Lower Extremities: Achilles Tendon Rupture and Tennis Leg

An Achilles tendon rupture is an extremely debilitating injury. The most likely scenario for a tendon rupture occurs during activity when a person is flat-footed with their ankle dorsiflexed and knee extended; thus, stretching the calf muscle, which attaches to the Achilles tendon, and engage in a sudden, violent eccentric muscle contraction. This scenario places the tendon at its maximum stretching point at the same time that it’s being placed under a heavy load. Expect to feel, and possibly hear, a big pop in the lower part of the back of the calf, causing the foot to unstable and unable to bear weight. Basketball and tennis are the most common sports during for an Achilles tendon rupture. Immediate medical attention is required for an injury of this magnitude.

Tendonitis can be treated with rest from the offending activity for about 3 to 6 weeks. Apply cold therapy to the injured tendon for at least 20 minutes, 2 to 4 times daily. Perform light stretches and isometric plantar flexion and dorsiflexion exercises. Do toe raises in an exaggerated slow motion. Use a foot brace to secure the Achilles tendon, which will take pressure off the injured area allowing time for it to rest and heal. If a heel lift is used instead it should be used in both shoes so there is no leg length discrepancy which could lead to additional injuries. Wearing cushioned shoes with a rear heel counter that doesn’t rub against the tendon is also helpful at relieving discomfort. Ultrasound and physical therapy may also influence developing scar tissue that forms during healing.

Stress fractures are the result of an accumulation of microscopic cracks along the length of the bone as a result of overuse or overtraining. The lower third of the tibia is a common site of stress fractures in the lower body. The injury doesn’t occur suddenly and neither does the pain. It sets in gradually, over a period of weeks, at first hurting only during or after a workout. In some cases, fatigue-related fractures in which the body’s repair process lags behind the process of bone degradation can be a sign of bone disease, so chronic problems should be evaluated by a physician.  As a stress fracture advances it gradually feels more painful as time lapses.

Compartment syndrome is caused by an increase in pressure within one or more of the four muscle compartments of the leg that are enveloped and separated by fascial connective tissue membranes. When working out, blood flow within these compartments increases, causing the muscles to expand by as much as 25%. If there are further increases in volume of the compartment, as a result of inflammation or bleeding, the fascia may not be able to expand enough. The pressure then increases, leading to pain, tingling, cramping or numbness. The onset can be sudden and acute or gradual and chronic. Acute episodes are usually brought on by a direct blow to the shin like a contusion that causes intra-compartmental bleeding, or by a sudden increase in the degree of exertion, which causes an injury to the muscle-tendon unit. The most common site for compartment syndrome is the anterior compartment in front of the leg, near the flat portion of the tibia. The condition can cause the muscles to cramp up so tightly that it forces a stop in activity. Often, as soon as the offending activity is stopped, the symptoms subside. In extreme cases, however, the blood flow is so severely restricted that nerve injury occurs, resulting in temporary or even permanent paralysis of the muscle.

For numbness, pressure or paralysis that aren’t immediately relieved by stopping activity, see a physician immediately. The fascia may have to be loosened by an incision to release pressure. When suffering from mild, chronic compartment syndrome, in which the pressure, pain and tingling only occur when running or cycling hard make sure to reduce the exercise load. Gradually build back up over time and take preventative measures so pain and injury do not reoccur.

Shin splints describe a condition of pain and inflammation on the inner and slightly posterior, or rear, aspect of the leg, usually along the lower half to third of the tibia, from overuse of the posterior tibialis muscle. Causes of this condition include an exaggerated stride, extending the leading leg out too far when running, distance running on hard surfaces and most often over pronation. The pain is caused by inflammation at the broad area where the posterior tibialis attaches to the tibia. The periosteum, the thin layer of tissue covering the bone, often becomes inflamed as well. As bone tissue is highly innervated this condition can be very painful. Refrain for at least a week of activities that exacerbate the pain. Apply cold therapy at least 2 to 4 times a day for 20 minutes at a time. When the pain subsides, a foot brace with elastic tension and compression will provide arch support that helps limit over pronation, relieving stress on the posterior tibialis. Make certain that shoes are fit to wear and that they maintain cushioning and support. Running on softer surfaces like dirt, cinder, track and grass will help lessen shearing forces.

Tennis leg or a gastrocnemius strain is a tear of the fibers in the more superficial calf muscle, the muscle closer to the surface. The gastrocnemius crosses two joints, the ankle and the knee. Like other biarticular, two-jointed muscles like the hamstrings, it’s most prone to injury while performing two different functions at either end simultaneously. For example, stepping forward, planting one foot in a position with the knee extended, a move common in tennis, hence the name tennis leg. The pain is typically sudden and will feel like a sharp pop or ping. The area over the injured tissue will immediately turn red and feel hot.

When suffering from a strain, immediately begin RICE. It can take up to 2 months for a calf strain to fully resolve. During that time, switch to conditioning activities that don’t place load or impact on the calf muscle. A foot brace, heel pad or shoe with a higher heel will help take pressure off the calf muscles during recovery. When playing tennis, it’s extremely important to maintain strength and flexibility in the calf muscles and Achilles tendon. Calf stretching should follow a light cardiovascular warm-up before hitting the court.