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A Practical Approach for the Differential Diagnosis of Chronic Leg Pain in the Athlete

Peter H. Edwards, Jr, MD^*,,, Michelle L. Wright and Jodi F. Hartman, MS

From the Ohio Orthopedic Center of Excellence, Upper Arlington, Ohio, the Ohio Riverside Sports Medicine Foundation, Upper Arlington, Ohio, and Orthopaedic Research & Reporting Ltd, Gahanna, Ohio

^* Address correspondence to Peter H. Edwards, Jr, MD, Ohio Orthopedic Center of Excellence, 4605 Sawmill Road, Upper Arlington, OH 43220 (e-mail: www.pedward3@columbus.rr.com).

Chronic lower leg pain results from various conditions, most commonly, medial tibial stress syndrome, stress fracture, chronic exertional compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome. Symptoms associated with these conditions often overlap, making a definitive diagnosis difficult. As a result, an algorithmic approach was created to aid in the evaluation of patients with complaints of lower leg pain and to assist in defining a diagnosis by providing recommended diagnostic studies for each condition. A comprehensive physical examination is imperative to confirm a diagnosis and should begin with an inquiry regarding the location and onset of the patient’s pain and tenderness. Confirmation of the diagnosis requires performing the appropriate diagnostic studies, including radiographs, bone scans, magnetic resonance imaging, magnetic resonance angiography, compartmental pressure measurements, and arteriograms. Although most conditions causing lower leg pain are treated successfully with nonsurgical management, some syndromes, such as popliteal artery entrapment syndrome, may require surgical intervention. Regardless of the form of treatment, return to activity must be gradual and individualized for each patient to prevent future athletic injury.

Key Words: chronic leg pain • medial tibial stress syndrome • tibial stress fracture • chronic exertional compartment syndrome • nerve entrapment • popliteal artery entrapment syndrome