Chronic Lower Leg Injuries in Runners; Management and Perspectives.

October 5, 2015
Mobility

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In the world of running there can be little more frustrating than chronic calf or lower limb injuries. 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 these injuries in parts.

Soleus Muscle
Probably the most dreaded of these injuries is the triceps surae tear or 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.

Soleus Key Concepts
The soleus is the muscle that ultimately becomes the achilles tendon, so achilles problems and soleus problems are inter-related.
It is 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 its 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 is 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 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
Gastrocnemius injuries or the bulkier, outer, upper calf injuries often are 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.

Gastrocnemius Key Concepts
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, or 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, possibly 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 and you can end up with inflexible peroneal muscles that are susceptible to anti-pronation orthotics or shoes and or running on a slanted camber.

Lateral Leg Key Concepts

An absolute hidden gem for all 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 (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 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 is pressed fairly firmly to planet earth during 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 resolution of these issues can be made quite complex but luckily resolves down to two key concepts.

Key Concepts of Medial Lower Leg Pain
The toe flexors usually become overworked when we do one or both of the following two things. Lean too far forward in running, this tends to slam the toes down, harden and lock the foot and 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 are locked and rigid. Remember the anatomists call them toe flexors because they make the toes go down when you contract them, 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. The foot can withstand around 10 tons of force when sprinting and jumping because of this protective function, 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 is natural to lean forward as we accelerate or sprint, it is 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 have attached 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 during running. If this is not 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 hard surfaces, but from a biomechanical point of view it is 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.

Worth a mention here is the posterior tibial muscle which along with flexor hallicus and toe flexors 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 is possible after travel and to do self-massage of the lower leg or 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 overworking the tibias anterior muscle and sometimes the big toe extensor as they try control 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 angel (it’s called the Spirit of Ecstasy!) will immediately change your center of mass and allow the foot to land more 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 did not 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 are 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 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 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 Foot
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 is uncommon for people to have plantar fascia injuries if they have adequate hip control and 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 do not 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.

Neural Tension
I very commonly find neural tension in stubborn foot injuries. What do I mean by neural tension? If you have a peripheral nerve (nerve outside of the spinal cord, for example, the well-known sciatic nerve) that is 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 are severe enough, from anywhere in the body. I had a professional triathlete who was unable to run properly and walk without pain because of a plantar plate tear, become able to walk and load the foot properly within 20 minutes after 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 are suffering from neural tension if you have any of the following: headaches, a stiff neck, lower back pain, thoracic spine pain, numbness, tingling, 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: 1. No pain for maximum gain. 2. Nerves love to glide and slide—but they are 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 YouTube channel at http://www.youtube.com/c/LawrencevanLingen

Run well,
Lawrence

Lawrence van Lingen

I have helped thousands of elite and desperate people overcome career ending or insurmountable injuries and helped many achieve significant breakthrough in performance. Learn how to run and move better and run faster with less injury.The channel has simple running fundamentals and then more advanced running concepts.Start with Rule no 1. of running "Control your Center of Mass" and start with a simple daily flexibility routine. I suggest you start with doing the "penguins".Ask if you need help and let me help you run and move your best.

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