone’s intrinsic ability to repair itself.

The term ‘overuse injury’ is falling out of favor within the research community, however, since the true cause of the injury has been more accurately described as ‘training load errors’ rather than overuse.

Since the fibula is not primarily responsible for weight-bearing, a stress fracture here is not as common as a fracture of the tibia. Much of the fibula’s surface is used for muscle attachment, which results in traction and twisting forces being placed on the bone. It’s this tug and pull, however, that could cause a stress fracture to develop over time on the fibula.

Athletes with excessive pronation, where the weight remains on the inner side of the sole, are more susceptible to a fibula fracture because the peroneal muscles work harder and longer during toe-off in the running gait cycle.

  • A fracture is thought to occur from a sudden change in frequency, mileage, pace, or terrain. Studies released this year build on a growing body of research that suggests it’s not how much you train in isolation, but how the training load changes (training load errors). For example, athletes (in this case elite rugby league players) who increased their training load by 60 percent as compared to their weekly average over the previous four weeks were more likely to get injured.
  • Lack of rest after long runs, running shoes greater than 6 months old or with more than 300 to 500 miles, and running on hard or cambered surfaces are other extrinsic factors that may also play a role in the development of a bony stress injury.
  • A runner’s gait may lead to higher load rates that put a runner at risk, including excessive hip movement (adduction), rear foot eversion (turning inward/outward), and stride length (stride will be covered in detail in a future post).
  • Muscle fatigue may also play a role in stress fractures since both muscles and bones serve as shock absorbers for the body. As muscles of the lower leg become fatigued they lose their ability to absorb shock, creating greater stress on the bone, and increasing the risk of fracture.
  • High-arched runners are more at risk for bone-related injuries like stress fractures in the shin and foot, and shin splints – by almost 50% more than low-arched runners – because they run with “stiffer” legs giving them less up-and-down motion causing the forces to be absorbed by the bones. (Low-arched runners have a higher relative muscle to lower-body stiffness making them more prone to soft-tissue and joint injuries like Achilles tendinopathy/tendinitis and runner’s knee – both according to observational findings from studies dating to the late 1990s and early 2000s).
  • In a recent study by Burgi et al., there were twice as many tibial stress fractures in women with low vitamin D concentrations.
  • Previous stress fractures also predispose stress fractures.
  • Female Athlete Triad: Energy deficiency is the main cause of the Triad. An energy deficiency is an imbalance between the amount of energy consumed and the amount of energy expended during exercise. The Female Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity, including: 1) Energy Deficiency with or without Disordered Eating, 2) Menstrual Disturbances/Amenorrhea, and 3) Bone Loss/Osteoporosis. Gender specific topics, such as the Female Athlete Triad, will be covered in detail in a future post.

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Where it hurts:

  • D27315E0-977B-4F5E-A47F-FD4EBC130589
    Jointessential.com

    Gradual onset of localized pain on the inner aspect of the shin bone. Pain is often sharp, increases with activity, and decreases with rest. Occasionally pain may be felt at rest or even at night. Walking may aggravate symptoms.

  • Although pain may radiate away from the injury, tenderness will be felt when firmly touching the site of injury.
  • A tibial stress fracture may also present as calf pain or on the front of the shin (as opposed to the inner side of the shin).
  • A stress fracture of the fibula will present as the gradual onset of pain in the calf. Pain may also present at the ankle, depending on the specific location of the fracture.
  • X-rays usually do not show new stress fractures, but can be used several weeks after the onset of pain. A CT scan, MRI, or 3-phase bone scan is more effective for early diagnosis with the MRI being the most effective.
  • Another diagnostic measure often used is the tuning fork test where a tuning fork is applied to the fracture site to produce pain. There is little supporting evidence for the tuning fork although one small study found it had a positive predictive value of 77%. Personal experience also supports the effectiveness of this diagnostic tool.

Treatment: Depending on the severity, complete rest may be advised using a brace, walking boot, crutches, or air cast. An air cast has pre-inflated cells that put light pressure on the bone, which promotes healing by increasing blood flow to the area.

  • POLICE is the new acronym (as opposed to RICE or PRICE).
    • Protection: is a method of off-loading stress from the injury using crutches and/or a supportive tape.
    • Optimal Loading: encourages healing by gradual loading of the tissue to promote the cellular responses required for healing.
    • Ice: used initially for pain relief then let the body do the work. Avoid heat and massage.
    • Compression: for support. Do not over-compress. Supportive tape, such as K-tape or a flexible elastic bandage, will partially off-load the injured tissue and provide flexible support during movement without constricting.
    • Elevation: raise and support the leg to reduce swelling; lower gradually to minimize fluid flooding back to the area. The goal is to reduce swelling, not inflammation, which is vital to healing. Don’t compress and elevate at the same time.
  • Cross-training to maintain fitness during recovery is possible and even preferred if it can be completed without pain to the injury. Cycling, the elliptical, or water exercises may be good alternatives. Avoid rocky terrain when cycling with a stress fracture; in fact, a stationary bike is the best alternative. Training, or ‘loading’, should complement the healing process by providing an acceptable level of stress to the injury – not pain. Consult your physician.
  • Recovery lasts 4-8 weeks or longer; healing will continue even after the injury is pain-free.
  • Although there’s little scientific evidence to support the practice, runners everywhere use the “hop” test to determine if a stress fracture has adequately healed enough to return to running.
  • Gradual return to training is recommended. One option is to use a reverse marathon taper program, or alternate running with cross training days to create a slow build-up of mileage.
  • Consult your physician if pain persists despite home treatments, or if a complete fracture is suspected.

Prevention:

  • Avoid sudden ‘peaks’ in training. It’s not necessarily high training loads that cause injuries, it’s how you get there.
  • Don’t increase training too fast, and allow adequate recovery between hard bouts of exercise.
  • 80% of training volume should be low intensity and only 20% high intensity. Adding more high intensity sessions won’t necessarily improve performance.
  • Incorporate calf muscle strengthening exercises to your routine.
  • Ensure a balanced diet, including calcium, vitamin D, and vitamin K – deriving these vitamins through diet rather than supplements is preferred.
  • Replace worn shoes. Experiment with various shoe styles to find what works best for you, or consider seeking the advice of a professional. It has been noted that some runners experiencing multiple lower leg injuries find relief in a gradual introduction to barefoot or minimalist running. The “less foot supportive” running styles are believed by some to result in less transmission of the forces that are known to lead to running injuries, such as stress fractures. Consider consulting your physician, a physiotherapist or a running shoe specialist.
  • Vary running surfaces between hard and softer surfaces.
  • Evidence suggests the risk of stress fracture may be lower among adult runners who have had a broad athletic background that includes childhood participation in “ball sports,” providing incentive to avoid sport-specialization in young athletes.
  • Sixty percent of osteoporosis risk is related to the amount of bone mass accrued by early adulthood, suggesting some athletes may be pre-disposed to injury. Read more: Bone Health in Endurance Athletes Runners Cyclists and Swimmers
  • Stretching leg muscles during warm-up before exercise has shown no significant effect on preventing tibia stress fractures even though studies show that calf tightness plays a role. Tight calves cause a premature lifting of the heel while running and transfers a significant amount of force into the forefoot. Try incorporating a stretching routine on non-running days to loosen tight muscles.
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Courtesy: OctaneFitness

Shin Splints (Medial Tibial Stress Syndrome – MTSS)

Medial tibial stress syndrome (MTSS or shin splints) is characterized by pain in the anterior/front, or sometimes on the inside front of the lower leg, and is a common injury among athletes in sports that involve running. Athletes have long used the term shin splint to reference pain generally felt along the shin bone, regardless of its specific location.

Why it hurts: Numerous studies since 2012 have investigated different aspects of MTSS and yet it is still unclear exactly how the injury occurs. These studies have proposed MTSS is caused by muscular or tendon strain, overuse of the muscle tissue surrounding the tibia (shinbone), or that it is a precursor to Periostitis (a condition caused by inflammation of the connective tissue that surrounds bone).

The accuracy of all these studies have been argued. In fact, anatomical research studies question whether underdeveloped muscles, muscle strains and overuse factors could even be considered risk factors since no tibialis muscle attachments exists in the areas where most shin splint symptoms present.

Traditional thought has been that shin splints occurred more often in inexperienced runners increasing mileage too quickly although, unfortunately, MTSS also occurs in trained distance runners and in athletes who have none of the suspected risk factors.

Risk factors include a pronated foot type, high body mass index (BMI), running on a canted surface, an excessively fallen arch (excessive navicular drop), and a foot tilt in relation to the ankle (medial calcaneal tilt).

Where it hurts: Pain presents along the length of the shin bone. Pain with weight-bearing is typically worse in the mornings and exacerbated by the end of exercising, when climbing stairs, and at night.

Treatment: few well-designed studies of MTSS treatments have been conducted, which leaves us with traditional treatment options as opposed to scientific data. Nonetheless, athletes across all disciplines have found relief in one or more of the following areas:

  • Reduce training, or cross train through recovery as long as there is no pain.
  • Avoid hills, which can aggravate the shins.
  • Taping the shin with an elastic bandage, K-tape or by using a neoprene sleeve will compress the muscles and limit muscle movement to provide support and some pain relief.
  • Run on more forgiving surfaces; avoid cement.
  • Consider specialized shoes or orthotics to correct pronation issues.

Is it a stress fracture or shin splints?

The pain of shin splints is generally described as diffuse tenderness along the length of the shin bone – although pain from a tibial stress fracture will also be felt throughout the shin bone (considered radiating pain) making the two conditions difficult to differentiate. With a tibial stress fracture, however, the pain is most prominent when pressing your finger on the specific spot of the fracture whereas there is no ‘specific’ spot of tenderness with shin splints.


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Calf Muscles

The gastrocnemius is the larger calf muscle, forming the bulge visible beneath the skin. The gastrocnemius has two parts or “heads,” which together create its diamond shape. The soleus is a smaller, flat muscle that lies underneath the gastrocnemius muscle.

Note: Calf muscles, also known as the “second heart,” contribute to proper circulation in the body. When calf muscles contract during movement, fluids are pumped toward the heart. Standing for extended periods of time without moving results in fluids draining to the feet and ankles causing swelling. This swelling makes the feet, ankles and lower legs feel achy and tired.

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Calf Muscle Injuries

Calf injuries usually occur from a sudden pushing-off movement or from excessive over-stretching of the calf muscles as with jumping activities or quick changes of direction.

Calf muscle strain: Stretching the calf muscle past its normal length results in tearing of some calf muscle fibers, and can vary from mild (slight pain) to severe (complete tear of the calf muscle). “Pulling” the calf muscle also stretches the calf muscle beyond its limit resulting in a strain.

Calf muscle tear: All calf muscle strains tear the muscle fibers although a more serious injury may result in a partial or complete tear of the calf muscle.

Calf muscle rupture: A complete tear of the calf muscle results in severe pain and an inability to walk. The calf muscle may collapse into a compact ball that can be felt through the skin.

Calf muscle myositis: a rare condition causing inflammation of the calf muscle as a result of infections or autoimmune conditions.

Rhabdomyolysis: Calf muscle breakdown due to long-term pressure, drug side effects, or a severe medical condition. Rhabdomyolysis usually affects multiple muscles throughout the body.

Where it hurts: Symptoms may vary significantly but usually involve a sudden sharp pain at the back of the lower leg. The calf muscle will often be tender to touch at the point of injury, swelling and bruising may appear within hours or days. Calf injuries are graded from 1 to 3, with grade 3 being the most severe.

Grade 1: a twinge of pain in the back of the lower leg or a feeling of “tightness”, it may be possible to continue exercise without pain or with mild discomfort. Post-exercise, however, there will likely be “tightness” and/or aching in the calf muscles which can take up to 24 hours to develop.

Grade 2: sharp pain at the back of the lower leg and usually significant pain on walking, swelling in the calf muscle with mild to moderate bruising, although bruising may take hours or days to be visible. Pain will be felt when pushing the toes and foot downwards towards the floor.

Grade 3: often referred to as “ruptures” is associated with severe immediate pain at the back of the lower leg. Likely exercise can not continue and walking is difficult or impossible due to weakness and pain. Considerable bruising and swelling may appear within hours. The calf muscle can not be contracted at all and a gap in the muscle can usually be felt.

 

 

 

Sportsinjuryclinic.net

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One of several ways to support a calf injury through taping: athletictapeinfo.com

Treatment/Prevention: 

  • P.O.L.I.C.E./P.R.I.C.E. is essential. (Optimal Loading should only be used if it can be performed pain-free, and depending on the Grade of the injury. A Grade 3 injury will likely follow P.R.I.C.E.)
  • Use a compression bandage immediately to stop the swelling – applied for no more than 10 minutes at a time (restricting blood flow can cause more damage). A calf support or sleeve can be applied for longer periods of time.
  • Wearing a heel pad to raise the heel and shorten the calf muscle will take some of the strain off the muscle. (Use heel pads in both shoes to avoid one leg being longer than the other, creating an imbalance and possibly leading to other injuries / pain, such as in the back.)
  • Resistance bands can be used initially after injury, followed by calf raises and eventually single leg calf raises – only if they are not painful. Once you can perform 3 sets of 20 single leg calf raises pain-free, gradually incorporate easy running. Incorporate plyometrics or hopping exercises to correct any muscle imbalances and prevent the injury recurring.

Read more at SportsInjuryClinic.net.

Strong Calf Muscles Will Make You Faster (Runner’s World)


Charley Horse / Cramps / Exercise-associated muscle cramps (EAMC)

Exercise-associated muscle cramps are a common condition experienced by recreational and competitive athletes alike.

Why it hurts: Theories abound, but the most prevalent causes have been attributed to dehydration or electrolyte imbalances – although neither have held up to scientific scrutiny. The American Academy of Orthopedic Surgeons’ information on the subject included inadequate stretching, poor conditioning, fatigue, age, intense heat, dehydration, and depletion of electrolytes among risk factors, but these too could not be proven.

Studies comparing the hydration and electrolyte levels of athletes experiencing cramps and those without cramps exhibited similar levels of both. Also of note is that digesting fluids and/or electrolytes takes too long to enter the body’s circulatory system to have an immediate effect for treatment.

The conclusions most accepted from these studies is that EAMS has been found to occur most often in less well-trained athletes, appears to be more common in some families, and in those more susceptible to heat illnesses. It is also more common in men than in women, and in fatigued muscles.

Where it hurts: Muscles that are the most prone to cramps are those that cross two joints. Examples of such muscles are the hamstrings, gastrocnemius (one of the calf muscles) and the quadriceps group which includes the rectus femoris (the longest of the quadriceps muscles).

The hamstrings span the hip and knee, the gastrocnemius spans the knee and ankle and the rectus femoris crosses the hip and knee.

Treatment: Stretching the affected muscles is the fastest way to stop cramps, as painful as this may be. One theory for the success of stretching is that tendon nerve receptors are stimulated to shut down the cramp signal.

Eating bananas will not prevent cramping, and as stated, cramping has no relationship to hydration or electrolyte levels. Increased hydration does not prevent cramping and can have other more lethal results (hyponatremia). Pickle Juice may be a surprising remedy, but it has been used to stop and prevent cramps since the 1950s. Recent studies show that it not only works, but it works in as little as 35 seconds. Coaches and athletes have found similar success with mustard and sour candy.

Recently, Roderick MacKinnon, a Nobel-prize winning neurophysiologist, avid kayaker and fellow cramp sufferer, has put his professional skills and desire toward understanding EAMC and the mechanism by which pickle juice resolves the problem. MacKinnon discovered two taste receptors in the mouth that are stimulated in response to the pickle juice, and corresponded this to the food versions of these stimulants, which turns out to be cinnamon, capsaicin, weak acid and ginger. He’s now formed a company that sells “Hotshot,” – a 1.7 ounce drink consumed 15-30 minutes before exercise to boost neuro muscular performance and prevent muscle cramps according to their website.

Isometric Stretching to stop leg cramps: watch the video at dailyvitamoves.com.


Compartment Syndrome

Compartment Syndrome is a condition of increased pressure within the lower leg compartments resulting in insufficient blood supply to tissue.

Why it hurts:

Acute Compartment Syndrome is commonly due to physical trauma, such as a bone fracture or crush injury, and includes severe pain, poor pulses, decreased ability to move, numbness, or a pale color. Treatment includes surgery.

Chronic compartment syndrome is caused by repetitive use of the muscles resulting in increased tissue pressure within the compartment. Muscle may increase up to 20% during exercise causing pressure to build in the tissues and muscle. This condition is often triggered by running or cycling, is more prevalent in those under the age of 35, and in males. Pain is felt during exercise and may include numbness, but typically resolves with rest.

Where it hurts:

Chronic Exertional Compartment Syndrome symptoms involve tightness, or a tingling sensation in the area most affected followed by a painful burning sensation, sometimes also described as aching, tightening, cramping, sharp, or stabbing – the pain may also be confused with the pain of shin splints, stress fractures and tendinitis. The differentiating symptoms of compartment syndrome is a moderate weakness and numbness. There may also be difficulty dorsiflexing the foot and ankle (moving it upward), or the foot may seem to “flop”. Feet and even legs may fall asleep due to reduced blood supply.

Symptoms occur at a certain threshold of exercise that will vary individually from 30 seconds to 10-15 minutes, after a certain distance or at a certain intensity of exertion after exercise begins, progressively worsens as exercise continues, and subsides within 10 to 20 minutes of stopping the activity. Over time, recovery time after exercise often increases. Taking a complete break from exercise or performing only low-impact activity might relieve symptoms, but usually only temporarily. Once running is started again, for instance, symptoms usually come back.

Compartment Syndrome may occur in conjunction with other injuries as well, such as fractures. Consult your physician sooner rather than later.

Treatment: A conservative treatment includes rest. Elevation is not recommended; the affected area should be kept level with the heart. Splints, casts, or tight dressings should be avoided. Do not tape or use compression of any kind.

In some people, compartment syndrome is an anatomical problem that cannot be “deconditioned” and will persist with physical activity. If the symptoms persists, a surgery known as a fasciotomy would be recommended, and is the most effective treatment option. Failure to relieve the pressure may result in serious complications.

Prevention: Exertional compartment syndrome is a form of overuse injury. Build mileage slowly ensuring adequate rest and recovery days are included in your schedule. Determine the point in which the pain arrives and stop running just prior to this threshold, slowly building time/distance. Low intensity cross training can be used to maintain conditioning while giving the body a rest from repetitive loading.

Note: A military study conducted in 2012 indicated that symptoms subsided in individuals with lower leg chronic compartment syndrome when taught to change their running stride to a forefoot running technique. (Wikipedia)


Antero-lateral dislocation of the fibular head (sometimes called a stuck fibular head)

2E0F7002-AD08-40D0-90AB-722ACFBB220FProximal tibiofibular joint dislocation is an uncommon injury, and is most often found in sports involving aggressive twisting of the knee, such as soccer, the long-jump, snow-boarding and horse-riding, although runners have also been affected.

Where it hurts: Lateral knee pain that is aggravated when pressure is applied over the fibula head. Limited knee extension; clicking or popping can be heard. Ankle movement may exacerbate the pain. Some runners complain of pain in the upper outside of the calf muscle (behind the fibula bone).

Treatment begins with a reduction of the dislocation: while the knee is flexed and the foot is dorsiflexed (flexed in an upward position) and externally rotated, pressure is applied over the fibula head until a “pop” is heard.

Alternatively, using a rolled towel placed high under a bent knee, bend the lower leg back onto the towel to apply pressure onto the fibula head. View a YouTube video here.

Reduce or eliminate training during recovery. K-tape or a Robert-Jones bandage has proven effective for support.


Venous Thromboembolism and Marathon Athletes

Venous Thromboembolism (VTE) is the collective term for deep vein thrombosis and pulmonary embolism where awareness is key to its prevention.

The risk of VTE is related to (1) the efficiency of blood flow, (2) the integrity of blood vessels, and (3) the physical composition of blood itself. Although rare, athletes, particularly those who travel or stay sedentary for prolonged periods of time in between training sessions, may develop blood clots.

It’s important to know that clots can occur anywhere in the body, including upper limbs. Because of overall conditioning (muscle tone and low body mass index), a high level of baseline fitness, and pain tolerance, athletes may not seem at risk for VTE. This is where we’re reminded how a health professional would view an athlete’s risk: being fit does not mean to be healthy.

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Virchow’s triad of risk factors for venous thromboembolism (VTE). Factors in red are associated with heightened risk in marathon athletes. Note that athlete-specific factors are present in all 3 sections of the triad; a cumulative risk of VTE in certain individuals is entirely possible. (Photo courtesy: AHAJournals.org)

Why it hurts: The body is designed with a natural balance between factors that cause the blood to clot and other factors that cause the blood to dissolve clots. Veins carry blood back to the heart from the rest of the body where clots can form in the deep veins of the legs, arms, pelvis, abdomen, or around the brain, which are called deep vein thrombosis (DVT). If a piece of the clot breaks off from a leg or arm and travels to the lung, it can cause a clot in the lung, called a Pulmonary Embolism – a life threatening medical emergency. Seek immediate medical attention if you have symptoms of a Pulmonary Embolism.

Deep Vein Thrombosis leg symptoms are often mis-diagnosed in athletes as muscle tears, a Charley horse, twisted ankle or even shin splints.

Chest symptoms of a Pulmonary Embolism may be attributed to a pulled muscle, inflammation of the joint between the ribs and breast bone (costochondritis), bronchitis, asthma, or even early signs of pneumonia.

Athlete-specific risk factors are common in endurance runners, such as inflammation, dehydration, low heart rate (bradycardia) and low blood pressure.

Where it hurts:

Deep Vein Thrombosis: 

  • Swelling, usually in 1 leg, often visible in the calf and ankle;
  • Leg pain, tenderness, or the sensation of chronic cramping that does not ease with ice, stretching, or painkillers;
  • Inactivity may exacerbate the pain, and activity may alleviate pain;
  • Reddish or blue skin discoloration (often obvious when bathing with hot water);
  • Leg warm to touch;
  • Unexplained upper arm or neck swelling (upper extremity deep vein thrombosis);

Pulmonary Embolism:

  • Sudden shortness of breath or breathlessness on exertion;
  • Rapid heart rate;
  • Cramp in side or chest, painful breathing.

Recovery:

  • Refrain from training for 1 month after diagnosis.
  • Anticoagulation therapies prescribed by a doctor increase the risk of bleeding: contact, impact, and high-intensity sports that increase the risk of physical trauma should be avoided.
    • High risk: cycling (on- and off-road cycling), boxing, rugby, baseball, soccer.
    • Low risk: power walking, running (moderate), swimming, controlled conditioning exercises in the gym.
  • Wear individually fitted compression stockings to reduce the long-term risk for post-thrombotic syndrome.

Prevention: Defense Wins Games

  • Take breaks and stretch legs when traveling long distances;
  • Stay well hydrated (during and after a strenuous sporting event, and during travel);
  • Know the symptoms of DVT and PE and seek early medical attention if they occur;
  • Be aware that DVT and PE can occur even in athletes;
  • Know the risk factors for blood clots, including whether you have a family history of blood clots;
  • In case of major surgery, trauma, prolonged immobility, or when in a cast: talk to your doctor about your specific DVT risks.
  • Learn more, or join the awareness campaign for athletes at stoptheclot.org.

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This post is meant for informational purposes only. Please consult a physician to discuss your specific injuries.

Additional Reading/References:

Miller K. Plasma potassium concentration and content changes following banana ingestion in exercised males. J Athl Tr. 2012;47:648-654.

Miller K, Mack G, Knight K, et al. Reflex inhibition of electrically-induced muscle cramps in hypohydrated humans. Med Sci Sports Exerc. 2010;42:953-961.

Miller K, Mack G, Knight K. Electrolyte and plasma changes following ingestion of pickle juice, water, and a common carbohydrate-electrolyte solution. J Athl Tr. 2009;44:454-461.

Miller K. Electrolyte and plasma responses following pickle juice, mustard, and deionized water ingestion in dehydrated humans. J Athl Tr. 2013 (in press).

Miller K, Knight K, Mack G, et al. Three percent hypohydration does not affect the threshold frequency of electrically-induced muscle cramps. Med Sci Sports Exerc. 2010;42:2056-2063.

Braulick K, Miller K, Albrecht J, Tucker J, Deal J. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2012;47:710-714.

Physical Medicine and Rehabilitation for Stress Fractures Stephen Kishner, MD, MHA et al 2017

Stress Fractures: Diagnosis, Treatment, and Prevention: American Family Physician

Proximal Tibiofibular Dislocation.” Emergency Medicine Journal : EMJ 23.5 (2006): e33. PMC. Web. 17 Sept. 2017.  

Runner’sWorld: How to take care of your calves

Runner’sWorld: Build Stronger Lower Legs 

Exercise Associated Muscle Cramps, Peter G Gerbino Sports Medicine and Rehabilitation Journal Review Article Published: 19 Dec, 2016

Advances in Understanding Medial Tibial Stress Syndrome, Debbie Craig Sports Medicine and Rehabilitation Journal Review Article Published: 20 Oct, 2016 

Exercise May Reverse Age-Related Bone Loss in Middle-Aged Men, Press Release July 2015

Will 1 Minute of Running a Day Really Strengthen Your Bones? Digging into the research behind a seemingly improbable health claim. By Alex Hutchinson JULY 26, 2017,

Malisoux, Laurent et al. “Injury Risk in Runners Using Standard or Motion Control Shoes: A Randomised Controlled Trial with Participant and Assessor Blinding.” British Journal of Sports Medicine 50.8 (2016): 481–487. PMC. Web. 20 Sept. 2017.

Phys Ed: Do Certain Types of Sneakers Prevent Injuries? New York Times BY GRETCHEN REYNOLDS JULY 21, 2010

Can Arch Height Predict Your Running Injuries? By Alex Hutchinson JULY 21, 2017

Bone Health in Endurance Athletes: Runners, Cyclists, and Swimmers

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