How to manage lower limb injuries

In the world of running there can be nothing more frustrating than lower limb injuries as they come with significantly longer healing times than injuries higher up in the body and can affect your fitness and motivation long-term.  

Over the years, I’ve witnessed that novice runners tend to suffer more knee or hip injuries, while elite and higher volume trainers battle with more lower limb injuries. Years of running can shape and forge your body into a purpose-built, efficient running machine. However, in some cases, a long history of running can make the body a bit more fragile and less adaptable – unless you focus on form and the right mobility exercises.

The key is to understand your body and work with your strengths and weaknesses. Don’t ignore persistent pain and get to the “root” of the problem.

Here are some common lower limb injuries: 

Soleus muscle problems

No, I’m not referring to your triceps in your arms. This injury occurs in the calf or soleus and gastrocnemius junction. It can flare up with little or no warning and will feel as though someone struck you or hit the back of your leg.

This injury tends to re-occur, usually when fit, and is a common reason for marathon runners to be side-lined. It can halt your running for at least 12- 16 weeks, frustrating, I know. I mention this under chronic injuries as the scarring or accumulation of calf tears is 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’s the muscle that does the most work and is under load the longest during the stance phase of running, which is when your heel touches the ground.
• It’s 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, not up.
• The soleus muscle has more bulk laterally (on the outside of your leg) than the medial or inner side.
• When it contracts, the vector (or force) of the muscle is a rotation that syncs with your hip translating forward, and your femur rotating inward.

Rehab and mobility

Stand with one leg back, weight on the outside of the foot and heel, then shift your hips forward as you go up onto your toes, in a coupled motion. This movement is less about a calf raise and more about a controlled forward float. Remember, it’s the muscle that works the longest in running—so, let it move you forward, don’t ask it to lift you up as well.

Remember, strengthening of the soleus (and Achilles) should always include a rotation and be single leg oriented. It should also focus on forward translation and not vertical or up and down movement.

To practice shifting forward and rolling onto the ball of your foot as opposed to going up and down, try one of my favourite mobility exercises known as the Awesomiser.

There are three parts to the Awesomiser:

• The set up and how to roll off your toes
• Getting into your hips – where you translate them forward and back (We then synchronize the hip and toe movements)
• Hip openers.

So, next time you go for a walk or run, head out the door 5 minutes early and practice this move before you get going. You’ll soon start to feel the benefits.

Did you know?

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 connected to the plantar fascia, which is the ligament that connects your heel to the front of your foot.

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 mobilise the calcaneus, but chances are, if you sit with no weight through your legs and your heels turn in, you may need help in that department.

Upper calf injuries 

Gastrocnemius injuries or the bulkier, outer, upper calf injuries are often a bit more forgiving and tend to heal well, with less complications. Common exceptions are large tears from sprinting, the already-mentioned triceps surae tears (above), nerve entrapments in the popliteal fossa (the diamond shaped area in the posterior side of the knee) 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 contribute to overuse of the calf complex.
• The way your hips and pelvis work together has a direct impact on your lower body.

Did you know?

There are 36 muscles in your hips and pelvis, and they all need to work together in concert. It’s far safer and more efficient to think of your hips providing a forward thrust and drive and supporting your pelvis in this forward drive, which ends up being the same thing. Focus on the function. Weak hips, or tight hips or poor hip control will translate to an overworked lower leg.

WATCH My happy hips video and try the move yourself to help you achieve functional, supple hips.

Lateral leg problems

The peroneal muscles are often a problem area for triathletes. In some cases, varus wedges (wedges placed under the big toe side) can load up the outside of your lower leg, and this, coupled with a stiff ankle during pedalling could cause inflexible peroneal muscles that are susceptible to anti-pronation orthotics and/or running on a slanted camber.

Lateral leg key concepts

• An absolute hidden gem for all suffering from lateral leg pain is to realise that your big toe flexor, the muscle that provides most forefoot control, crosses over at your heel and inserts on the upper, outside of your leg, two thirds up, where incidentally the bulk of your 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 you forward off the forefoot from the outside of your foot off the toes.
• The “Great Toe” is the captain of the ship and the counterpoint to the extension of your hip which is also a coupled motion that supports and drives you forward. A stiff big toe or poor big toe control is a major culprit of failed running mechanics and can cause chronic running injuries all the way up to the hip.

Rehab and mobility

Peroneal problems are usually easily rectified with self-massage, doing multidirectional foot exercises and gradually increasing your tolerance of uneven surfaces. Consider adding grass or off-road trail running and balance exercises to your regime.

Again, try to think function. Remember, your foot controls your body in running as it’s pressed fairly firmly to planet earth during running and not the other way round. So, doing lateral foot movements (wiggling your foot) with an exercise band is going to have less functional trade-off than doing multi-directional lunges, or side and crossover stepping where your foot controls your body.

If you’re dealing with any lateral leg injury, don’t forget the “Great Toe” and its life partner- the soleus. Also check for local nerve entrapment of the common peroneal nerve on the outside of your knee.

In my blog on running without orthotics, I discuss how to achieve independent big toe and four-toe control.

Medial leg injuries

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 – a good example is shin splints. Fixing these issues can be quite complex, but ultimately it boils down to two key concepts.

Medial lower leg key concepts

The toe flexors usually become overworked when you lean too far forward in running.

This lean motion tends to slam the toes down, harden and lock the foot and subsequently the calf complex. Additionally, the entire weight of your body, multiplied by a factor of 2.2 to 2.5, goes through your toe and foot structures while they’re locked and rigid.

Remember they’re called toe flexors because they make the toes go down when you contract them. 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 your foot.

The key is to not run with a “sprinter’s foot”, but rather with a gentle hold, like a firm, comfortable grip of a golf club or a pen in writing. This will ensure your feet use the right amount of protective force.

Try this test:

To determine whether you run with too much toe downforce or a locked foot, slide your hands into your running shoes and see if you 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, but 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.

WATCH my video on the difference between a forward lean and a forward shift

Rotation stress

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 isn’t the case, then your ankle could be rotating 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. From a biomechanical point of view, it’s often when the hip “fights” the foot. As you transfer weight on the stance leg into extension and hip drive, it’s important to have hip extension and hip support. If hip extension and internal rotation is lacking, the normal inward rotation of the lower limb encounters external rotation from the hip (not the healthy internal rotation), which can cause pain.

The job of your lower leg and ankle is to support your body and translate energy into a forward motion, just like your hip complex.

Rehab and mobility

The posterior tibial muscle (which runs along the inside of the leg and ankle), along with the flexor hallicus (a deep muscle which runs along the calf) and toe flexors forms the deep posterior compartment of the lower leg.

Long haul flights or driving for long periods can cause a build-up of fluid and swelling in the lower leg, which can lock up the posterior tibial muscle and thus restrict ankle movement.

For quick relief try:

• Going for a 45-60-minute walk as soon as possible
• Do self-massage on your lower leg
• Try foam rolling with ankle movements of your lower leg.

When you roll, focus on gently rolling over your Achilles tendon to target the deeper muscles close to the shin bone. The tendon can also be overworked if it tries to support your medial arch, which is in fact, your big toe’s job.

Shin splints 

The anterior shin is often prone to shin splints or sometimes compartment syndrome. This is usually caused by overworking the tibias anterior muscle and/or the big toe extensor as they try control your 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, it’s likely 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’ll notice that your feet kick out in front of you with a pronounced heel strike.

Swinging your arms behind you and extending them behind you like the wings of the Rolls Royce angel will immediately change your center of mass and allow your foot to land under your hip with a 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 run pain free.

Anterior shin tension can block your natural 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 of you. Straighten up and shift those hips forward by drawing your shoulders back.

Remember, this isn’t about controlling your feet. The foot’s job is to control your body, your job is to control your center of mass so that your foot lands appropriately and can do its job. Your foot should function autonomously. If you’re not happy with how your feet hit the ground, modify your posture while running.

Your running posture

A good way of checking your running posture is to walk up to a wall, press your toes to the wall and press your hips into the wall. This gentle forward “shift” of your hips with your shoulders above your hips is preferable to a forward “lean” where your shoulders are in front of your hips. This is how to avoid your toes slamming down when you run, or tight feet.

How comfortable do your face and hands feel if you were to run like this? For most people the wall is uncomfortably close to your face and your hands feel completely out of place, yet I’m certain 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.

You can also check out my blog on simple ways to improve your running position. 

Your feet

Your feet are one of the most elegant and complex structures in the body. They have over 30 joints, and more nerve endings than your hands.

Forefoot control and movement key concepts

• It’s uncommon to have plantar fascia injuries if you have adequate hip control and forefoot control, as well as independent toe movement.
• Almost every runner that ends up with plantar fascia problems is unable to independently pick up their big toe and leave their four toes on the ground and then do the opposite and lift their four toes, while the big toes go down.
• Work on toe flexibility, both up and down by gently mobilising your toes up and down, and then make sure you can go up and off your toes adequately under progressive load.

Neural tension

I often 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’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.

For example, many patients who come to see me have mild piriformis pain (literally a pain in the butt where the sciatic nerve crosses through or under the piriformis muscle). Others have similar entrapments or adhesions in the lower leg that aggravate lower limb conditions.

You may have neural tension if you suffer from:

• Headaches
• A stiff neck
• Lower back pain
• Thoracic spine pain
• Numbness
• Tingling
• Burning pain anywhere in the body

Nerve entrapments and treatment are beyond the scope of this article, but it’s important to emphasise the need to have a healthy posture and a full 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, remember two things:

1. No pain for maximum gain
2. Nerves love to glide and slide—but they’re inflexible and can’t stretch.

You can mobilise and/or release or floss nerves better, but you can’t stretch them better. So please seek specialised help when it comes to nerves.

I hope that this leaves you with a deeper understanding of problematic lower leg injuries. I can’t 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.

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If you would like further thoughts or self-help tutorials on running injuries, please visit my YouTube channel

A similar version of this article was shared by my friends at Precision Hydration. Read their article here.