Anterior Lower Leg
ANTERIOR LOWER LEG
Dull Ache / Sharp Pain
Tibialis anterior, Extensor digitorum longus, Extensor hallucis longus mild strain / hypertonicity
- Dull ache on front of lower leg
- May refer down to into foot
- May be caused by increased running, jumping, or sudden stopping in sport
- Diagnosed through palpation and active testing muscle
- Severe strains (tears) may present with increased pain, swelling, bruising, and loss of function (ultrasound / MRI)
- Treatment through manual therapy and rehab exercises
Interosseous membrane sprain
- Dull deep ache on front of lower leg
- Local pain
- May be caused by increased running, jumping, or sudden stopping in sport
- Diagnosed through articulating tibia with fibula and comparing restrictions with opposite leg
- Treatment may involve rest from activity, manual therapy to surrounding tissues
Tibia / Fibula stress fracture
- Aching local pain
- Pain can get progressively worse after activity
- Common in Running athletes
- Diagnosed through X -ray, Bone scan, MRI
Treatment / prognosis
- Good prognosis. Rest from activity while wearing a moon boot for 6-8 weeks
Delayed onset muscle soreness (DOMS)
- Pain on front of leg felt after gym sessions, exercise, or repetitive activities
- Exercise routine may have included jumping, running, or cross fit training
- Self resolves within a week
Foraminal / Central canal stenosis with nerve root compression at L4,L5 Lumbar Vertebra level
Symptoms:
- Numbness, tingling, or burning sensation with radiculopathy down leg
- May also present only locally in front of leg with similar neurological symptoms
- Severe pain in low back region
- Painful to lean backwards (may produce sharp pain or neurological symptoms in front of leg)
- Weakness in leg(s)
- Muscle atrophy in lower limb
- Patient may find relief laying on their back with knees bent and legs raised onto a chair
A) Lumbar Disc herniation (M>F 40-60)
Caused by:
- trauma
- poor posture,
- repetitive activity
- overweight
Diagnosed via:
- Muscle testing (myotomes)
- Sensory testing (dermatomes)
- Patella tendon reflexes
- Lying / Sitting straight leg test
- Valsalva manoeuvre
- Observing for atrophy in muscles
- Case history of trauma, or poor lifting techniques involving twisting
- MRI
Treatment:
- Surgery
- Cortisone injection
- Conservative – medication, rest, manual therapy to surrounding musculature
- Disc herniations can heal on their own in 6-9 months
B) Vertebral spurs
Caused by:
- Osteoarthritis
- Trauma / Injury / fractures
Diagnosed by:
- X-ray
Treatment:
- Medication to reduce inflammation and pain
- Cortisone injection
- Surgery
- Manual therapy to surrounding musculature
C) Anterior longitudinal ligament ossification (Thickening)
Caused by:
- Unknown
- Hereditary
- Diffuse idiopathic skeletal hyperostosis (DISH)
- Trauma
Diagnosed by:
- X-ray / MRI
Treatment:
- Medication to reduce inflammation and pain
- Manual therapy to surrounding musculature
- Cortisone injection
- Surgery indicated when airways are potentially being blocked
D) Space occupying lesion (Cyst)
Caused by:
- Genetics
- Chronic inflammatory conditions
- Trauma / Injury to arteries, veins, lymphatics
- Blockages to ducts
Diagnosed by:
- MRI
Treatment:
- Surgery
Drainage
- Injecting cyst to reduce swelling and pain
- Laser removal
E) Space occupying lesion (Tumour)
Symptoms:
- May include systemic signs such as night pain, night sweats, fever, or enlarged lymph nodes
Caused by:
- Genetics
- Trauma / Injury
- Infectious disease
- Obesity
- Cigarette smoking / Excessive alcohol
Diagnosed by:
- MRI
Treatment:
- Surgery
- Radiation / Chemotherapy
ANTERIOR LOWER LEG
Numbness, Tingling, Weakness, Burning or Muscle atrophy
Foraminal / Central canal stenosis with nerve root compression at L4,L5 Lumbar Vertebra level
Symptoms:
- Numbness, tingling, or burning sensation with radiculopathy down leg
- May also present only locally in front of leg with similar neurological symptoms
- Severe pain in low back region
- Painful to lean backwards (may produce sharp pain or neurological symptoms in front of leg)
- Weakness in leg(s)
- Muscle atrophy in lower limb
- Patient may find relief laying on their back with knees bent and legs raised onto a chair
A) Lumbar Disc herniation (M>F 40-60)
Caused by:
- trauma
- poor posture,
- repetitive activity
- overweight
Diagnosed via:
- Muscle testing (myotomes)
- Sensory testing (dermatomes)
- Patella tendon reflexes
- Lying / Sitting straight leg test
- Valsalva manoeuvre
- Observing for atrophy in muscles
- Case history of trauma, or poor lifting techniques involving twisting
- MRI
Treatment:
- Surgery
- Cortisone injection
- Conservative – medication, rest, manual therapy to surrounding musculature
- Disc herniations can heal on their own in 6-9 months
B) Vertebral spurs
Caused by:
- Osteoarthritis
- Trauma / Injury / fractures
Diagnosed by:
- X-ray
Treatment:
- Medication to reduce inflammation and pain
- Cortisone injection
- Surgery
- Manual therapy to surrounding musculature
C) Anterior longitudinal ligament ossification (Thickening)
Caused by:
- Unknown
- Hereditary
- Diffuse idiopathic skeletal hyperostosis (DISH)
- Trauma
Diagnosed by:
- X-ray / MRI
Treatment:
- Medication to reduce inflammation and pain
- Manual therapy to surrounding musculature
- Cortisone injection
- Surgery indicated when airways are potentially being blocked
D) Space occupying lesion (Cyst)
Caused by:
- Genetics
- Chronic inflammatory conditions
- Trauma / Injury to arteries, veins, lymphatics
- Blockages to ducts
Diagnosed by:
- MRI
Treatment:
- Surgery
Drainage
- Injecting cyst to reduce swelling and pain
- Laser removal
E) Space occupying lesion (Tumour)
Symptoms:
- May include systemic signs such as night pain, night sweats, fever, or enlarged lymph nodes
Caused by:
- Genetics
- Trauma / Injury
- Infectious disease
- Obesity
- Cigarette smoking / Excessive alcohol
Diagnosed by:
- MRI
Treatment:
- Surgery
- Radiation / Chemotherapy
Local peripheral nerve damage (Superficial fibular peroneal nerve)
- Numbness and tingling
- Sharp, jabbing, or throbbing pain
- Sensitive to touch
- Gradual onset of symptoms
- Caused by local trauma, repetitive movements, crushed, or cut nerves (surgery),
- Medical causes: Diabetes, Multiple sclerosis, Guillain-Barre syndrome
- Electromyography (EMG test), Ultrasound, Nerve conduction test
- Treatment: self-resolving in 12 months, Surgery, or may not fully resolve
Multiple sclerosis (F>M 20-40)
- Peripheral neuropathies (numbness, tingling)
- Commonly unilateral
- Blurred or loss of vision in one eye
- May cause atrophy of muscles or loss of motor control
- May cause tremors
- Weakness in one or both legs
- Clumsiness of limb
- Feeling of walking on cotton wool
- Diagnosed through MRI (looking for lesions on brain or spinal cord), Lumbar puncture looking for abnormalities in antibodies in cerebrospinal fluid associated with MS)
- Often a diagnosis of exclusion as other conditions produce similar symptoms
- Treatment: medications
Diabetes
- Feeling of thirst
- Losing weight
- Urinating often
- Blurry vision
- Hunger
- Numbness and tingling
- Tiredness
- Dry skin
- Wounds may have trouble healing
- Prolonged bruising
Type 1
- Condition where the pancreas produces little or no insulin
Caused by:
- Unknown, has genetic links
Diagnostic tests:
- Random blood-sugar test
- Glycated Hemoglobin A1C blood test measures your blood sugar level over 2–3-month period to determine if it is consistently high
Management:
- Insulin injections
- Insulin pump
Type 2 (more common)
- Condition where the pancreas does not produce enough insulin
- Insulin that is produced in the pancreas does not work effectively
- Insulin is produced in the pancreas, but the body’s cells do not respond effectively
Caused by:
- Family history
- Age 45+
- Overweight
- High blood pressure
- Polycystic ovarian syndrome
- Gestational diabetes
- Giving birth to baby over 4.5kg (9lbs)
Diagnostic tests:
- Glycated Hemoglobin A1C blood test measures your blood sugar level over 2-3 month period to determine if it is consistently high
- Fasting glucose test
Management:
- Medication
- Lifestyle changes
Reflex sympathetic disorder (Complex regional pain syndrome)
- Chronic limb pain
- Pain is greater than expected than injury that may have caused it
- Continuous throbbing, burning, numbness and tingling
- Sensitive to touch (painful)
- Skin colour and temperature changes
- Not well understood
- May be post-surgery, injury, stroke, or heart attack
- May involve abnormal inflammation or nerve dysfunction
ANTERIOR LOWER LEG
Medical Considerations
Anterior compartment syndrome
Symptoms:
- Aching, burning and cramping
- Increased pain with activity
- Visual swelling and bulging of muscle
- Tightness and weakness of limb
- May present with numbness and tingling
- May present with foot drop in severe cases
- Commonly caused by running or sports involving running
- Diagnosed by measuring the compartment pressure. Needle is inserted into muscle before and after exercise.
Treatment
- Conservative treatment involves rest from aggravating activity, manual / physical therapy, inserts in shoes to help improve biomechanics of foot (Orthotics), and anti-inflammation medications
- Severe symptoms would include pain, paraesthesia (numbness and tingling), Pallor (colour fading), poikilothermia (ability to control the body’s core temperature independant of ambient temperature), paralysis, and pulselessness
- Severe cases will require surgery (Fasciotomy – procedure where the fascia surrounding the muscle is cut to help relieve tension, swelling and pressure. This allows an increase in circulation to aid with healing)
Deep Vein Thrombosis (DVT)
- Blood clots forming in a deep vein
- Swelling and bruising
- Leg colour changing to blue
- Painful
- Increase in temperature
- May have NO painful symptoms
- Caused by: stationary for long periods, pregnancy, injury to vein, obesity, post-surgery, increased age, blood disorders
- Duplex ultrasonography: an imaging test that uses sound waves to look at blood flow in the veins
- Compression stocking and anti-coagulants (blood thinners given orally or by injection, typically do not break up clots, but prevent new ones from forming)
Vascular claudication
- Dull pain in front of leg, thighs and calve muscles
- Radiates proximally
- Cramping, aching, squeezing feeling after walking for short distance
- Relieved with rest and sitting down
- Commonly over 50
- Commonly caused by aortoiliac arterial occlusive disease
Diagnosed via:
- Measuring pulse in hands and feet
- Blood pressure measurement in arms and legs (compare locations)
- Walking test: How far can patient walk without pain
- Doppler ultrasound
- MRI or CT angiography (narrowed blood vessels)
Treatment
- Conservative treatment involves walking-resting-walking for 30 minutes approximately 3x/week
- Severe cases with increased symptoms require surgery. Angioplasty involves widening a damaged artery and vascular surgery involves taking a healthy blood vessel from another part of the body to replace the damaged one.
Tibia / Fibula stress fracture
- Tenderness over region
- May not walk with a limp
- Sore to weight bear, but can still walk
- Minor swelling
- May have no visible sign of deformity
- Common in repetitive activity, sports, and running
- Diagnosed via: X-ray, MRI, Bone scan
- Treated with moon boot for 6-8 weeks
Tibia / Fibula fracture
- History of trauma
- Immediate swelling
- Tender to touch
- Bruising
- Limping
- Visible signs of deformity
- Unable to weight bear
- Diagnosed via X-ray
Reflex sympathetic disorder / Complex regional pain syndrome (CRPS)
- Chronic limb pain
- Pain is greater than expected than injury that may have caused it
- Continuous throbbing, burning, numbness and tingling
- Sensitive to touch (painful)
- Skin colour and temperature changes
- Not well understood
- May be post-surgery, injury, stroke, or heart attack
- May involve abnormal inflammation or nerve dysfunction
Treatment: Challenging to manage as results vary between patients. Some options may include:
- Acupuncture
- Pain relief medication, anti inflammatory medication
- Nerve block injection, morphine
- Intravenous Ketamine
- Manual / Physical / Exercise therapy
- Meditation, relaxation therapies