How to manage common chronic lower leg injuries
In the world of running there can be little more frustrating than chronic calf or lower limb injuries. One of the world’s leading sports injury specialists Dr Lawrence Van Lingen discusses some of the more common ailments and shares some tips for managing them...
Lower limb injuries come with significantly longer healing times than injuries higher up in the body and also usually affect the fit and motivated. Novice runners tend to suffer more knee or hip injuries, elite and higher volume trainers tend to suffer more lower limb injuries.
Years of running tend to shape and forge one’s body into a purpose-built and efficient running machine, but it often seems that we become a bit more fragile, less malleable and less adaptable with a long history of running.
Let’s go through some of the common injuries...
Probably the most dreaded of these injuries is the triceps surae tear, or the soleus and gastrocnemius junction tear.
This typically occurs with little or no warning, will feel as though someone struck you or hit the back of your leg, and will put an end to your running for 12 to 16 weeks.
This injury tends to re-occur - usually when fit - and is a very common reason for marathon runners to be sidelined.
I mention this under chronic injuries as the scarring or accumulation of calf tears is, I believe, part of the cause of recurrent calf injuries. The soleus also plays a significant role in achilles injuries and lateral soleus tears, both injuries that can tend to stick around.
The soleus is the muscle that ultimately becomes the achilles tendon, so achilles and soleus problems are inter-related.
It's the muscle that does the most work and is under load the longest during the stance phase of running.
It is known as the “heart of the lower leg" as it assists with pumping venous blood back up the leg.
It contracts and releases with rotation and it's job is to propel you forward and not up. The soleus muscle has more bulk laterally (on the outside of your leg) than the medial or inner side. So the vector of the muscle when it contracts is a rotation that syncs with the hip translating forward and the femur rotating inward.
Rehabilitation or strengthening of the soleus (and achilles) should always include a rotation and be single-leg oriented and should focus on forward translation and not vertical or up and down movement.
Think of it this way:
Stand with one leg back, weight the outside of the foot and heel, then shift your hips forward as you go up onto the toes, a coupled motion.
It's less about a calf raise and more a controlled forward float. Remember, it is the muscle that works the longest in running—so, let it move you forward, don’t ask it to lift you up as well.
Soleus health is very reliant on calcaneal alignment. The calcaneus (the large heel bone through which you bear weight) needs to be neutrally aligned and have a normal range of motion.
The achilles tendon wraps around the calcaneus and is directly anatomically connected to the plantar fascia. The calcaneus is the guiding keystone of the elastic forces and energy return when you run. These are large forces, think two and a half times your body weight.
You probably need a skilled therapist to help you assess and mobilize the calcaneus, but chances are that if you sit with no weight through your legs and your heels turn in, you may need help in that department.
Gastrocnemius injuries - or the bulkier, outer, upper calf injuries - are often a bit more forgiving and tend to heal well and with less complications.
Common exceptions are large tears from sprinting, the already-mentioned triceps surae tears and nerve entrapments in the popliteal fossa and or lateral gastrocnemius and hamstring junctions.
The gastrocnemius (and soleus complex) are linked to the hip extensors and hip supporters, weak and or inhibited hip extension and or weak hip supporters or lack of hip control will overuse the calf complex.
Someone has to do the job, it will go better for you if you use the big guns in the hips.
Note that I did not say Glute strength, as I feel the overwhelming cultural perception of glute strength in running somehow involves the glute medius. There are 36 muscles in the hips and pelvis and all need to work together in concert. It’s far safer and more efficient to think of the hips providing forward thrust and drive and supporting the pelvis in forward drive, which ends up being the same thing.
Focus on the function. Weak hips, tight hips or poor hip control mean an overworked lower leg.
Outside Lower Leg, Peroneal Muscles and Flexor Hallicus Longus
The peroneal muscles are often a problem area for triathletes, it's possible that the varus wedges (wedges placed under the big toe side) tend to load up the outside of the lower leg and, coupled with a stiff ankle during pedaling, you can end up with inflexible peroneal muscles that are susceptible to anti-pronation orthotics/shoes and/or running on a slanted camber.
An absolute hidden gem for all those suffering from lateral leg pain is to realize that the big toe flexor (Flexor Hallicus Longus) - the muscle that provides the majority of forefoot control - crosses over at the heel and inserts on the upper outside of the leg, two thirds up, where, incidentally, the bulk of the upper soleus muscle inserts.
Coincidence? I think not.
Remember, the soleus has a rotary component to its action and it has a coupled motion that helps propel us forward off the forefoot from the outside of the foot off the toes.
The “Great Toe” is the captain of the ship and the counterpoint to the extension of the hip, which is also a coupled motion (that supports and drives us forward). A stiff big toe or poor big toe control is a major culprit of failed running mechanics and chronic running injuries all the way up to the hip.
Peroneal problems are usually easily rectified with self-massage, doing multiplanar or multidirectional foot exercises and gradually increasing tolerance of uneven surfaces; think about adding grass or off-road and trail running and balance exercises.
Again, try to think function:
Remember that the foot controls the body in running as it's pressed fairly firmly to Planet Earth when running and not the other way round, so doing lateral foot movements (wiggling the foot) with an exercise band is going to have less functional trade-off than doing multi-planar lunges, or side and crossover stepping (for instance) where the foot controls the body.
Don’t forget the “Great Toe” and its life partner the soleus in any lateral leg injury. Also check for local nerve entrapment of the common peroneal nerve on the outside of the knee.
Medial Leg Injuries, Toe Flexors and Rotation Stress
On the inside of the lower leg we have the home of the toe flexors. Just like the big toe flexor, the tendon to the muscle crosses over at the heel, going from the outside of the foot to the inside of the leg.
Pain on the inside of the shin usually comes from the insertion of the toe flexors or from the shin bone, think shin splints.
The toe flexors usually become overworked when you lean too far forward when running. This tends to slam the toes down, harden and lock the foot. Subsequently the calf complex and the entire weight of the body - multiplied by a factor of 2.2 to 2.5 - goes through the toe and foot structures while they're locked and rigid.
Remember, anatomists call them toe flexors because they make the toes go down when you contract them when lying on the anatomy table, but from a functional point of view the toe flexors provide stability, control, balance and grip.
When they contract hard along with the small muscles to the toes, they wrap around and reinforce the bones of the foot during running, jumping and sprinting.
Because of this protective function, the foot can withstand around 10 tons of force when sprinting and jumping, yet will break with comparatively little force if you drop a weight onto the top of the foot.
The key is not to run with a “sprinter’s foot”, but rather, like gripping the club just enough during golf, or the pen in writing, to let your feet use the right amount of protective force.
It’s a certainty that you run with too much toe downforce or a locked foot if you slide your hands into your running shoes and find deep dents in your insole where your toes are.
Learn to run with soft toes and control the amount of forward lean when you run, especially while running easy or long. It's natural to lean forward as we accelerate or sprint; it's not natural to run in a sustained forward lean.
Working on hip flexibility and strength will also make a more upright running stance feel natural. I've shared an image of forward lean vs. forward shift below.
As far as medial shin pain is concerned, it almost certainly indicates that you lack internal rotation and extension in your hip when running.
If this isn't the case then more than likely your ankle rotates inwards when you load it up. Either way, the shin acts as a shock absorber or is loaded under rotation.
Stress often occurs here during periods of high load and intensity or when running on hard surfaces, but from a biomechanical point of view it's often when the hip fights the foot.
As we transfer weight on the stance leg into extension and hip drive we must have hip extension and hip support. If hip extension and its coupled movement (internal rotation) is lacking, the normal inward rotation of the lower limb encounters external rotation from the hip (not the healthy internal rotation).
Sensing a common theme here?
The lower leg and ankle is about supporting the body and translating energy into forward motion, just like the hip complex.
The posterior tibial muscle is worth a mention here. Along with flexor hallicus and toe flexors, it forms the deep posterior compartment of the lower leg. Long haul flights and driving tends to see fluid and swelling accumulate in the lower leg and it can lock up the posterior tibial muscle and thus restrict ankle movement.
Many a destination race has been ruined because of a stiff and swollen posterior tibial muscle.
The best relief is to go for a 45 to 60 min slow walk as soon as possible after travel and to self-massage the lower leg or do some foam rolling with ankle movements of the lower leg, particularly deep through the achilles tendon, to target the deeper muscles close to the shin bone.
The tendon can also be overworked if it tries to support the medial arch, think poor medial arch of the foot control which is primarily the big toe’s job.
The Anterior Shin and Controlling Center of Mass
The anterior shin is often prone to shin splints or sometimes compartment syndrome.
This is usually caused by overworking the tibias anterior muscle and sometimes the big toe extensor as they try to stop the forefoot from slapping onto the ground.
It’s very common to overwork these muscles on long or steep descents. If you have problems in this area on the flats, it’s almost a certainty that you have a “center of mass” control problem.
If you walk with your hands and arms out in front of you like a zombie you will notice that your feet kick out in front of you with a pronounced heel strike (see pictures below).
Swinging your arms behind you and extending them behind you like the wings of the Rolls Royce "Spirit of Ecstasy" will immediately change your center of mass and allow the foot to land under the hip with a more whole foot striking pattern.
Voilà: anterior shin pain resolved.
No, you don’t have to run with both your arms behind you, just be more angel and less zombie to find ecstasy!
Note that I didn't tell you to think about controlling your foot:
The foot’s job is to control your body, your job is to control your center of mass so that the foot lands appropriately and can do its job.
Your foot should function autonomously rather like if you can touch type, you think the words, they then appear on the screen.
Thinking about your fingers is sure to slow you down and end in typos. If you're not happy with how your feet hit the ground, modify your posture and center of mass while running.
Trying to become a forefoot runner if you run like a zombie will only end in tears!
A good way of checking your running posture is to walk up to a wall, place your toes to the wall and press your hips into the wall. This gentle forward “shift” of your hips, with your shoulders above hips, is preferable to a forward “lean” where shoulders are in front of hips.
This is how to avoid your toes slamming down and tight feet and lower leg structures.
How comfortable do your face and hands feel if you were to run like this?
For most, the wall or a convenient palm tree is uncomfortably close to your face and your hands feel completely out of place, yet probably your lower legs are welcoming the proper placement of your upper body.
Practice this simple trick often until it feels comfortable and manifests in your running. Your lower legs and running will thank you.
You may even get more likes on Instagram.
Of major importance is the fact that anterior shin tension blocks ankle extension, which in turn results in reduced hip extension. So, running like a zombie is a real no no. Running happens underneath and behind you, not in front. Straighten up and shift those hips forward by drawing your shoulders back.
The most elegant and complex of structures.
A wonder of 33 joints, and more nerve endings than your hands.
The most important take home for foot injuries are the following...
Forefoot Control and Movement
It's uncommon for people to have plantar fascia injuries if they have adequate hip control, forefoot control and independent toe movement.
The foot is not a plank at the end of your leg that you stuff into the latest fashion accessory as you head out on a run.
People without hands can type, text, write, paint and brush their teeth with their feet. Almost every runner that ends up with plantar fascia problems is unable to independently pick up their big toe and leave their 4 toes on the ground and then do the opposite and lift their four toes, while the big toes go down.
Most people don't have enough toe flexibility and cannot adequately bend their toes both down and up. So work on learning that party trick and work on toe flexibility, both up and down by gently mobilizing your toes up and down, and then making sure you can go up and off your toes adequately under progressive load.
I have folded my toes underneath me and am stretching the tops of my feet and toes as I type.
I very commonly find neural tension in stubborn foot injuries.
What do I mean by neural tension?
If you have a peripheral nerve (a nerve outside of the spinal cord, for example, the well-known "sciatic nerve") that's entrapped, pinched, tethered or gets stuck along its pathway, then the tissue that it innervates, or that the nerve ends up in, tends to get tight or restricted or has altered tension and reaction to movement.
As an example, many people are aware that they have a mild piriformis pain or issue; literally a pain in the butt where the sciatic nerve crosses through or under the piriformis muscle.
Many people have similar entrapments or adhesions in the lower leg that aggravate lower limb conditions. These don’t have to occur in the leg on the injured side and can affect the lower leg if they're severe enough, from anywhere in the body.
I worked with a professional triathlete who was unable to run properly and walk without pain because of a plantar plate tear. He became able to walk and load the foot properly within 20 minutes of working on a whiplash injury (right brachial plexus - nerves roots in the neck and shoulder - and ulnar nerve in the elbow entrapments)!
It’s likely that you're suffering from neural tension if you have any of the following:
- a stiff neck
- lower back pain
- thoracic spine pain
- zinging or burning pain anywhere in the body—particularly if you have “Hot Foot” or numbness and tingling in the forefoot.
Nerve entrapments and treatment are beyond the scope of this article, but it’s appropriate here to emphasize the need to have a healthy posture and a whole body mobility program.
If you suspect that this is your problem, then you should talk to your therapist about peripheral nerve entrapments and neural flossing.
When you treat nerves, please remember two things:
- No pain for maximum gain
- Nerves love to glide and slide, but they're inflexible and cannot stretch. You can mobilize and or release or floss nerves better, you cannot stretch them better. So please seek specialized help when it comes to nerves.
I hope that this leaves you with a deeper understanding of problematic lower leg injuries.
I cannot overstate the importance of controlling your center of mass and learning to run with soft toes.
A daily or weekly regimen of self-massage and foot flexibility and dexterity is also invaluable. If you would like further thoughts or self-help tutorials on running injuries please visit my website or my YouTube channel.
Dr. Lawrence van Lingen is a Chiropractor who worked with the Mr Price Comrades Marathon Team for 10 years, helped Durban Surf Lifesaving Club to three world titles and Glenwood Falcons become regional Club Rugby Champions. He was Red Bull South Africa's High Performance manager in 2013.
Lawrence has treated and prolonged the careers of many of South Africa’s standout runners, triathletes and cyclists. He currently lives in California and helps numerous world class athletes with treatment and movement. He works with the Santa Cruz Syndicate and triple World Down Hill Mountain bike Champion Greg Minnaar. He also dabbles in coaching.