Dr David White — Exercise Induced Leg Pain — Injury Rehab Network

The last Injury Rehab Network with BASRaT of 2025 featured a presentation from Dr David White, Consultant Physician in Sport, Exercise and Musculoskeletal Medicine (SEM) at the OrthTeam Centre. The online event took place on the afternoon of Thursday 18th December with 200 sports rehabilitation practitioners in attendance.

Dr White shared insights into exercise induced leg pain. The recording is available to watch here.

Dr David White, Consultant Physician in Sport, Exercise and Musculoskeletal Medicine (SEM) at the OrthTeam Centre

Dr David White is a highly experienced Consultant Physician in Sport, Exercise and Musculoskeletal Medicine (SEM) at the OrthTeam Centre, with expertise in managing a wide variety of musculoskeletal presentations across a patient’s journey. He works as part of a multidisciplinary team dedicated to delivering high-quality care to every patient.

He is a Clinical Lead for the SEM clinic at Manchester Foundation Trust (MFT), having been initially appointed in 2016. Alongside this, he has worked in elite level football for 15 years. This includes a position as Lead Medical Officer for the Irish Football Association, where he also works as Senior Men’s Team Doctor. Dr White has also worked for several years within Premier League and Championship settings. He is a member of the new FSEM ‘Team Care Committee,’ with a responsibility for standard-setting and training within the elite team care environment.

Dr White has a keen interest in medical education and holds the role of Trust Speciality Training Lead for MFT. He is a Clinical and Education Supervisor of SEM trainees across their training programme, and an affiliate lecturer at Manchester Metropolitan University, teaching on a range of SEM topics. He is also a Course Lead on the UEFA Football Doctor Education Programme (FDEP) held in Northern Ireland each year.

Exercise Induced Leg Pain

Dr White commenced his presentation with an introduction to exercise induced leg pain (exertional pain in leg) and highlighted the need for a multi-disciplinary team (MDT) approach. Practitioners are advised to carefully consider history to support good diagnosis and treatment. The term shin splints is now seen as outdated with exercise induced leg pain, better addressing with complexities associated with lower limb pain.

David referenced a quote from Abraham Maslow, “When all you own is a hammer, every problem starts looking like a nail.” This quote reinforced the point that practitioners should expand their diagnostic toolbox, skills, and knowledge for the effective management of exercise induced leg pain.

Diagnostic Framework

A working group led by Nat Pandhiar undertook a scoping review; Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP). This review is similar to the Doha consensus on groin pain.

The elements of the diagnostic framework for EILP include:

• Patient history
• Symptoms
• Physical findings
• Investigative tools

Patient history and symptoms are the most important elements.

Diagnostic Possibilities

Dr White considered the diagnostic possibilities that he would go on to discuss in further detail:

• Chronic Exertional Compartment Syndrome (CECS)
• Medial Tibial Stress Syndrome (MTSS)
• Tibial stress fracture
• Popliteal Artery Entrapment Syndrome (PAES)
• Myofascial Tear
• Lumbar Radiculopathy
• Superficial Peroneal Nerve Entrapment Syndrome (SPNES)
• McArdle’s Syndrome
• Accessory, low-lying Soleus

David provided a useful table to assist practitioners in considering history, exam, and investigation options for each of the diagnostic possibilities.

Chronic Exertional Compartment Syndrome (CECS)

CECS is often seen in athletic patients and is always bilateral. Pain is predictable and progressive with exertion and athletes cannot run through the pain. However, there is a quick resolution of pain after activity cessation and there may be a normal examination at rest.

Dr White discussed compartment pressure testing and advised caution as it is shown to offer supplemental but imperfect diagnostic guidance.

Treatment of CECS may involve fasciotomy surgery. David provided guidance for post-fasciotomy rehabilitation.

Medial Tibial Stress Syndrome (MTSS)

MTSS is usually bilateral with medial sin pain that does not immediately resolve after ceasing activity. MTSS presents as diffuse tenderness on palpation along the posteromedial tibia. MRI may show periostitis.

Tibial Stress Fracture

May be linked to history of recent load increase with pain at the very outset of exercise. Tenderness can be pinpointed to the tibia and most commonly at the distal third.Patients may have an inability to hop. X-ray can be normal unless practitioners measure and look carefully. MRI +/- bone scan is the investigation of choice. Treatment must include correction of any vitamin D deficiency.

For more information about bone stress injuries please see the Injury Rehab Network presentation from Dr John Rogers.

Popliteal Artery Entrapment Syndrome (PAES)

Features claudication-like exertional pain and is usually unilateral (bilateral in one-third of cases). Caused by occlusion of popliteal artery and shown arterial duplex US with plantaflexion. MR angiography and Dynamic Angiography imaging will display the syndrome. PAES surgery is complex and patients may now be offered Botox injections as initial treatment prior to surgery.

Dr White discussed a case of a 52-year-old male with peripheral arterial disease. The patient was non-athletic and diabetic. Pain in the right calf was progressive on exertion. On investigation the right femoral pulse was absent, but the distal pulses were palpable. Imaging showed complete occlusion of the right Common Iliac Artery.

Myofascial Tear (with muscle herniation)

There may be a history of blunt trauma in unilateral cases whereas congenital weakness may be present in bilateral cases. Pain is anterolateral with swelling linked to activity. Imaging using dynamic ultrasound can support a positive diagnosis. Herniation may be promoted by placing the patient into a lunge/ fencing stance.

Dr White recommends a four-stage rehabilitation programme:

• Stage 1 = Rest
• Stage 2 = Exercise loading
• Stage 3 = Eccentric exercises
• Stage 4 = Plyometric exercises

Lumbar Radiculopathy

Patients are more likely to have pain at rest and at night and may have paraesthesia. Positive clinical signs on lumbar spine examination include positive straight leg raise (SLR) lumbar test and positive slump test. MRI may also be used to inform diagnosis.

David shared a case of a 24-year-old male who was identified as having Berlotti’s Syndrome where there is fusion of the lower lumbar vertebra transverse with the sacrum. When combined with back pain this is termed Berlotti’s Syndrome and can be unilateral or bilateral. Radicular leg pain can precede back pain.

Superficial Peroneal Nerve Entrapment Syndrome (SPNES)

Presents as exertional pain and altered sensation over the anterolateral shin and dorsum of foot. Seen in endurance athletes with compression of the SPN as it exits the fascia by muscle. Can be identified through a positive Tinel’s test at the exit point. Anatomical pain mapping may be used to visualise areas of pain.

A diagnostic guided local anaesthetic injection can be used to identify the problem area. Surgery may be required to release the nerve.

McArdle’s Syndrome

Dr White discussed McArdle’s Syndrome which is a rare genetic disorder affecting approximately 1 in 150,000 people. It is a glycogen storage disease with deficiency in enzyme muscle glycogen phosphorylase (PYGM). This is needed to break down glycogen into glucose for energy. The patient is unable to utilise muscle glycogen stores.

The condition presents in the twenties with exercise intolerance due to muscle pain and weakness. Onset is at the very start of exercise in the anaerobic stage. Patients may get a second wind phenomenon (pathognomonic). There are chronically raised levels of creatine kinase (CK), even at rest. Tests may include post-exercise lactate graph, genetic testing, and muscle biopsy.

Accessory, low-lying Soleus Muscle Syndrome

This condition has 3% prevalence with an additional soft mass in posteromedial distal calf and is usually unilateral. This may lead to an increase in the superficial posterior compartment pressure during exercise (symptoms mimic CECS). It may often be asymptomatic and can be identified through ultrasound of MRI.

Take Home Points

David concluded his presentation with the following advice and take-home points for practitioners:

• Approach with broad differential diagnosis.
• Solid anatomy knowledge is helpful.
• Educated history is the cornerstone of diagnosis – supported by examination and investigations.
• Consensus papers on diagnosis, investigation and structured management are on the horizon.
• Consider SEM referral to coordinate multidisciplinary approach to management.

Q&A

David kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from David to the questions.

Presentation Recording

The recording of Dr White’s presentation is available to watch here

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