A HARVARD MEDICAL SCHOOL

SPECIAL HEALTH REPORT

Healing Leg Pain

A troubleshooting guide to common disorders that affect the legs

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HEALING LEG PAIN
SPECI A L HE A LT H REPORT
Medical Editor
Contents
Robert H. Shmerling, M.D. Why your legs hurt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Associate Professor in Medicine, Harvard
Medical School
Hip pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Clinical Chief, Division of Rheumatology, Beth
Israel Deaconess Medical Center Hip anatomy 101. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Executive Editor Bursitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Anne Underwood Groin pull (strain). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Writer Copy Editor Hip fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Stephanie Watson Robin Netherton Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Creative Director Tendinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Judi Crouse
Production/Design Manager Upper leg pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Susan Dellenbaugh
Upper leg anatomy 101 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Illustrators
Barb Cousins, Harriet Greenfield, Scott Leighton Deep-vein thrombosis (DVT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Published by Harvard Medical School
Hamstring strain or tear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
David Roberts, MD Iliotibial band syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Dean for External Education Meralgia paresthetica. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Urmila R. Parlikar Sciatica. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
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Knee pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
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Ron Goldberg, Chief Financial Officer; Tom Canfield, Vice Ligament injuries (sprains) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
President, Circulation.
Meniscal tears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Copyright © 2019 by Harvard University. Permission is
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the material contained herein. Submit reprint requests to: Patellofemoral pain syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . 35
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Fax: 617-432-1506 Lower leg pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Website Lower leg anatomy 101 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
For the latest information and most up-to-date publication Achilles tendinitis and tendon tear. . . . . . . . . . . . . . . . . . . . . . . 39
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Cellulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
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(toll-free), or write to Harvard Health Publishing, P.O. Box Peripheral artery disease (PAD) and claudication . . . . . . . . . . . . 43
9308, Big Sandy, TX 75755-9308. Peripheral neuropathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Ordering Special Health Reports Pseudoclaudication (lumbar spine stenosis). . . . . . . . . . . . . . . . 46
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ISBN 978-1-61401-232-0
The goal of materials provided by Harvard Health Publishing Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
is to interpret medical information for the general reader.
This report is not intended as a substitute for personal medical
advice, which should be obtained directly from a physician. Cover Image: © PredragImages | Getty Images

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 Harvard Health Publishing
Trusted advice for a healthier life

Dear Reader,

It’s so easy to take your legs for granted. From the time you could walk, they seemed to just be
there whenever you needed them—sturdy, reliable limbs that carried you from one place to
another without so much as a conscious thought on your part. In fact, you might not recog-
nize just how much you rely on your legs until they hurt or they no longer work as well as they
should.

When trouble strikes—if you injure a knee or hip, for example—it quickly becomes clear just
how debilitating a leg injury can be. When you can’t walk without pain, it can become difficult
to work, play sports, exercise, or even climb the stairs from one floor to another in your home.
If the damage is significant enough, it can lead to permanent disability. The sheer number of
possible conditions that can contribute to leg pain illustrates the need to get medical attention
as soon as problems arise. These conditions run the gamut from fractures and sprains to long-
term problems caused by vascular disease or diabetes.

Whether you have an acute (short-term) injury such as a ligament tear or a muscle strain from
playing sports, or you are experiencing chronic (long-term) knee or hip pain from a condition
like arthritis, this report is designed to help you find ways to cope with—and in many cases,
resolve—your leg pain. You’ll learn where to turn for help and which tests your provider will
use to pinpoint your diagnosis. Then, you’ll discover the recommended treatments for each
type of problem. The solution might be something as simple as rest and over-the-counter
pain relievers, or it may involve state-of-the-art surgical procedures and devices. Sometimes a
combination of therapies is needed.

Finally, you will learn exercises and other strategies to strengthen your joints and the other
structures in your legs, to guard them against injury and disease in the future. It’s well worth
the effort.

Sincerely,

Robert H. Shmerling, M.D.

Medical Editor

Harvard Health Publishing | Harvard Medical School | 4 Blackfan Circle, 4th Floor | Boston, MA 02115
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 Why your legs hurt

I n theory, your legs should be among the last parts of

your body to cause trouble. Tasked with getting you
from one place to another, they are among the stur-
the calves and ulcerations of the skin. In fact, there are
so many ways for damage to occur, it’s a wonder we
don’t suffer more leg pain than we do.
diest, most powerful features of the human anatomy. This report covers more than two dozen of the
In sheer bulk, they account for roughly 40% of your most common problems to afflict the legs, from arthri-
body weight. The thighbone is your largest, strongest tis to varicose veins. They are listed in one of four
bone—so strong, in fact, that it takes approximately chapters, according to the primary location where
900 pounds of force to break. Similarly, the hip is your they occur—the hip, upper leg, knee, or lower leg.
largest joint and one of the most stable. And power- (Note that for the purposes of this report, the legs stop
ing it all, the leg and buttock muscles are among the at the ankles. Ankle and foot problems are covered in
strongest you have. In short, centuries of evolution another Harvard Special Health Report, Healthy Feet:
have prepared your legs to be able to withstand a beat- Preventing and Treating Common Foot Problems.)
ing on a daily basis, for decades on end. Fortunately, leg problems do not usually signal
Yet there are so many ways for things to go wrong. a medical emergency, but sometimes the condition
For example, overweight and obesity can take a toll, causing pain can be serious enough to require imme-
adding to stresses on bones, joints, tendons, ligaments, diate medical attention (see “When leg pain signals
and other tissues. A strong impact—whether from a an emergency,” page 3). Even if your leg pain does
fall, a sports accident, or a car crash—can cause bones not require urgent action, you should consult a doc-
to fracture and muscles to tear. Painful nerve damage tor about any persistent, unexplained problem. Some-
can result from a disease such as diabetes or for no times it can signal a systemic problem, such as heart
identifiable cause. Poor circulation can lead to pain in disease or diabetes (see “What your legs tell you about
your health,” page 5). Even strictly localized problems
are worth a visit to the doctor. Medical knowledge
about the causes of leg pain has never been greater.
There are tests to pinpoint causes that were unclear in
the past. And once you have a diagnosis, treatments
exist that can at least reduce your pain, if not fully
resolve it.
This chapter delves a bit more into why we develop
problems with our legs. But first, a broad overview of
leg anatomy may be helpful. More detailed anatomical
© Dean Mitchell | Getty Images

information will follow in each chapter.

Leg anatomy: An overview

Unlike the hands, which have 27 bones each, or the
There are so many ways for our legs to develop problems, it’s a feet, with 26 apiece, the entire leg has just four bones.
wonder we don’t suffer more leg pain than we do. Fortunately, Yet the legs are far more complicated than this mod-
most of the time, leg trouble does not signal a medical emergency. est number would imply. To provide the precision you

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need for running, walking, danc- When leg pain signals an emergency
ing, jumping, or climbing stairs,
each of your legs relies on a complex
construction that includes not just
M
ost leg pain results from gradual wear and tear or minor
issues that will resolve in time or with conservative
treatment. Yet, a few symptoms signal a much more serious problem that
bones, but also ligaments, muscles, requires immediate attention. Call a doctor or 911 or go to an emergency room if
tendons, nerves, blood vessels, and you think you might have one of these conditions.
more. Avascular necrosis. Certain diseases, Deep-vein thrombosis (DVT).
Bones provide the framework such as sickle cell anemia, or an DVT is a blood clot that forms in a
to which the other parts of the leg injury such as a fracture or dislocation deep vein of the leg (see “Deep-vein
can damage the vessels that supply thrombosis,” page 17). It can occur
attach (see Figure 1, page 4). There blood to bones in the leg. Also called when blood flow slows—for example,
are three major bones in your legs— osteonecrosis, avascular necrosis after surgery, or when you’ve been
the thighbone (femur) in the upper occurs when a disruption in the immobile for many hours on a long
leg, and the shin bone (tibia) and blood supply causes the bone to die. car or plane trip. If the clot travels to
Eventually, the bone can break apart a lung and becomes lodged there, it’s
calf bone (fibula) in the lower leg. and collapse. called a pulmonary embolism—a life-
You may not even be aware of the threatening condition.
Symptoms: Bone pain, which may
fibula, but it is a slender bone that begin suddenly and increases over Symptoms: Swelling and redness in
runs parallel to the shin bone and time. the leg, tenderness. If the clot travels
helps stabilize it. In addition, the to the lung, symptoms may include
Bone cancer. Bone cancer is rare,
kneecap (patella) is a small bone shortness of breath, chest pain, and
accounting for less than 1% of all
coughing.
that protects the knee joint. The cancers. Most cancer in the bones has
traveled there from other organs, such Arterial thrombosis. This occurs
bones of the upper and lower legs
as from the breast or prostate gland. when a blood clot forms in an artery.
connect to additional bones in the Cancer can damage and weaken bone If the clot is not treated, the condition
hips and ankles. to the point where it fractures. may lead to gangrene (with a dark
Without the other struc- discoloration of the toes or foot).
Symptoms: Bone pain, fatigue, unin-
tures in the leg, however, bones tended weight loss, swelling in the Symptoms: Sudden pain and
would collapse into a useless heap. area, fractures, especially in someone swelling in one leg, accompanied by
with a prior diagnosis of cancer. discoloration.
Specifically:
• Ligaments are the tough bands Compartment syndrome. In this Fracture. The force of an accident
serious condition, pressure within or weakening due to osteoporosis or
of connective tissue that connect the muscles and other tissues in cancer can cause a bone to fracture,
bones to other bones. They link the legs builds to the point where or break. Fractures range in severity
the thighbone and shin bone at it prevents oxygen-rich blood from from a simple break in one bone to a
the knee joint and connect the reaching nerves and muscles. Without shattering in which a bone breaks into
treatment, it can lead to permanent multiple pieces or pierces the skin.
thighbone to the pelvis at the hip muscle and nerve damage.
joint. Ligaments also stabilize Symptoms: Pain, swelling and
Symptoms: Intense pain, a feeling of tenderness of the skin over the injury,
joints, restricting movement to a tightness or fullness in the affected bruising, deformity, trouble moving or
range that will not cause damage. muscle, tingling or burning. using the injured leg.
(For a more detailed discussion,
see “Hip anatomy 101,” page 7,
and “Knee anatomy 101,” page 27.) and soleus muscles help you point and flex your
• Muscles provide the force to move bones at the foot, walk, jump, and run. The gluteus maximus,
joints. In the upper leg, these include the powerful medius, and minimus muscles of the buttocks give
quadriceps muscles on the front of the thigh, the shape to your rear end, support your lower body,
hamstrings at the back of the thigh, and the hip and allow your hips to rotate.
flexors (most notably, the iliopsoas), which help • Tendons are the strong bands of connective tis-
you lift your thigh. In the calf, the gastrocnemius sue that attach muscles to bones. One of the best-

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 signals also travel back up
Figure 1: Anatomy of the legs to the brain from your legs
and feet. Sensory nerves
Pelvic Abductor tell you where your leg
bone muscles and foot are in space. They
tell you where the ground
Gluteus
muscles
is, whether it’s slippery or
Hip Adductor uneven, and where there’s
joint muscles
a pebble so you don’t step
too hard. Temperature
receptors can alert you to
Femur Hamstring
Quadriceps muscles something that’s danger-
muscles
ously hot or cold, while
pressure receptors are sen-
Kneecap sitive to compression and
(patella)
tell you whether something
is touching your leg or foot.
In order to bend,
Gastrocnemius
muscle
straighten, and support the
body’s weight, the legs also
Fibula
rely on a steady supply of
Tibia
oxygen- and nutrient-rich
blood pumped from the
heart. A network of arter-
ies delivers blood from the
heart to the legs. Another
network of blood vessels,
the veins, ferries oxygen-
Front view Rear view depleted blood back to the
The femur is the main bone of the upper leg, while the fibula and tibia bones make up the lower leg. heart and lungs.
The patella protects the knee. Thick, strong quadriceps muscles cover the front of the upper thigh. In The circulatory system
the back of the leg are the hamstrings and gastrocnemius muscles. is a finely tuned hydraulic
masterpiece. If it weren’t,
known tendons in the body is the Achilles tendon, how could it force blood to flow upward, against grav-
which connects your calf muscle to your heel. ity? If gravity alone ruled, all of your blood would soon
However, producing movement takes more than pool in your feet. To keep the blood moving, your
having all the anatomical parts strung together, like a veins contain tiny valves that close as the blood passes
skeleton in a biology lab. To move smoothly, groups through, preventing it from flowing backward. In addi-
of muscles must flex and extend, contract and relax in tion, as you walk or run, your calf muscles compress
complementary fashion. Otherwise you would move and relax, helping to squeeze the blood back up.
in a stiff, awkward, or jerky manner, like Frankenstein.
To guide their movements, muscles receive instruc-
tions from the brain, which sends its messages using Who gets leg pain?
electrical signals that travel through nerves. Motor Any of the structures in the legs can develop prob-
nerves tell you which muscles to flex and relax. But lems, so perhaps it’s not surprising that virtually all of

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 us suffer leg pain at some point. Leg pain can strike causes fluid to pool in your lower extremities—a prob-
at any age. In childhood, you may have had growing lem known medically as edema (see page 41).
pains or broken a leg. As an adult, you’re more likely
to suffer muscles strains or shin splints. In advanced
age, arthritis becomes increasingly likely. Accord- What your legs tell you about your
ing to the CDC, nearly half of Americans have knee health
osteoarthritis by age 85, and a quarter develop hip The primary purpose of your legs is to keep you
osteoarthritis. upright and mobile. Yet, your legs can also act as an
The vulnerability of the legs comes in part from indicator of your overall health. Although some symp-
the fact that we rely on these limbs for so much. While toms you may experience are specific to a leg problem,
it’s true the legs are designed for durability, the human others can suggest trouble with your heart, nervous
life span for most of evolutionary time was much system, kidneys, or other organs. Use the following
shorter than it is today. For millennia, people com- symptom guide to help you decipher what broader
monly lived only 30 to 40 years. Legs didn’t have to problems your leg pain might suggest.
last longer than that. Symptom: Leg cramps.
Your joints are particularly vulnerable because of Possible cause: Dehydration. A cramp in your
their complexity and the stresses you subject them to. leg after you’ve been working out, especially in the
Your knees and hips are your largest joints. While sup- heat, could be an important sign that your body is low
porting your weight as you stand upright, they must on fluids. To contract and relax normally, muscles rely
also execute the complex maneuvers involved in a on water and electrolytes like sodium and potassium.
broad variety of movements. For example, getting in Too little fluid or electrolytes can hypersensitize the
and out of a car may seem simple when the hips and nerves that control muscles in the legs, causing the
knees are fine, but if you have hip arthritis or torn car- muscles to contract abnormally, or spasm.
tilage in your knee, the amount of flexing, turning, All of your organs rely on fluids to function nor-
and balancing required by these maneuvers can be mally. Dehydration prevents cells from properly using
quite challenging. So it’s not surprising, given all that energy, transporting nutrients, and dividing. If not
your knees and hips do, that they’re prone to injuries quickly remedied, it can become a life-threatening
and deterioration. That’s why nearly half of this report condition. To avoid getting too low on fluids, drink
relates to knees and hips. water or an electrolyte-containing sports drink before,
But problems can also develop in muscles, nerves, during, and after exercise.
or blood vessels. Poor Symptom: Calf pain
circulation in the arter- during activity.
ies can produce calf Possible cause:
pain (claudication; see Atherosclerosis. Pain in
“Peripheral artery disease your legs that’s triggered
and claudication,” page by activity—along with
43), and people with dia- weak pulses in your legs
© PORNCHAI SODA | Getty Images

betes can have blood flow and feet, pale skin, and
problems that lead to skin sores on your legs or feet
ulcers. Veins, too, can that don’t heal well—are
cause trouble if the little signs of peripheral artery
valves in the veins no disease (see page 43), a
longer function properly. Poor circulation in the arteries (peripheral artery disease) can blockage in blood flow to
This condition, known produce a type of calf pain known as claudication. By contrast, leg your legs. The most likely
as venous insufficiency, cramps after you work out are likely the result of dehydration. cause is atherosclerosis, a

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hardening and narrowing of the arteries as a result of least worrisome level, it may be the result of an injury,
sticky cholesterol and fat deposits called plaques. such as a sprain or strain, or venous insufficiency (see
If your legs are suffering from inadequate blood “Edema,” page 41). Or it could point to a more serious
flow, likely your heart is, too. Peripheral artery dis- problem, such as
ease shares risk factors with heart disease—namely, • a blood clot in the leg (see “Deep-vein thrombosis,”
smoking, high cholesterol, diabetes, and high blood page 17)
pressure. It increases your risk of developing heart • heart failure
disease and of having a heart attack or stroke in the • kidney disease or kidney failure
future. Peripheral artery disease is a serious condition. • liver disease (cirrhosis).
To avoid complications, you need to make changes Each of these conditions is unique and requires
to your lifestyle by losing excess weight, getting more you to work with your doctor to get a diagnosis and
active, eating a heart-healthy diet, and quitting smok- start on a treatment plan.
ing. Sometimes surgery is needed to open up or bypass Symptom: Slow walking (in older adults).
a blocked artery. Your doctor may recommend blood Possible cause: Problems with multiple organ
thinners and vasodilators (medications that help open systems. If you’ve ever watched a parent or grandpar-
up blood vessels). ent slow down with age, you know how concerning
Symptoms: Pain, burning, numbness, and tingling. this sign can be. Research suggests that your walking
Possible cause: Diabetes. These feelings in your speed may be a marker for your overall health, to the
legs or feet could be signs of diabetic neuropathy— point where the pace at which you walk may be able to
nerve damage due to persistently high blood sugar predict your life expectancy. In one study published in
(see “Peripheral neuropathy,” page 45). High blood JAMA—a pooled analysis of nine studies with a total
sugar damages not only the small blood vessels that of 34,000 participants, ages 65 and older—walking
send oxygen and nutrients to the nerves, but also the speed was just as good a predictor of life expectancy as
nerves themselves, preventing them from sending the a host of other health indicators, such as chronic con-
correct signals to your brain. ditions, smoking history, blood pressure, body mass
The keys to preventing neuropathy, as well as index, and hospitalizations. Across the entire range of
other diabetes complications like vision loss, heart dis- gait speeds—parsed by as little as inches per second—
ease, and kidney damage, are to keep your blood sugar those who walked faster lived longer.
under good control and modify other risk factors. Walking relies on multiple organ systems working
Don’t smoke; also, bring down high blood pressure well and in tandem—the circulatory system, nervous
and cholesterol. Tight blood sugar control requires system, musculoskeletal system, and nervous system.
a combination of dietary changes, physical activity, A slowed gait could indicate a problem with one or
blood sugar monitoring, and sometimes blood sugar– more of these systems. One day, doctors might use
lowering medications. walking speed to evaluate your health, just as they
Symptom: Leg swelling. currently use electrocardiograms and blood pressure
Possible causes: Heart, kidney, or liver disease. measurements. Until then, keep a watchful eye on
Many things can cause swelling in the legs. At the your walking speed.

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 Hip pain

W atch a ballet dancer,

and you can appre-
ciate the hip joint’s abil-
large region that extends
to the groin and thigh.

ity to move in almost any Bones

direction, if only the mus- Key bone structures in
© Getty Images

cles are willing. The hip the hip include

is a ball-and-socket joint • the ilium (the upper-
with a remarkable range The hip — the largest and sturdiest joint in the body — allows a most and largest part of
of motion. It is also both remarkable range of motion, and it can take a pounding for decades. the pelvis; see Figure 2,
the largest and sturdiest But over time, osteoarthritis and other problems can develop. page 8)
joint in the body. With a • the femur (thighbone)
protective girdle of strong muscles surrounding it, the • the femoral head (the rounded top of the thigh-
hip joint was built for endurance. bone, which serves as the ball of the hip’s ball-and-
It isn’t indestructible, however. Osteoarthritis is socket joint)
one of the leading causes of chronic hip pain, espe- • the acetabulum (the indentation in the pelvis that
cially as you age. If a fall or another injury leads to forms the socket of the ball-and-socket joint)
intense pain, you could have a fracture. Pain on the • the greater trochanter (a protrusion on the upper
outside of your hip or thigh suggests an issue with the part of the femur to which a number of muscles
muscles, ligaments, or tendons. attach).
This chapter contains an overview of some of
the most common problems that can cause hip pain Ligaments
(listed in alphabetical order), along with a description The hip joint is surrounded by a strong joint capsule
of treatments that are available. It starts with a review made up of four ligaments, the most important of
of hip anatomy, to familiarize you with the various which is the iliofemoral ligament. These tissues keep
structures you will be reading about in this chapter. you from moving the hip to an extreme position that
could dislocate the joint (pull the ball out of the socket).

Hip anatomy 101 Cartilage

As the old song says, “The hip bone’s connected to the The hips have two kinds of cartilage:
thighbone.” But that simple line doesn’t do justice to • Articular cartilage coats the bones within the joint
the complicated, finely tuned machinery of the hip’s itself—specifically, the femoral head and the ace-
ball-and-socket joint. To support the full weight of tabulum (the ball and socket).
your body while allowing movement in different direc- • The socket is further cushioned and deepened by a
tions, the top of the thighbone is shaped as a smooth vital rim of cartilage called the labrum. The labrum
ball that fits snugly within the socket of the pelvis. In helps keep the joint fixed in place and lubricated.
addition to the bones themselves, muscles, ligaments, Additional lubrication in the joint comes in the
cartilage, and bursae all play important roles. While form of synovial fluid from the lining of the joint
people tend to think of the hip as a single bone they capsule (the synovium). Thanks to the perfect fit of
can feel on the side of the body, the hip is actually a the bones in the joint, along with the slick articular

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 thigh move your legs out away from your body, so
Figure 2: Hip anatomy you can pull your leg out of bed or swing it over a
motorcycle to climb aboard.
• Adductors (including the adductors longus, brevis,
Iliac crest and magnus) pull your leg in toward your body.
Ilium
• The large gluteus maximus muscle in the buttock
Acetabulum extends the hip when you move your leg backward
(socket)
Femoral head or to the side.
(ball)

Iliofemoral Bursae
ligament
Labrum Places in the hip where tendons, muscles, and bones
Greater meet are protected by small, liquid-filled sacs called
trochanter bursae. The body has more than 150 of these cushion-
Ischium
Femur Lesser ing sacs, which reduce friction between bones and soft
(thighbone) trochanter tissues. In the hip, there are three (see Figure 3, page 9).

The hip joint forms where the head of the femur fits into the
acetabulum, or socket of the pelvis. A rim made of rubbery
cartilage, called the labrum, surrounds the hip joint and keeps it
Bursitis
lubricated. Muscles attach to the hip at a bony knob called the Although the bursae (see above) are designed to
greater trochanter. Others attach at the lesser trochanter, just reduce friction around joints, they can become irri-
below it. tated, leading to a problem known as bursitis. The
suffix –itis means inflammation. Thus, bursitis is
cartilage and the synovial fluid lubricating the space inflammation of a bursa.
between them, the friction between the ball and Often it is the bursa covering the greater trochan-
socket in a healthy hip is less than that of two ice cubes ter that is affected, resulting in greater trochanteric
rubbing together. pain syndrome (also known as trochanteric bursitis;
see Figure 3, page 9). Greater trochanteric pain syn-
Muscles drome can result from a hard fall on your hip or the
Muscles in the thigh and lower back help stabilize the accumulation of minor stresses—such as small inju-
hip and move the upper leg at the hip joint (see Figure
6, page 16).
• The quadriceps muscles in the front of the thigh
help you lift your leg—for example, when you climb
stairs.
• The hamstrings in the back of the leg extend the
hip—for example, helping you straighten your leg
© monkeybusinessimages | Getty Images

again when climbing stairs.

• The iliopsoas (a muscle complex that runs from
the lower back to the front of the thigh) helps flex
the hip when you lift your leg to the front. It is one
of several muscles known as hip flexors, which
also include the rectus femoris, sartorius, and
pectineus. Climbing is no simple task. It requires mutiple sets of muscles—the
• The abductor muscles (gluteus medius, gluteus quadriceps, hamstrings, hip flexors, and gluteal muscles—to work
minimus, piriformis, and tensor fasciae latae) in the together, alternately contracting and relaxing in coordination.

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ries, excess pressure on one hip when you walk (from
scoliosis, other joint damage, or unequal leg lengths), Symptoms of hip bursitis
or even from lying on one side for an extended period, For greater trochanteric pain syndrome:
such as after another injury that requires bed rest. • Aching or burning on the outside of the upper thigh
Or, like other forms of bursitis, it may develop for no • Pain that moves down the outside of the thigh to the
apparent reason. knee
Less often, people develop ischial bursitis, which • Increasing pain when you push on or lie on the
affected side
occurs when the bursa under one of the ischia (the
• Pain that interferes with sleep
bones you sit on) becomes inflamed. As suggested by
• Pain triggered by walking, climbing stairs, or getting
its nicknames “weaver’s bottom” and “tailor’s seat,” it
up from sitting
can occur from prolonged sitting on a hard surface, as
For ischial bursitis:
well as from a fall or repeated friction during bicycling
• Dull or sharp pain in the lower buttock
or rowing.
• Pain that increases when you sit down (especially on a
The iliopsoas bursa—the protective sac that lies
hard surface) or lie on your back
between the front of the hip joint and the iliopsoas
For iliopsoas bursitis:
muscle, one of the hip flexors—can also be affected.
• Pain in the front of the hip that worsens when you flex
Iliopsoas bursitis can be associated with rheumatoid
the hip
arthritis or osteoarthritis of the hip, or with overdo-
• Radiating pain down the front of your thigh
ing activities that require repeated hip flexing (such as
• Limping (if only one leg is involved) or taking smaller
soccer, ballet, jumping hurdles, or running uphill). steps
• Limited range of motion in the hip
Diagnosing hip bursitis
Your doctor will examine
your hip, feeling for tender
areas. In some cases, you Figure 3: Bursitis
may need an imaging test Front view of hip Rear view of hip
such as an x-ray or mag-
netic resonance imaging
(MRI) to rule out a frac-
ture, arthritis, or another
painful hip condition.
Gluteus
Iliotibial maximus
Treating hip bursitis
band
Treatment for hip bursitis
starts by avoiding whatever
activity triggered the pain Trochanter
and inflammation. You can bursa

help control the pain by

taking an over-the-counter
anti-inflammatory pain Iliopsoas bursa Ischial bursa
reliever—such as aspirin,
ibuprofen (Advil, Motrin), The hip has several fluid-filled sacs, called bursae, that cushion the joint. When one of these sacs
or naproxen (Aleve)—or becomes irritated or inflamed, the condition is known as bursitis. Inflammation of the trochanter bursa
applying cold or heat to the at the widest part of the hip is the most common type of bursitis in the hip. But inflammation can also
inflamed hip. Your doc- occur at the iliopsoas bursa near the groin and the ischial bursa that you sit on.

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tor may send you to a physical therapist to teach you fact, groin strains make up 10% of all hockey injuries).
exercises that strengthen your hip muscles as well as However, you don’t need to be an athlete to strain your
stretches to relieve tension in the hip. groin. Lifting something heavy or slipping while you
For longer-term pain relief, you can see your doc- walk can also cause this injury.
tor for a corticosteroid injection directly into the tro-
chanter bursa. (Injection into an iliopsoas or ischial Diagnosing a groin pull
bursa requires imaging to guide the needle placement, Your doctor will apply slight pressure to the affected
which may require you to see a specialist.) These injec- leg to check for pain, and will also look for bruising
tions can continue to relieve pain for a few months. and other symptoms that indicate a groin pull. An
After treatment, be careful to avoid or modify MRI can help confirm the diagnosis and rule out con-
whatever activity caused the bursitis so you don’t ditions with similar symptoms; however, this imaging
develop it again in the future. test is usually unnecessary to diagnose a groin pull.
Rarely is surgery necessary unless the bursitis Doctors assign one of the following three grades
results from an infection (which is rare). to groin strains based on the degree of muscle damage
that occurs:
• Grade 1 is a partial stretch, or a tear of a few muscle
Groin pull (strain) fibers. You’ll have some tenderness, but you should
The area that we call the groin sits at the junction still be able to walk and use the affected leg.
between the abdomen and thigh. A groin pull, or • Grade 2 is a moderate stretch or tear of a larger
strain, typically involves stretching or tearing the number of muscle fibers. You’ll have pain, loss of
adductor muscles, on the inside of the hip and thigh. strength, and trouble walking.
These muscles help stabilize the trunk and pull the • Grade 3 is a severe tear. Sometimes the muscle rips
legs inward. Groin injuries are common in people who completely. You’ll see bruising under the skin in the
play sports that involve running, jumping, and quick area of the tear. It will be very painful and difficult
movements or direction changes, such as soccer, foot- for you to use the affected leg.
ball, skiing, track and field, and hockey. You might
suffer a groin strain while sprinting off the starting Treating a groin pull
block in a track race, or shooting a goal in hockey (in You’ll need to rest the affected leg to give it time to
heal. Apply a cold pack to the injured area for 15 or
20 minutes at a time, up to every two hours for the
first couple of days. (Note: you should never apply ice
directly to the skin; instead, place a thin towel between

Symptoms of a groin pull

• A popping feeling or noise when the injury occurs
• Sharp or throbbing pain in the groin and the inside of
the thigh
© alvarez | Getty Images

• Pain that intensifies when you raise your knee, pull your
legs together, or move your legs apart
• Muscle spasms in the groin
• Bruising in the thigh or groin area

It’s not unusual for people who play sports involving running, • Weakness in the leg when you try to walk or climb stairs
jumping, and quick changes of direction to pull their groin muscles • Limping when you walk
(the adductor muscles on the inside of the hip and thigh).

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them to avoid skin damage.) An over-the-counter
anti-inflammatory pain reliever—such as aspirin, ibu- Symptoms of a hip fracture
profen, or naproxen—can help keep you comfortable • Severe pain in the hip or groin

while the injury heals. As soon as you have healed • A deformed appearance to the hip, or a turned-out leg

enough, your doctor may refer you to a physical thera- that may appear shorter than the other
pist. The therapist will work you through a number of • Swelling, tenderness and bruising around the hip

exercises to strengthen the muscles around your hip • Inability to stand up, or a hip too weak to lift the leg

and prevent another groin injury in the future.

moved well out of place, or if you are older and not

Hip fracture active, he or she may replace the head of the femur
For thousands of people who break a hip, life is never with a metal device, a procedure called a partial hip
the same again. As many as half will no longer be able replacement. Or, if arthritis is present, the surgeon may
to walk without assistance—even if they were healthy perform a total hip replacement (see Figure 5, page 13).
and mobile beforehand. One in five people over age After surgery, it can take several months for the
50 dies within a year of a hip fracture from ensuing hip to heal completely. The goal of rehabilitation is to
health complications. get you back on your feet as soon as possible.
The two most common types of hip fracture
involve the thighbone (femur):
• A femoral neck fracture occurs in the horizontal Osteoarthritis
section of the thighbone, about one to two inches The word arthritis comes from arthron, the Greek
from the ball of the hip joint (see Figure 2, page 8). word for “joint,” and –itis, a suffix denoting inflamma-
• An intertrochanteric fracture occurs in the thigh- tion. There are more than 100 types of arthritis, but
bone three to four inches below the ball of the hip. osteoarthritis—the so-called wear-and-tear form of
Fractures of the hip socket, which are considered
to be pelvic fractures, are less common.
Figure 4: Osteoarthritic changes in the hip
Diagnosing a hip fracture
A possible hip fracture needs immediate evaluation.
As x-ray is likely to show a fracture if one exists. But if
it doesn’t and your symptoms strongly suggest a frac-
ture, MRI may reveal a break that has not moved out
of place or a fracture involving the hip socket.

Treating a hip fracture

The goal of treatment is to reconnect the broken bone
and hold it in place, so the hip works properly until
it can heal—about three months. Surgery within 24
hours is usually necessary to make this repair. If you
must wait for the operation, the hip may be held in
traction (using weights to extend the muscles around
This x-ray shows what happens when osteoarthritis affects the
the hip) while you wait. hip — in this case, the patient’s left hip (shown on the right side
If you have a femoral neck fracture in which the of the image). Compared with the visible outline of the ball-
pieces are not displaced, the orthopedic surgeon may and-socket joint on the opposite side, the joint on this side has
connect the bone with surgical screws. If the bone has noticeably deteriorated.

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arthritis—is the best known. It is also the most com- joint. As the protective cartilage is worn away, the
mon form of degenerative joint disease, affecting more space between the femur ball and the hip socket nar-
than 30 million adults in the United States. Weight- rows (see Figure 4, page 11). As a result, the bones of
bearing joints like the hips and knees are most com- the hip joint rub painfully against one another. New
monly affected. One or both hips may have arthritis. bone begins to grow as a reaction to the joint degen-
Osteoarthritis begins with degeneration of the eration, forming bone spurs (known medically as
articular cartilage that normally helps cushion the osteophytes).

Finding the assistive device that fits you

A fter an injury to your hip or leg, or if you have a mobility-compromising condition like arthritis, an assistive device such as a
cane or walker can be invaluable for helping you get around and keeping you safely active. These devices take some of the
weight off the painful leg, increase stability, and improve your balance.
It’s important when you do select a cane or another mobility offset cane, and may be useful to people who have difficulty
aid that you get the right fit. One study found that more than balancing. Plus, they’re freestanding, in case you need to use
two-thirds of people with canes have ones that are damaged, one or both of your hands. Because all legs of the cane need
the wrong height, or otherwise inappropriate for them. For to be firmly on the ground for stability, you may walk more
example, a long cane will put too much pressure on your slowly with this type of cane.
arms, while a short one will force you to lean forward in an Standard walkers have four rubber-tipped legs. This is the
unnatural position. For help in getting fitted for one of these most stable type of walker, but also the slowest, because
devices, see your doctor. you’ll need to pick it up and put it down as you walk. Walkers
Standard canes typically come in wood or aluminum, with are ideal for people with arthritis of the knees and hips on
a curved or T-shaped handle. They’re reasonably priced and both sides of the body, weakness in both legs, and more
lightweight. Some fold for easier storage. A standard cane significant balance issues. Yet you’ll need the upper-body
will improve your base of support, but it won’t bear a lot of strength to pick up and put down the walker with each step.
weight. This type of cane can be helpful if you have arthritis in Two-wheeled walkers have two wheels in the front and two
only one hip or one knee, and you haven’t lost your ability to rubber-tipped legs in the back. They provide easier movement
balance. than a standard walker, while still offering a good amount of
Offset canes have a handle that curves away from and then stability.
toward you to distribute your weight over the cane. They’re Four-wheeled walkers (rollators) most closely allow you
designed to support more weight than a standard cane, and to replicate your normal walk, and they may be preferable for
they may be helpful if you have painful arthritis in your hip or people who have trouble lifting and setting down a standard
knee. walker. You can move more quickly with four wheels than you
Multiple-leg canes have three or four legs. They provide would with a standard walker, but a wheeled walker won’t
more support and can bear more weight than a standard or bear as much of your weight.

Canes Walkers

Standard Offset Multiple-leg

cane cane canes Standard walker Two-wheel walker Four-wheel walker

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 Osteoarthritis tends to appear later in life. As you
get into your 60s and beyond, osteoarthritis may cause Symptoms of hip osteoarthritis
joint aching and stiffness, especially when you first • Pain in your thigh or groin that may radiate to your
wake up in the morning or after you’ve been in the buttocks
same position for a while (such as after a long drive). • Stiffness in the hip

The discomfort will likely increase until you take steps • Reduced range of motion in the hip

to manage your arthritis. • A grinding or popping feeling when you move the joint
While osteoarthritis has long been considered an
age-related disease, we now know that genes, obesity,
injury, inflammation, and other factors may contribute motion in the hip joint, and problems with your gait
to its development. You can’t stop the aging process or (the way you walk). An x-ray can reveal narrowing of
change your genes, but you do have control over your the joint space, bone spurs, and damage to the carti-
weight, which is the leading modifiable risk factor for lage that are the hallmark signs of osteoarthritis (see
osteoarthritis. The hips are weight-bearing joints, and Figure 4, page 11).
the more weight they have to bear, the more stress the
bones and cartilage will endure. People who are obese Treating hip osteoarthritis
are nearly seven times more likely to develop osteo- Your doctor will typically start you on the most con-
arthritis than those who are at a normal weight. The servative measures first. The goal is to relieve your
extra weight strains joints and makes it harder to exer- pain without causing unnecessary side effects. Exer-
cise. A lack of exercise deconditions joints further and cise is one strategy that offers pain relief with little
leads to even more weight gain. And the painful cycle risk. A combination of low-impact aerobic activities
continues. like walking and bike riding, as well as resistance
training, helps with weight loss and may strengthen
Diagnosing hip osteoarthritis the muscles that support your hip joint and improve
Your primary care doctor can serve as your first point range of motion. A physical therapist can help design
of contact if you suspect you have osteoarthritis. a program that’s well-suited to your needs and abili-
Later, you might also see a rheumatologist and pos- ties. Water exercise is among the best choices for
sibly an orthopedic specialist. During the exam, your arthritis because the buoyancy of water takes pressure
doctor will look for signs like pain, limited range of off sore joints. A local chapter of the Arthritis Foun-
dation may offer classes in your
area (see “Resources,” page 52).
Figure 5: Total hip replacement surgery Medication is another
When rough and damaged cartilage option. Acetaminophen (Tyle-
prevents the bones of the hip from nol) or an over-the-counter
moving smoothly, an orthopedic surgeon
nonsteroidal anti-inflammatory
can install an artificial joint with two Acetabular cup
parts. The head of the thighbone (femur) drug (NSAID) such as aspirin,
is replaced with an artificial ball with ibuprofen, or naproxen may
Femoral
a long stem that fits down inside the component help. Prescription versions of
bone. This part of the prosthesis is called many of these drugs are also
the femoral component. The other part available. But because NSAIDs
of the prosthesis, called the acetabular
can cause side effects such as
cup, fits inside the hip socket. Cement
may be applied, depending on which
stomach ulcers, gastrointestinal
type of artificial joint is used. The two bleeding, heart attack, or stroke,
pieces fit smoothly together to restore Cement do not use these drugs on a daily
comfortable ball-in-socket movement. basis unless recommended and

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monitored by your doctor. Acetaminophen, too, may
cause problems. It can cause liver damage if you regu- Symptoms of hip tendinitis
larly exceed the maximum dose of 3,000 milligrams. • Pain in the front of your hip, especially when you bend
Using a combination of acetaminophen and an your hip or raise your leg
NSAID can help you take a lower dose of each pain • Soreness in the groin area when you touch it (because
reliever. the iliopsoas tendon sits close to the skin)
For a more powerful anti-inflammatory effect, • A snapping or clicking sensation when you walk
your doctor may inject a corticosteroid medication
directly into the affected joint. This approach is used
only when absolutely necessary—and usually no more Tendinitis
than two or three times a year—because frequent A tendon is a specialized part of a muscle that con-
injections of these drugs can damage a joint and may nects the muscle to a bone. Inflammation in the ten-
increase the risk of infection. don that connects the iliopsoas muscle (the main hip
Taking pressure off the joint can also help. If hip flexor muscle) to the upper thigh is known as hip
arthritis makes it hard for you to get around, a cane, flexor tendinitis. (Damage from microscopic tears and
walker, or other assistive device could be key to main- degeneration is known as hip flexor tendinosis. The
taining your independence and preventing a fall. Hold umbrella term covering both hip tendinitis and tendi-
a cane in the hand opposite your bad hip. (For tips on nosis is hip flexor tendinopathy, but most people just
selecting a device that suits your needs, see “Finding refer to both as tendinitis.)
the assistive device that fits you,” page 12.) Hip tendinitis often affects people who play sports
Surgery is always a last resort, but it may become that involve repetitive hip movements, particularly
necessary if your hip pain doesn’t improve with other cyclists, runners, swimmers, triathletes, dancers, and
treatments. Two procedures are available to fix the tennis players. In older people, it tends to affect those
damage of hip osteoarthritis: hip resurfacing and total whose gait has been thrown off by related problems in
hip replacement. A total hip replacement removes the the spine, knees, ankles, or hips. An injury such as a
damaged femur head and socket and replaces them fall can also injure the tendon in the hip.
with prosthetic versions made from metal or ceramic
(see Figure 5, page 13). In hip resurfacing, the sur- Diagnosing hip tendinitis
geon removes damaged bone and cartilage from the Your doctor will ask about your symptoms and
hip socket and replaces it with a metal cup. The femur whether you participate in any activities that might
head is left intact, but it is covered in a layer of smooth have contributed to tendinitis. Typically, the diagnosis
metal. can be made from symptoms alone, without the need
Both procedures come with possible risks, includ- for an MRI scan.
ing infection, excess bleeding, and blood clots. A
resurfaced hip offers the advantages of being less likely Treating hip tendinitis
to dislocate and providing a total return to activities Rest the hip to give it a chance to heal. Avoid any sports
like running and climbing, which may make it pref- or other activities that might have contributed to the
erable for younger, more active people. Yet there are injury. To reduce pain and swelling, hold an ice pack
downsides to resurfacing, too. As the metal surfaces to your hip for 15 or 20 minutes at a time, a few times
of ball and socket interact, they can potentially release a day. An over-the-counter anti-inflammatory pain
harmful metal into the blood. A resurfaced hip is also reliever such as aspirin, ibuprofen, or naproxen can
more likely to fracture, especially in women whose also be helpful for pain and swelling. Corticosteroid
bones are weakened from osteoporosis. For these rea- injections can provide more sustained pain relief. Once
sons, resurfacing is typically reserved for younger men the immediate injury has healed, work with a physical
who have strong bones. therapist to regain the strength in your hip muscles.

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 Upper leg pain

Upper leg anatomy 101

Y our upper legs are where you’ll find some of the
strongest muscles in your body. These muscles
power your movements, whether you’re climbing the
When it comes to providing the raw power for loco-
motion, the upper legs play the starring role. It takes
stairs, getting up from a chair, or jumping hurdles on all their anatomical structures working in tandem to
a track. But as strong as they are, these muscles can make that happen. Following is a quick rundown.
suffer injury. You can strain, tear, or otherwise dam-
age the muscles themselves or their tendons as the Bone
result of overuse, repetitive motions, accidents, sud- No complicated anatomy lesson is necessary here. There
den movements that wrench your leg, or exercising is one bone in the upper leg—the thighbone (femur).
without properly warming up first. As noted earlier, it is both the longest and strongest
The nerves that supply feeling to the upper leg or bone in the body. It takes significant force to break the
that run through it can also cause unpleasant sensa- shaft of the femur, helping to explain why motor vehicle
tions in the upper leg, ranging from pain to numbness accidents are the leading cause of femur fractures. The
and tingling. And redness or swelling in the thigh upper end of the thighbone fits into the hip socket. The
after surgery or a long period of immobility could lower end forms the upper portion of the knee joint.
indicate a blockage in one of the leg’s deep veins.
This chapter reviews some of the leading causes Muscles
of upper leg pain (listed in alphabetical order), along The musculature of the upper leg is more complicated
with the methods used to diagnose and treat them. than the bone structure. It includes several important
The chapter begins with a review of upper leg anatomy. muscle groups.
Quadriceps. Covering the front of the thigh is a
large group of muscles known as the quadriceps (see
Figure 6, page 16). Quad- comes from the Latin word
for “four.” The name is well suited, given that this
muscle group has four parts: the rectus femoris, vas-
tus lateralis, vastus medialis, and vastus intermedius.
The quadriceps starts at the hip bone and attaches to
the kneecap. Its muscles work just about every time
you use your legs, whether you’re straightening your
knees, standing up, or walking.
Hamstrings. Running down the back of each
© kate_sept2004 | Getty Images

thigh from the bottom of the pelvis to just below the

knee are the three hamstring muscles: the semitendi-
nosus, semimembranosus, and biceps femoris. They
are responsible for movements of the hip and knee,
allowing you to bend your knee and extend your leg.
The powerful quadriceps muscles in the front of your thighs work Iliopsoas. The iliopsoas muscle is a powerful,
just about every time you use your legs. The hamstring muscles in hardworking muscle that flexes the hip joint and lifts
the back of your thighs help control their movements. the knee whenever you walk or run. The strongest of

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the four muscles known as hip flexors, the iliopsoas is gling, and pain known as sciatica (see page 23).
formed from the junction of two muscles—the psoas Other nerves in the upper leg include the
major and iliacus—which begin at the lower spine, following:
cross the hip joint, and then connect into one band Common peroneal nerve. This branch of the sci-
in the thigh. A tendon attaches this merged muscle to atic nerve provides feeling to the front and sides of the
the thighbone at the lesser trochanter, a small bony legs and activates the muscles that flex the toes.
projection below the greater trochanter (see Figure Femoral nerve. It provides feeling to the front of
2, page 8). A tight iliopsoas muscle sometimes causes the thigh and activates the muscles that allow the knee
pain in the lower back, a deception that has earned to extend.
this muscle the nickname “hidden prankster.” Lateral femoral cutaneous nerve. This nerve is
Adductors and abductors. The word adductor part of the lumbar plexus, a network of nerves in the
derives from the Latin prefix ad–, for “toward,” and lower back. It provides feeling to the front and sides of
ducere, which means “to lead.” The word perfectly the thighs.
captures movement of the adductor muscles—pulling
one leg in toward the other. Their opposing muscles, Blood vessels
the abductors, pull the legs away from each other and A network of arteries delivers blood to the legs. Chief
rotate them outward. If you’ve ever used abductor and among them is the femoral artery, the main artery
adductor machines at the gym, you’ve seen these two in the thigh. Because this artery is large and easy to
muscle groups at work. feel through the skin, hospital clinicians often use it
Gluteal muscles. Bringing up the rear (literally), as an insertion point for catheters that can be snaked
are the three gluteal muscles that make up the buttocks: through the arteries to other parts of the body, to help
gluteus maximus, gluteus medius, and gluteus mini- diagnose and sometimes treat problems involving the
mus. The gluteus maximus
is by far the largest of these
three muscles. Together, Figure 6: Anatomy of the thighs
this muscle trio helps to
control movement in the Pelvic Abductor
bone muscles
hip and thigh. You’ll use
them whenever you climb Iliopsoas
muscle Gluteus
stairs, stand up from a muscles
Hip Adductor
squatting position, or run. joint muscles

Sartorius Iliotibial
Nerves muscle band
Running down from the Femur Hamstring
Quadriceps muscles
lower back through the muscles
buttocks and down the
back of each leg to the feet
Kneecap
is the sciatic nerve. It’s the (patella)
longest nerve in the body
and supplies feeling to
the legs. Pressure on this
nerve from a herniated Front view Rear view
disc, narrowed spine, or The quadriceps are usually treated as a single unit, but there are actually four quadriceps muscles at
other medical condition the front of the thigh. In the back of the thigh, there are three hamstrings. In addition, a variety of
creates the numbness, tin- muscles known as hip flexors, abductors, and adductors help you to move your leg as you want to.

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heart, brain, and kidneys. Although the femoral artery
can suffer from peripheral artery disease (PAD; see Symptoms of deep-vein thrombosis (DVT)
“Peripheral artery disease and claudication,” page 43), A clot in a deep vein causes these symptoms:
PAD more often affects smaller arteries in the lower • pain in the upper leg or calf
legs. • red, swollen skin on the leg
Veins return blood to the heart. They can be either • warmth over the leg.
deep inside muscles (deep veins) or near the surface
of the skin (superficial veins). Deep veins carry more If the condition progresses to pulmonary embolism, you
may have the following symptoms:
blood and can potentially be involved in more seri-
• shortness of breath
ous problems than superficial veins (see “Deep-vein
thrombosis,” below). Much of the blood from superfi- • chest pain that may get worse when you inhale or

cial veins eventually flows into the deep veins. cough

• lightheadedness, dizziness, feeling as though you’re
about to pass out

Deep-vein thrombosis (DVT) • rapid heart rate

Deep veins are the major blood vessels that carry • coughing up blood.

90% or more of blood away from the legs and back Pulmonary embolism can be life-threatening. If you have
to the heart. As discussed earlier (see “Leg anatomy: these symptoms, ask for medical assistance, call 911, or
An overview,” page 2), tiny one-way valves in the leg go to an emergency room right away.
veins close as blood passes through, in order to propel
blood upward against gravity, thereby preventing it
from flowing backward. But muscles surrounding the drome, which is characterized by pain, swelling, color
deep veins also assist by squeezing the veins—a pump- changes, and sometimes open sores. About 40% of
ing action that helps propel blood upward toward the people who suffer DVT will develop some degree of
heart. Prolonged inactivity—for example, sitting in a post-thrombotic syndrome, and in about 8% the con-
cramped position for an extended time—can cause dition will become severe enough to be disabling.
blood flow in the deep veins to become sluggish, DVT is perhaps best known for developing dur-
which in turn encourages blood to coagulate, forming ing long airplane flights, giving rise to the nickname
a blood clot (thrombus). The condition is known as “economy class syndrome.” But a recent study of
deep-vein thrombosis, or DVT. Japanese people fleeing a 2016 earthquake also docu-
DVT causes pain, redness, and swelling in the leg, mented an “epidemic” of leg clots among earthquake
as blood flow is blocked by the clot, and blood pools victims who couldn’t find room in shelters and had to
behind it. But complications of DVT can be far worse spend the night in their cars. Extended immobility for
than that. DVT can have stealthy and sometimes other reasons—such as prolonged bed rest following
deadly consequences, when a blood clot that forms surgery or an injury—can also lead to DVT.
in the leg travels up to the lungs and becomes lodged Other potential causes or risk factors for clotting
in an artery there, preventing blood from reaching in the deep veins of the upper leg include
the lungs. Pulmonary embolism, as this problem is • older age (over 65)
known, is a serious complication of DVT. These two • diseases such as cancer, heart disease, heart fail-
conditions are known collectively as venous thrombo- ure, lung disease, and inflammatory bowel disease
embolism, or VTE. (Crohn’s disease and ulcerative colitis)
Another problem associated with DVT is the • inherited blood clotting disorders (inherited
damage that the buildup of blood behind the clot can thrombophilia)
do to the little valves in the leg veins. This damage • direct damage to leg veins (for example, from injury
leads to a complication called post-thrombotic syn- or surgery)

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 • obesity (which leads to higher pressure on large imaging test right away to conclusively diagnose it.
veins, changes in blood chemistry, and other D-dimer is a protein that tends to increase when your
changes) body forms blood clots. However, it’s not a perfect test:
• smoking (which leads to changes in the lining of other conditions may cause an elevation in this test,
blood vessels) and not everyone with a DVT has an elevated level of
• the use of birth control pills or hormone therapy D-dimer.
(which can affect clotting) Lower-extremity ultrasound is a test that uses
• pregnancy (the risk continues for three months sound waves to visualize the flow of blood and detect
after giving birth). clots in your leg veins. A technician runs a transducer
As many as 900,000 Americans experience DVT over your leg; this device releases sound waves, which
in any given year, and up to one in nine die from it. bounce off of structures inside your leg to create an
image on a monitor.
Diagnosing DVT
If you have symptoms of DVT, get to a hospital emer- Treating DVT
gency room as soon as possible. If your doctor thinks Anticoagulants, or blood thinners, are the main
you have DVT after performing an exam and getting treatment for DVT. They don’t dissolve the clot, but
a rundown of your symptoms, he or she may recom- they prevent new clots from forming and the ini-
mend a D-dimer blood test and ultrasound or another tial clot from growing larger while the body breaks
it down. Initial anticoagulation
treatment usually includes an
How to prevent DVT

© AndreyPopov | Getty Images

injected medication (such as hep-
To avoid DVT, observe the following arin or fondaparinux) or an oral
precautions: drug such as rivaroxaban (Xarelto)
• On long flights, get up and walk or apixaban (Eliquis), followed by
around every two to three hours. another three months of oral med-
While you sit, exercise your legs by ication, such as warfarin (Cou-
alternately squeezing and releasing • During pregnancy, stay active. Try to
madin). The cause of your DVT
your leg muscles, circling your feet, walk every day, and avoid prolonged
and pointing and flexing your toes. bed rest. Stay hydrated. Drinking will determine the length of your
• On long car trips, stop every couple of plenty of water can help keep your treatment. If the DVT developed
hours to stretch and walk around. blood from thickening to the point because of bed rest after surgery or
where it forms clots. another known and reversible risk,
• After surgery, get up and move as
• If you smoke, ask your doctor about you may only need to stay on these
soon as you are allowed to. Some
hospitals use intermittent pneumatic nicotine replacement products, medications for three months.
compression devices to prevent blood medication, therapy, and other
methods to help you quit.
But if the cause is unknown and
clots from forming after surgical
you may have a chronic clotting
procedures. These devices look like • If you’re overweight, get help to
large cuffs or leg warmers that lose the weight from a dietitian or problem, treatment could take six
alternately fill with air and squeeze a structured program like Weight to 12 months, or even continue
your legs to keep blood circulating. Watchers or Jenny Craig. indefinitely.
You can also ask your doctor about compression stockings. These hose-like Once you’ve had an episode
stockings exert constant pressure on the legs to keep blood flowing. The research of DVT, your risk of another one
on compression stockings in people who have had DVT has been mixed—some increases. About 30% of people
studies suggest it prevents post-thrombotic syndrome, while others have not
who’ve had either DVT or a pul-
found a benefit. Some people find these stockings uncomfortable and unattractive.
If your doctor suggests that you wear them, you may reduce the discomfort by monary embolism will have a sec-
having them custom-fit, so that they’re not too tight, too long, too hot, or the like. ond one within 10 years (see “How
to prevent DVT,” at left).

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Hamstring strain or tear
Located at the back of the leg, the hamstring mus- Symptoms of a severe hamstring strain
cles run down the back of each thigh and across two or tear
joints—the hip and knee—enabling you to bend your • Sudden, sharp pain in the • Bruises on the back of

knee and straighten your leg at the hip. Together with back of the thigh your upper leg
the quadriceps at the front of the thigh and the gluteal • A popping sensation • Weakness and difficulty

muscles in your buttocks, the hamstrings alternately • Swelling in the first few bearing weight on the
hours after the injury injured leg
contract and relax so that you can walk, climb stairs,
get up out of a chair, and perform a host of other
actions. They also provide the speed and agility you
need to be competitive on the sporting field. ing. The doctor may ask you to move your leg into
However, quick movements and sudden stops specific positions to determine exactly which muscle
while playing sports such as tennis, basketball, track, you’ve injured.
or soccer can stretch these bands of tissue to the point Hamstring strains range in severity from a mild
of injury—either overstretching (a strain, or pull) or strain to a complete tear:
an actual rip in the muscle (a hamstring tear). The • Grade 1 is the least severe type of strain, in which
hamstrings are more vulnerable to injury than the the muscle is overstretched.
quadriceps, in part because of imbalances in strength • Grade 2 is a partial tear.
between the two muscle groups. The quadriceps are • Grade 3 is a complete tear of the muscle from its
usually stronger, so the hamstrings may fatigue faster, connection to bone. In the worst-case scenario, the
setting up the possibility of strains. Overworked, torn hamstring pulls part of the bone away with
fatigued hamstrings are also more vulnerable to tear- it (an avulsion fracture). An x-ray, ultrasound, or
ing, because they can’t absorb as much energy during MRI can identify muscle tears and avulsion frac-
exertion. Muscle overload is another hazard, which tures; however, these tests are not usually necessary.
occurs when you suddenly put the full weight of your
body onto the muscle as it is lengthening—for exam- Treating a hamstring strain or tear
ple, as you push off a starting block into a sprint. Treatment for a hamstring muscle strain or tear fol-
In fact, the hamstrings are among the most com- lows the same general protocol as for many other
monly injured muscles in athletes. Hamstring injuries sports-related injuries: rest, ice, compression, eleva-
account for 37% of all muscle injuries in professional tion (RICE).
soccer players, and they are responsible for 25% of • Rest. Avoid the activity that caused the injury.
missed games among athletes over all. That said, any- Depending on the extent of the pull, your doctor
one can suffer a hamstring injury when placing large, might recommend that you use crutches to take
sudden demands on these muscles—for example, weight off the affected leg until it heals.
when dashing for the bus. These injuries often hap- • Ice. Hold an ice pack to the hamstring for about 20
pen when people have not warmed up before a work- minutes at a time, several times a day. Wrap the ice
out or when their quads are much stronger than their in a towel to avoid injuring your skin.
hamstrings, setting up an imbalance in how the two • Compression. Wrap the leg in a bandage to keep
muscle groups work with each other. down the swelling.
Most hamstring injuries affect the thick center • Elevation. Prop up your leg on a pillow. Raising the
portion of the muscle. leg helps move fluid back toward your heart, which
brings down swelling.
Diagnosing a hamstring strain or tear An over-the-counter anti-inflammatory drug such
During the exam, your doctor will gently press on the as aspirin, ibuprofen (Advil, Motrin), or naproxen
back of your thigh, looking for tenderness and swell- (Aleve) may be useful for easing pain right after the

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injury, although research hasn’t shown that these pain
relievers help with healing. Symptoms of iliotibial band syndrome
Once the muscle has healed, your doctor might • Pain along the iliotibial (IT) band, from the hip to below
the knee
refer you for physical therapy. There, you’ll learn exer-
• Pain, swelling, warmth, or redness in the outer part of
cises to improve your mobility, increase your range
the knee
of motion, and rebuild strength in your upper leg
• Pain on the outside of the hip that is worsened by
muscles. Your doctor and physical therapist will let
pressure, such as when lying on the affected side
you know when it’s safe to return to sports and other
• Pain when you start to exercise, but that improves as
physical activities. you warm up (eventually you may have pain even while
If you have a total muscle or tendon tear—or an at rest)
avulsion fracture, in which a tendon rips away from • Pain that gets worse when you run down hills or stairs,
the bone, bringing a piece of the bone with it—you lengthen your stride, or sit for long periods of time with
may need surgery to fix it. During this procedure, the your knees bent
surgeon pulls the hamstring muscle back into place
and secures it to the bone with stitches or sutures. A
tear in the muscle is stitched together. Because of the Iliotibial band syndrome
severity of the injury, it can take about six months to The iliotibial (IT) band is a thick band of connective
rehabilitate and recover. tissue that runs down the side of your upper leg, from
A relatively new treatment called platelet-rich the iliac crest of your hip bone to the outside of your
plasma (PRP) injection is currently under investiga- knee. Alongside the knee, this band passes over the
tion for treating hamstring injuries. Along with red epicondyle, a bony bump at the outside of the lower
and white blood cells, platelets are a component of the end of your thighbone. A bursa keeps the movement
liquid portion of blood (plasma). Platelets not only of the IT band smooth over this bony protrusion and
help your blood clot, but they also promote healing prevents friction as you walk or run. But when you
after an injury. To prepare the PRP, a small amount repeatedly flex and extend your knee—for example,
of your blood is removed from a vein. It is then spun from running up and down hills or cycling for long
in a centrifuge to separate out the platelets. Plasma periods of time—the IT band rubs back and forth
enriched with platelets is then injected back into the against the epicondyle and gets irritated and swollen.
muscle. Early evidence suggests this treatment could Both the tendon and bursa can become inflamed and
speed healing, although the research isn’t conclusive sore, a condition known as iliotibial band syndrome.
at this point. The treatment also isn’t usually covered The pain and tenderness may be confined to the outer
by insurance. part of your knee, or it can spread to the thigh and hip.
Unfortunately, hamstring injuries are often not a A tight IT band can also cause people with hip prob-
one-time occurrence. One out of every three people lems to lose range of motion in the joint.
who suffers one of these injuries will have another IT band syndrome affects up to 14% of runners.
one, sometimes within the first two weeks after they But the condition can occur in anyone who overdoes it
return to the sport that caused it. To avoid future inju- while running, cycling, skiing, or playing soccer. You’re
ries, make sure you warm up before working out or more likely to develop IT band syndrome if you
playing sports—for example, by marching in place for • train intensively or for long periods of time
several minutes first. After your workout, be sure to (although this condition can also occur in people
stretch your hamstrings. One way to do that is to sit who exercise or play sports at more typical intensi-
on the floor with both legs extended in front of you. ties and durations)
Slide your hands down your legs until you feel a slight • don’t warm up properly before an activity
pull in the backs of your legs. Hold for 30 seconds, and • suddenly increase the intensity or frequency of your
then return to an upright position. training sessions

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 • are in poor physical condition and suddenly start or give the injury enough time to heal, it can continue
return to physical activities for much longer, and you may end up with chronic
• use poor form when you run or play sports inflammation of your tendon and bursa. To relieve
• have a tighter-than-usual IT band pain and inflammation, hold ice to your knee for 15
• have bowed legs (a space between your lower legs to 20 minutes at a time, once every two or three hours.
and knees when your feet are pressed together) Take over-the-counter anti-inflammatory pain reliev-
• have weak muscles in your knee or hip. ers if you need them and your doctor says they’re safe
IT band syndrome is often a secondary prob- for you. Steroid injections are another option to relieve
lem, which means that it develops because of another pain from IT band syndrome.
injury or condition. Lower back or hip pain, for Your doctor will likely prescribe a physical ther-
example, can cause a limp that leads to IT band syn- apy program that includes stretching and strengthen-
drome, particularly in elderly people. The syndrome ing exercises to improve your balance, coordination,
is more common in those who have tight IT bands, and posture (referred to collectively as neuromus-
unbalanced leg muscle strength, high or low arches, or cular re-education). In addition to working your
unequal leg lengths. knees and hips, the therapist will give you exercises
to strengthen your core muscles—not just in your
Diagnosing iliotibial band syndrome abdomen, but in your back and buttocks. Weakness
During the examination, your doctor will press on in your core destabilizes your body and can con-
the outside of the leg or injured knee, looking for any tribute to IT band syndrome. Some therapists use
tenderness and swelling. The doctor might move your manual therapy, in which they move certain muscles
knee into different positions to see if the IT band is and joints that you may not be able to work yourself.
tight. X-rays or other imaging tests aren’t usually Manual therapy helps to improve strength and range
needed, but they may help your doctor rule out other of motion.
conditions as possible causes of your pain. Surgery is rarely necessary. The procedure to treat
IT band syndrome removes part of the IT band, the
Treating iliotibial band syndrome bursa, or both. The IT band is then reattached to pre-
Most people can completely relieve IT band syndrome vent it from rubbing against the bone on the side of
within six weeks by resting the knee. If you don’t your knee.
To prevent another episode of IT band syndrome
in the future, make sure you warm up for at least
Figure 7: Iliotibial band stretch five to 10 minutes before running, cycling, or doing
other athletic activities. Try to avoid running up and
down hills, or at least limit the time you spend on
hills. And when you do run, wear good-quality shoes
that properly support your feet (see “How to find the
With your right arm against
right running shoes,” page 22). Also, stay on a con-
the wall for support, cross
your right foot behind your sistent training schedule. If you have to stop training
left. With both feet on the for several days or weeks, get back into your old rou-
floor, slowly lean your hip tine gradually to avoid injury. And don’t overtrain, but
toward the wall. Hold for 20 rather give yourself time to recover in between exer-
seconds. Switch sides and cise sessions. Work with a trainer to learn the proper
repeat.
training techniques for your activity.
Finally, it’s very important to stretch after exercis-
ing. That should include regular stretching of the IT
band (see Figure 7, at left).

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 © Believe_In_Me | Getty Images
How to find the right running shoes

O ften, knee and leg problems result from overuse or an immediate injury.
But sometimes, wearing the wrong running shoe contributes to poor body
mechanics, which in turn leads to pain. Don’t just choose whatever shoes are on
sale. Have them fitted correctly, and make sure they’re comfortable right away.
Following are a few tips to help.
Give your shoes an expiration date. No matter how much Decide what amount of cushioning you want. If a
you paid for them, running shoes won’t last forever. With traditional running shoe with a lot of cushioning is working
each step, you slowly wear out the material that cushions well for you, then stick with it. The shoe should feel light in
and protects your feet and legs. Plan to buy a new pair about your hand but have enough flexibility to let your foot bend
once every 350 to 500 miles. For many people, that works naturally.
out to a new pair about once every three to six months. If you’re getting repeated stress injuries, consider
Get fitted. Many discount shoe stores make you find and switching to a minimalist shoe. These very light shoes,
fit your own running shoes. Take the time to go to a store which have much thinner soles, are designed to shift your
where a knowledgeable salesperson will help you get the landing position from the heel to the middle or front of the
right fit. He or she can help you determine the best shoe for foot, thereby lessening the heavy impact of a heel landing.
your foot shape and your style of running. If you do make the switch, dial back the number of miles
Go for a test run. Some stores have a treadmill you can you run at first and build back up gradually, in order to
use for a test run. Other stores without a treadmill might adjust to the new style of running and avoid new injuries.
let you take the shoes outside for a run to help you decide. Consider special insoles. If running is causing you pain,
Make sure your heel doesn’t slide up and down in the shoe special shoe inserts made of gel, foam, or plastic can make
while you run, and be sure your toes don’t hit the front of a difference. These insoles are available at most stores that
the toe box. Give them some wiggle room. sell running shoes. Substitute them for the insole in the shoe.

Meralgia paresthetica About four out of every 100,000 people will

Meralgia paresthetica is a condition marked by develop meralgia paresthetica. This condition is most
numbness, tingling, and burning in your outer thigh. common in people ages 30 to 40. Meralgia paresthet-
“Meralgia” comes from the Greek words meros, mean- ica has recently earned the nickname “skinny pants
ing “thigh,” and algos, meaning “pain.” It’s caused syndrome” in reference to the trend among young
by pressure on the lateral femoral cutaneous nerve, people of wearing tight, constricting jeans.
which runs from your spine through your pelvis and
upper thigh and supplies feeling to the skin of your Diagnosing meralgia paresthetica
thigh. Increased pressure in your groin area can trap Meralgia paresthetica is often misdiagnosed because it
this nerve. Possible causes include can mimic other problems such as spinal nerve dam-
• wearing tight pants, stockings, or belts age, uterine fibroids, appendicitis, or a tumor. Usually
• weight gain, obesity a medical history and physical exam will provide your
• pregnancy
• wearing something heavy (like a tool belt) around
your waist or carrying something heavy (such as Symptoms of meralgia paresthetica
a wallet or cellphone) in your front or side pants • Numbness, tingling or buzzing, or burning pain on the
pocket outside of one thigh
• scar tissue from a past surgery in your groin area • Pain or numbness that gets worse when you stand or
• nerve damage from diabetes, alcohol abuse, or an walk, and improves when you sit down
accident • Aching in the groin that may spread to the buttocks

• lead poisoning.

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doctor with enough information to diagnose this con- around the lateral femoral cutaneous nerve (neuroly-
dition. The doctor may ask you to describe how you sis) or cutting out part of the nerve to relieve pressure.
feel and what could have happened to trigger nerve
compression.
The main method used to diagnose meralgia par- Sciatica
esthetica is the pelvic compression test. You lie on your A sudden, intense pain running down the back of your
side with the affected leg up. The doctor will press thigh might feel like a leg injury, but it could actually
down on the area where the nerve is compressed and be a sign of a nerve problem stemming from your
hold it for about 45 seconds. If you have the condition, lower back. Sciatica isn’t a condition itself. Rather, it’s
you will feel pain when the doctor presses down. The a symptom—a radiating pain in your leg that usually
doctor may also test for numbness by running a brush
lightly over the side of your thigh.
Imaging tests such as x-ray, CT, or MRI are not Figure 8: Cat-cow stretch
needed to diagnose meralgia paresthetica, but may
be recommended to rule out other possible causes of
your pain. As examples, an x-ray of your pelvis and
hip can identify osteoarthritis of the hip. MRI can rule
out a herniated disc or nerve damage. And ultrasound
can help determine whether fibroids are the cause
in women. Electromyography and nerve conduction
studies (see “Nerve studies,” page 25) can help diag-
nose other nerve-related conditions, such as a pinched
nerve in the spine.

Treating meralgia paresthetica

The goal in treating meralgia paresthetica is to relieve
pressure on the nerve. You may be able to do this by
wearing looser clothing or losing weight. An over-
the-counter pain reliever such as ibuprofen or acet-
aminophen (Tylenol) can help with discomfort in the
meantime.
Physical therapy strengthens the leg muscles,
improves flexibility, and relieves tension in your lower
back and buttocks. One exercise that helps take pres-
sure off the lateral femoral cutaneous nerve is called
cat-cow (see Figure 8, at right). This popular stretch is good for the back, chest, and abdomen.
Here’s how to do it:
Most people will get better within a few weeks
using these treatments. If you need something • Get on all fours with your hands placed directly under your
shoulders and your knees directly below your hips at a 90°
stronger, your doctor might recommend a tricyclic
angle.
antidepressant, or an antiseizure medicine such as
• Slowly drop your head down and round your back up toward
gabapentin (Neurontin), phenytoin (Dilantin), or pre- the ceiling. Hold for about 15 seconds. Then return to the
gabalin (Lyrica). These drugs can help ease nerve pain. starting position.
Only rarely is surgery necessary to take pres- • Now flex your back in the opposite direction, lifting your chest
sure off the nerve. Surgery for meralgia paresthetica and head toward the ceiling. Hold this position for about 15
involves removing scar tissue or other restricting tissue seconds. Repeat the entire sequence three to five times.

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occurs when a spinal disc presses on nerve roots in develops a tear, the insides of the disc can bulge out,
your lower spine. similar to what would happen if you were to gently
To understand sciatica, it helps to know a little bit press on a jelly donut. The bulging disc puts pressure
of back anatomy. Your spine is made up of 24 bones on nerve roots around it.
called vertebrae. The five vertebrae in the lower back Other possible causes of sciatica include a narrow-
are known collectively as the lumbar spine. In between ing of the spinal canal (spinal stenosis), bone injuries,
each vertebra and the one next to it is a flat, round disc tumors, infections, and pregnancy. Compression may
filled with a thick, jelly-like substance. These discs act develop gradually over the years, as the result of wear
as cushioning between the vertebrae. and tear that accumulates with age. Or, it may result
The sciatic nerve is formed from several nerves from an injury or more rapid damage to the disc.
that individually run down your lower back, converge You’re most likely to develop sciatica during your 30s,
into one nerve in your buttocks, and then stretch down 40s, or 50s.
each leg. It’s the longest nerve in your body, extending Though the nerve pressure is centered in your
all the way down through each foot and into your toes. lower back, it radiates down the nerve into your legs.
Its job is to relay messages to and from your brain, You’ll feel the pain in different areas, depending on
through your spinal cord, to your legs and feet. which nerve root the bulging disc pinches (see Fig-
Sciatica happens when the roots of the sciatic ure 9, below left).
nerve in your lower back are compressed or squeezed.
The most common cause is pressure from a herniated Diagnosing sciatica
(“slipped”) disc. When the outer covering of a disc Both patients and doctors have a tendency to use the
term “sciatica” to describe any sharp nerve pain in
the back of the thigh. But not all pain in this region is
Figure 9: Sciatica: Roots of the problem caused by pinching of the sciatic nerve. Other causes
include arthritis in the joints of the back or a different
Nerve roots
L4 nerve disease (such as peripheral neuropathy; see page
45). Because treatment of sciatica may differ from
treatments for other causes of pain, it’s important for
L4 L5 your doctor to determine whether or not your symp-
L5
toms truly come from sciatica.
S1
During your exam, the doctor will ask you what
your pain feels like and where you experience it. You
might be asked to move in different ways—such as
S1
walking on your heels or toes, lying on your back and
raising one straight leg, or squatting—so your doc-
tor can assess the source of the pain. These move-
ments will pinpoint weakness or poor reflexes, which
can help your doctor determine whether you have a
problem with one of the discs in your back and which
Sciatic nerve nerves are involved.
Your doctor may also use imaging or nerve studies.
Nerve roots exit from between vertebrae in the spine. At the
Imaging. An x-ray or an MRI scan can help your
lower spine, five nerve roots merge to form the sciatic nerve
in the leg. If a bulging disc pinches one of these nerve roots, it
doctor see exactly which nerves are compressed,
causes sciatica, sharp pain that typically radiates down the leg. although it won’t necessarily add any information
You’ll feel the pain in different areas, depending on which nerve that will aid in your treatment, since sciatica is often
root the bulging disc pinches. treated conservatively with rest and exercise.

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 reliever such as aspirin, ibuprofen, or naproxen can
Symptoms of sciatica make you more comfortable while you heal, as can
• Lower back pain and a cramping, dull, sharp, throbbing, using a heating pad or cold pack on your lower back
or shooting pain or a feeling like an electric shock or legs for 15 minutes at a time throughout the day.
down the back of your leg
The pain reduction these therapies provide will help
• A burning, tingling, or pins-and-needles sensation in
you complete the exercises your doctor recommends.
the leg
Prescription pain medication may be an option for
• Increased pain when you move, sit, cough, or sneeze
more severe pain, but opioid pain relievers are usu-
• Weakness in your legs ally avoided because of the risk of dependence and
other side effects. A prescription muscle relaxant such
as cyclobenzaprine (Flexeril) may help with muscle
Nerve studies. Some doctors perform electro- spasms, but it may not be recommended for older
myography (EMG) and nerve conduction studies to adults, who can become sedated or confused while on
determine whether there has been any loss in the speed these drugs. If these therapies are not enough, ask your
and intensity of nerve signals as they travel through doctor about a corticosteroid injection into your spine.
the sciatic nerve. During EMG, the doctor inserts a There’s some evidence that acupuncture may be
thin needle into the muscle and records the electrical helpful for relieving sciatica pain. Acupuncture has
activity both when the muscle is still and when it is been used in China for more than 3,000 years to treat
active. During a nerve conduction study, electrodes a variety of medical conditions. Practitioners use
are placed on the nerve being tested. Then the nerve is hair-thin needles to stimulate various pressure points,
stimulated. A computer records the speed and size of which is thought to promote the flow of qi (energy)
nerve impulses to the muscle. Such findings can help and blood throughout the body. A 2015 review of 12
confirm the diagnosis and provide more information studies on acupuncture for sciatica found the prac-
about where the nerve compression is located. tice effective for reducing pain, with few side effects
(although the authors acknowledged that the overall
Treating sciatica quality of studies on the subject is poor).
The pain of sciatica is deceptive. It can be so intense
that you think you’re dealing with a serious problem
that requires surgery. Yet surgery is rarely needed. Figure 10: Single knee pull
Sciatica treatment is simple and basic. Rest and time
are your two greatest allies. Take it easy, avoiding
activities that aggravate your pain, but don’t retreat to
your bed or couch for hours at a time. Sitting for pro-
longed periods can actually increase pressure on the
discs in your lower back. Gentle movement balanced
with short periods of rest are preferable. Try to walk
each day. Start with just a few minutes on the tread-
mill or outside, and gradually lengthen the duration
of your walks. This stretch can help with sciatica. Here’s how to do it:
You should also do exercises on your own or with • Lie on your back with your legs straight.
the help of a physical therapist to strengthen your • Raise one knee toward your chest, clasp your hands behind
lower back and the abdominal muscles that support it. your thigh, and gently pull in.
Gentle stretching can also help. One helpful stretch for • Hold the position for 15 to 30 seconds. Repeat with the other
sciatica is the single knee pull (see Figure 10, at right). leg.
An over-the-counter anti-inflammatory pain • Repeat the sequence three times, alternating legs.

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 In up to 90% of people, sciatica will get better with
conservative measures within a few weeks. If a herni- Symptoms of tendinitis in the upper leg
ated disc caused your sciatica, it should improve on • Pain in the lower thigh, above the knee (quadriceps

its own within three to four months. Rarely is surgery tendinitis)

needed to treat a herniated disc, and typically your • Pain in the back of the knee (hamstring tendinitis)

doctor will recommend it only if you have severe pain • Swelling or warmth in the affected area

that isn’t improving, trouble walking, weakness, or a

loss of control over your bladder or bowels (a con-
dition known as cauda equina syndrome, a medical the top of your lower leg bones. They help you bend
emergency) as a result of the compressed nerve. Sur- your knee and straighten your hip when you run,
gery may also be recommended for a complication jump, or kick. Tendinitis can also develop elsewhere in
known as foot drop, which is difficulty lifting the front the leg (see page 14 for tendinitis in the hip and page
part of your foot as you walk. This dragging of the foot 36 for tendinitis in the knee).
results from the nerve injury in your spine, which pre- Injuries due to overuse or quick movements
vents nerve signals from reaching the muscles needed (starting, stopping, turning) may cause tendinitis in
to lift your foot. the upper leg. People who play sports that involve
Your pain, and how long you can tolerate it, may quick acceleration and deceleration, such as soccer,
ultimately dictate whether you choose surgery. If you basketball, or volleyball, are most vulnerable to these
can wait it out, you may be able to avoid an operation. injuries. Runners can also get tendinitis, especially if
After about six to 12 months, people who waited tend they train at high intensity or for long periods of time.
to do just as well as those who had surgery. Having tight muscles—for example, when you don’t
The surgical procedures used to treat sciatica are adequately warm up before a workout—can increase
known collectively as spinal decompression surgery. your risk for this injury. Being obese also makes you
There are two types: more likely to develop tendinitis by putting additional
• Microdiscectomy is used to remove a herniated strain on the tendons.
disc. It is performed through a small opening in
your back. During the procedure, your doctor will Diagnosing tendinitis in the upper leg
remove the damaged part of the disc, along with Your doctor will perform a physical exam, during
any loose disc fragments that are putting pressure which he or she will ask about any activities that might
on your spinal nerve. have led to the injury. The doctor will then check your
• Laminectomy removes the bony plate, called the range of motion and strength in the affected leg and
lamina, covering the back of a vertebra to relieve may order an x-ray to make sure there’s no fracture, or
pressure on the sciatic nerve. Laminectomy may be MRI to look for inflammation or tears in the tendon.
done at the same time as microdiscectomy.
Treating tendinitis in the upper leg
Treatment starts by resting the affected leg and tak-
Tendinitis ing an anti-inflammatory pain reliever such as aspi-
As described in previous chapters, tendons are the rin, ibuprofen, or naproxen. A physical therapist can
thick cords that anchor muscles to bone. Inflamma- teach you exercises to strengthen and stretch the
tion or irritation of a tendon is known as tendini- injured area, and he or she may use additional treat-
tis. In the upper leg, tendons in the quadriceps and ments such as heat, cold, or ultrasound (which deliv-
hamstrings can be affected. The quadriceps tendon ers heat to the tendon). Wearing a brace (for which
attaches the quadriceps muscles to the kneecap (see the physical therapist can fit you) takes pressure off
Figure 11, page 28). It helps to straighten your leg. The the tendon, so you can go about your regular activi-
three hamstring tendons extend from your pelvis to ties while it heals.

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 Knee pain

Knee anatomy 101

T he knee isn’t the strongest joint in the body—that
honor goes to the hip—yet the knee manages to
support even more weight, while simultaneously
The knee joint is a hinge that allows your lower leg
and foot to swing easily forward or back as you walk,
permitting enough flexibility to bend and straighten run, or kick. A healthy knee allows almost 150° of
when you need to sit, stand, kneel, walk, climb stairs, movement. But unlike a simple hinge, the knee can
or ride a bicycle. We ask a lot of our knees, which helps also rotate slightly, thanks to its unique anatomy (see
explain why they can cause so much trouble. Figure 11, page 28).
The knee can be compared to an expensive sports
car—a finely tuned machine that is capable of great Bones
power but also highly vulnerable to breakdown. Knees The knee joint forms at the junction of three bones:
suffer more injuries than any other joint, in part • the thighbone (femur)
because of their complex anatomy and in part because • the shin bone (tibia)
of the demands we place on them. Knee problems can • the kneecap (patella).
have their roots in a slowly degenerative disease like At the knee, the thighbone divides into two
osteoarthritis, or they can happen as the result of a sud- rounded knobs called condyles. These balance on top
den injury. Overuse injuries can also occur over time. of the shin bone, which is more or less flat on top with
Whatever the cause, knee pain and stiffness can turn a bump in the middle. In contrast to the perfectly con-
the simplest activities, like climbing the stairs or walk- toured fit between bones in the hip and many other
ing to the mailbox, into difficult and painful endeavors. joints, the knee’s mismatch in shape allows for com-
This chapter explores some of the most common plex movement but is quite unstable, like two door-
knee ailments (listed in alphabetical order). It begins knobs balanced on an uneven plate.
with an overview of knee anatomy, to explain the dif- The kneecap is a small bone in the front of the
ferent ligaments and other parts of the knee that can knee. By serving as the attachment point for the quad-
cause problems. riceps tendon above the knee and the patellar tendon
below the knee (see below), it helps provide leverage
for straightening your knee. It sits in a small hollow
called the trochlear groove, which is between the two
condyles of the thighbone. Whenever you bend and
straighten your knee, the kneecap slides up and down
inside this groove.

Ligaments and tendons

© JohnnyGreig | Getty Images

Because the thighbone and shin bone do not fit neatly

together, ligaments play an especially important role
in the knee. Four ligaments running alongside and
through the knee create stability and prevent the knee
The knee acts as a hinge, but unlike a simple hinge—such as one from moving in ways that could damage it.
on a jewelry box or a door, in which any wobble is undesirable— • The medial collateral ligament (MCL) connects the
the knee can also slightly rotate or move side to side. thighbone to the shin bone on the inside (big-toe

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 side) of the knee joint, limiting sideways motion. Cartilage
• The lateral collateral ligament (LCL) does the same Knees have two types of cartilage:
thing on the outside (little-toe side) of the knee, but • Articular cartilage coats the ends of the bones,
it connects to the fibula instead of the shin bone. enabling the joint to move smoothly.
• The anterior cruciate ligament (ACL), located deep • Rubbery cartilage pads, each known as a meniscus
within the joint, connects the thighbone to the shin (plural, menisci), act as shock absorbers between
bone in the center of the knee; it keeps the knee the thighbone and shin bone. These rubbery pads
from rotating too far or letting your shin get out in are wedge-shaped—thick on the outer edge and
front of your thighbone. ACL injuries occur when thin on the inside. You have two of them in each
a sudden stop or turn tears the ligament (see “Liga- knee: the medial meniscus on the inside of the knee
ment injuries,” page 30). joint, and the lateral meniscus on the outside. For
• The posterior cruciate ligament (PCL) helps keep their small size, the menisci take a lot of pound-
the shin bone in place. It crosses behind the ACL, ing. The medial meniscus carries up to 50% of the
and the two form an X in the center of the knee. load put on the inside of the knee, while the lateral
In addition, the patellar tendon—actually a liga- meniscus absorbs about 80% of the force applied to
ment, despite its name—connects the kneecap to the the outside of the knee.
shin bone. At the top of the patella, the quadriceps Arthritis of the knee usually involves the degen-
tendon connects the quadriceps muscle to the knee- eration of both types of cartilage. Excess body weight
cap and provides the power to extend the leg. can accelerate degenerative changes in the knee.

Figure 11: The knee: Strong and flexible

Front view of knee Three-quarter view of knee

Anterior cruciate Femur Posterior cruciate

ligament: (thighbone) ligament:
Connects the Crosses behind
femur to the the ACL and keeps
tibia and limits Patella the shin bone in
rotation and (kneecap) place
forward motion
Quadriceps
of the tibia Femur
Lateral collateral tendon
(thighbone)
Condyle Condyle ligament:
Connects the femur Patella
to the small bone (kneecap) Condyle
of the calf (fibula)
Medial collateral
ligament: Connects
the femur to the Articular Lateral
tibia, limiting Tibia Menisci: Shock- cartilage collateral
sideways motion (shin bone) absorbing cartilage ligament
Fibula Patellar
tendon
Menisci
The knee joint forms at the junction of the femur, tibia, and patella.
Ligaments connect these bones and prevent the knee from moving in a way Tibia
that could cause damage. The patellar tendon (actually a ligament) attaches (shin
the bottom of the patella to the top of the tibia. Two bony protuberances bone)
Fibula
of the femur, called condyles, perch atop the shin bone. Articular cartilage
coats the ends of these bones, enabling them to move smoothly against
one another. Tendons give the knee stability.

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Bursae
Fluid-filled pouches called bursae act as cushions to Symptoms of Baker’s cyst
prevent bones and soft tissues—muscles, tendons, • A soft lump behind your knee

and skin—from rubbing against one another. All told, • Pain in your knee

the body has 150 bursae, including in the hips, knees, • Stiffness
shoulders, and other joints. The knee contains a num- • Difficulty fully bending your knee
ber of bursae, including the following: • Swelling in one leg
• the prepatellar bursa, between the kneecap and the
skin
• the deep infrapatellar bursa, between the patellar Treating Baker’s cyst
tendon and the tibia Some cysts will gradually disappear on their own or
• the pes anserine bursa, between the semimembra- burst, in which case your body will reabsorb the fluid.
nosus hamstring muscle and the tibia. Resting and elevating the leg as well as holding an ice
Inflammation of these pillow-like sacs results in pack to the back of your knee will help control inflam-
the painful condition known as bursitis (see “Bursitis,” mation. A corticosteroid shot can sometimes shrink
below right). the cyst more quickly. If the cyst doesn’t go away, your
doctor can drain the fluid with a needle (a procedure
called needle aspiration). In addition to managing
Baker’s cyst symptoms with these measures, you’ll need to treat the
When a lump appears behind your knee, it can be dis- cause of the cyst. Anti-inflammatory or pain medicines
concerting at the very least, if not alarming. But if the (see “Treating knee osteoarthritis,” page 34) or surgery
lump is a Baker’s cyst, you can rest easy knowing that to repair torn cartilage (see “Treating meniscal tears,”
you have a benign condition that is relatively simple to page 32) can prevent the problem from recurring.
relieve. A Baker’s cyst (also called a popliteal cyst) is a
fluid-filled sac, or cyst, that forms when the knee pro-
duces too much synovial fluid (the viscous liquid that Bursitis
lubricates this joint and prevents friction). Arthritis or Bursae are the pillow-like pouches that act as cushions
an injury such as a tear in the cartilage or a menis- between bones and soft tissues. There are 11 bursae in
cus can ramp up synovial fluid production. Baker’s and around the knee. When any one of them becomes
cysts are named for William Morrant Baker, the 19th- inflamed because of an injury, excessive pressure, or
century surgeon who described the condition in eight other causes, that is called bursitis. These are the three
of his patients. In Baker’s era, treatment sometimes most common types of knee bursitis:
involved amputation. Today, much less radical mea- • Prepatellar bursitis—nicknamed “housemaid’s
sures are used. knee” or “clergyman’s knee”—affects the bursa
Although this condition isn’t serious, any swelling between the kneecap and your skin, causing swell-
behind your knee should prompt a call to your doc- ing on top of or in front of the kneecap. It is com-
tor. There is a small chance that an unusual growth mon among people whose jobs or hobbies require a
or fluid collection indicates an infection, aneurysm, lot of kneeling, such as plumbers, roofers, garden-
blood clot, or other serious condition. ers, and housecleaners.
• Infrapatellar bursitis affects the bursa just below the
Diagnosing Baker’s cyst kneecap. It is also common in people who spend a
Sometimes your symptoms alone will reveal the cause lot of time kneeling.
of the lump. You may need an imaging test such as • Pes anserine bursitis affects the bursa between your
ultrasound or MRI to confirm that you don’t have a shin bone and the hamstring tendons. It is more
blood clot or another serious condition. often seen in runners.

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 The ACL is the most commonly injured knee liga-
Symptoms of knee bursitis ment. The ACL can stretch or tear during any sud-
For prepatellar or infrapatellar bursitis: den movement in which your feet stay in place while
• Swelling on top of the kneecap (prepatellar bursitis) or your knees twist, which often happens in sports like
below the kneecap (infrapatellar bursitis) skiing, football, soccer, or basketball. Female athletes
• Warmth and tenderness are two to eight times more likely to tear an ACL than
• Pain when you move, rest, or kneel male athletes. One factor is female anatomy. Because
For pes anserine bursitis: women have wider hips relative to their body size, the
• Pain located inside the knee, below the knee joint thighbone slants inward toward the knee at a steeper
• An increase in pain when you climb stairs or exercise angle than in men (see Figure 12, page 31), placing
• Pain when your knees touch as you lie on your side additional stress on this ligament and making it more
vulnerable to tearing.
The PCL in the back of the knee is also commonly
Diagnosing knee bursitis injured. Because of the PCL’s more protected location,
Your doctor will examine your knees, looking for tearing it usually requires a hard blow, for example,
warmth, redness, and pain. Imaging tests such as MRI from a football tackle or a car crash.
or ultrasound can show if there is any swelling in the The two collateral ligaments give stability to the
knee bursae. inner and outer knee. The MCL and LCL can be torn
by a hit to the inner or outer side of the knee, which
Treating knee bursitis may occur in sports like football or hockey. Because
Bursitis often gets better on its own, once you stop of the way the knee joint is structured, an injury of
doing the activity that caused it. Follow the RICE the LCL will usually occur along with damage to other
protocol: rest, ice, compression, and elevation (see structures of the joint, such as the ACL or a meniscus.
“Treating a hamstring strain or tear,” page 19).
Take an over-the-counter anti-inflammatory pain Diagnosing ligament injuries
reliever—such as aspirin, ibuprofen (Advil, Motrin), Your doctor will ask about the injury and then exam-
or naproxen (Aleve)—to reduce swelling and pain. A ine your knee, looking for areas of tenderness, insta-
physical therapist can work with you to increase flex- bility, limited range of motion, and buckling when
ibility and strengthen the muscles that support your you walk. The location of the pain and buckling can
knee. If the cause is an infection, an antibiotic should help your doctor pinpoint which ligament you have
clear it up. For more stubborn swelling, you might injured. For example, in an MCL sprain the knee will
try a corticosteroid injection or aspiration to remove buckle toward the outside. If the exam indicates a liga-
excess fluid from the knee. If bursitis doesn’t improve, ment injury, you may get an imaging test such as an
your doctor might recommend surgery to remove the
inflamed bursa.
To prevent knee bursitis in the future, avoid Sprains and strains: What’s the difference?

S
kneeling on hard surfaces for any length of time. If prains and strains are easy to confuse since only one
you do have to kneel, use a cushion or knee pads for letter separates these two conditions, but they are not
protection. the same.
• A sprain is a stretch or tear in a ligament. In the case of
the knees, that means one of the four knee ligaments
(see “Ligament injuries,” at left).
Ligament injuries (sprains) • A strain is a stretch or tear in a muscle or tendon. In the
A sprain (stretching or tearing) of any of the knee’s knee, that would be a muscle or tendon supporting the
four ligaments (see Figure 11, page 28) can destabilize knee (see “Strains,” page 36).
the joint and make it difficult to turn or twist the leg.

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x-ray or MRI to look for tears and other damage to the A knee ligament that is completely torn makes
joint. Doctors grade ligament sprains as follows: it difficult to twist or turn the knee. The joint may
• Grade 1 sprains occur when the ligament stretches, become too weak to support your weight, causing it
but not to the point where the knee becomes to give way or buckle. If this happens, you may need
destabilized. ligament repair surgery. During this procedure, the
• Grade 2 sprains, or partial tears, happen when the surgeon will take a piece of tendon from your knee-
ligament is stretched enough to loosen, or destabi- cap, hamstring, or quadriceps (called an autograft)
lize, the joint. or from a donor (called an allograft) and attach it to
• Grade 3 sprains, or complete tears, occur when the your thighbone and shin bone to hold the knee joint
ligament rips and cannot support the joint. together and support it. Often this is done arthroscop-
ically, through small incisions.
Treating ligament injuries
As with other injuries, rest, ice, compression, and ele-
vation (RICE) is the primary treatment (see “Treating Meniscal tears
a hamstring strain or tear,” page 19). Over-the-coun- The knee comes equipped with two built-in shock
ter anti-inflammatory pain relievers can be helpful absorbers between the shin bone and thighbone—
for bringing down swelling. Your doctor will recom- crescent-shaped pads of cartilage called the medial
mend that you sit out sports or exercise until the knee meniscus and the lateral meniscus (plural, menisci).
heals and wear a protective knee brace when you do Although thick and rubbery, the menisci can rip if
play again. Physical therapy will help strengthen the
muscles that support your knee. Most mild (grade 1
or 2) sprains heal within two to four weeks, but more Figure 12: What’s your Q-angle?
severe tears take up to a year to fully heal, and they
Female Male
may require surgery.

Symptoms of ligament injuries

For injury to the anterior cruciate ligament (ACL):
• A popping sound when the injury happens
• Swelling, which may cause pain
• Difficulty standing on the affected knee, or a feeling like
your knee is giving way
For injury to the posterior cruciate ligament (PCL):
• Mild to moderate pain that may cause a slight limp or
difficulty walking
Harriet Greenfield

• Swelling in the knee

• Instability in the knee, which may feel as if it’s going to
give way
For injury to the medial collateral ligament (MCL):
It’s not obvious, but your thighbone (femur) and your shin bone
• Pain and tenderness on the inside of the knee
(tibia) are not positioned in a straight line. The line of the femur and
• Wobbling of the knee or the knee giving way the line extending from the ankle through the kneecap (patella)
• Swelling form what is known as the Q-angle. Women usually have a more
• Sensation of “opening up” with each step (in severe pronounced Q-angle than men. Because a greater Q-angle is
injuries) associated with a higher incidence of tears in the anterior cruciate
ligament (ACL), women are more susceptible to these tears.

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exposed to enough force, such as from a football
tackle or by twisting the knee while skiing or dancing.
Meniscal tears (see Figure 13, below) are among
the most common knee injuries, particularly in ath-
letes who play football and other contact sports.
Older adults are also prone to these tears, as cartilage

© ultramarinfoto | Getty Images

of the knee wears away over time and leaves the joint
more vulnerable. In an older adult, a simple twist of
the knee can tear an already weakened meniscus.
Such injuries are called degenerative meniscal tears.
Doctors classify meniscal tears by their location,
pattern, and severity. Each meniscus has three zones— Skiing is among the sports that pose a risk of meniscal tears.
the anterior horn (at the front), the body (in the mid- A small tear on the outer edge of the meniscus may not need
dle), and the posterior horn (at the back). Tears can treatment, since the outer third has an ample blood supply.
occur in any of these three areas. The posterior horn
is the thickest and most weightbearing part of the runs in a straight line across the lower portion of the
meniscus, and the most common location for tears. meniscus. Tears that encompass more than one type
Meniscal tears come in a variety of patterns. Their are called complex tears.
names are often colorful ways of describing their
shapes. For example, a bucket-handle tear describes Diagnosing meniscal tears
an injury in which part of the meniscus rips and flips After asking about your symptoms and the activities
over, forming an upside-down U shape like the han- that preceded them, your doctor will feel your knee
dle on a bucket. A parrot-beak tear cuts through the joint for pain and swelling. One way to check for a
meniscus, producing a curved cut-out that resembles meniscal tear is with the McMurray test. Your doctor
the hooked shape of that bird’s beak. A horizontal tear will bend, straighten, and rotate your knee. A clicking
sound heard during these movements can indicate a
meniscal tear. MRI can help your doctor visualize the
Figure 13: Torn meniscus tear, while an x-ray helps to rule out osteoarthritis and
other bone-related causes of knee pain.
Femur

Treating meniscal tears

Patella Where a tear occurs and how large it is will dictate
how it is treated.
Tear in
meniscus
Symptoms of a meniscal tear
• A popping sensation
• Swelling and stiffness that increases in the day or so
after the injury
Tibia • Pain that gets worse when you twist or bend the knee
• A feeling that the knee is catching or locking when you
walk
• Difficulty fully straightening your knee
When the shock-absorbing cartilage in the knee is torn by injury or
worn ragged by use, the result is a torn meniscus. Stiffness and a • Weakness and reduced range of motion in the knee
sensation that the knee is catching or locking often result.

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 Small tears on the outer edge of the meniscus may archaeologists show signs of arthritis in their knee
not need treatment, unless they cause excessive pain joints. But the condition is on the increase. Since the
or instability, since the outer third of the meniscus middle of the 20th century, arthritis has doubled in
has an ample blood supply that can help the wound prevalence, in part because of preventable risk factors
heal. Follow the RICE (rest, ice, compression, eleva- like weight gain and certain types of sports injuries.
tion) protocol, and take an over-the-counter anti- The average age at which knee osteoarthritis strikes
inflammatory pain reliever such as aspirin, ibuprofen, has dropped from 69 to 56 since the 1990s.
or naproxen to manage pain and swelling. These mea- Whatever the cause, the result is pain and dis-
sures may have a noticeable effect in four to six weeks. ability. Early in the course of the disease, the space
Tears in the center of the meniscus or large tears, between your thighbone and shin bone decreases as
however, will not heal on their own. For these tears, the cartilage wears away (see Figure 14, below). Once
arthroscopic surgery may be an option. Through tiny the cartilage disappears, bone rubs on bone, causing
incisions, using a miniature camera and small instru- stiffness, an aching pain, or occasional flares of intense
ments, the surgeon will trim away the damaged menis- pain, and often the formation of bony growths known
cus tissue (partial meniscectomy) or reattach the torn as bone spurs (osteophytes) around the joint.
pieces with sutures (meniscus repair). If the knee is
completely locked (unable to bend or straighten), sur- Diagnosing knee osteoarthritis
gery must be done right away to remove the section of Your doctor will ask about your symptoms and will
torn meniscus that is trapped and blocking movement look for signs of arthritis like swelling, warmth, red-
of the knee. After meniscus repair surgery, you will ness, loss of motion, or a crackling sound (crepitus)
need about three months of rehabilitation to regain when you bend and straighten the knee. An x-ray can
strength and function in your knee. reveal narrowing in the joint space, as well as abnor-

Osteoarthritis Figure 14: Knee osteoarthritis

Arthritis is a collection of diseases that cause pain,
swelling, and stiffness in the joints. The most common
of these is osteoarthritis. Although osteoarthritis can Condyles
appear in any joint, the knee is particularly vulner-
able, in part because it repeatedly bears almost all the Arthritic
body’s weight and partly because it is also subject to erosion of
cartilage
sudden injuries, such as meniscal tears (see page 31).
Arthritis is not unique to the modern era. Skel-
etons of prehistoric hunter-gatherers unearthed by

Symptoms of knee osteoarthritis

• Stiffness and swelling in one or both knees Menisci
• Warmth and redness in the joint
• Pain that gets worse with use or if you sit for a long
period of time
Age, mechanical wear and tear, genetics, and biochemical factors
• A cracking, popping, or sticking sound when you move
all contribute to the gradual degeneration of the cartilage and the
the knee meniscus. In this illustration, articular cartilage in the knee has worn
• Weakness in the knee down and eroded. Tenderness, stiffness, and morning pain are tell-
tale signs of osteoarthritis.

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 some of the bodywide side effects
Figure 15: Total knee replacement surgery of the oral drugs.
The surgeon first cuts away To relieve more severe pain,
thin slices of bone with Femur your doctor might recommend
damaged cartilage from Femoral injections of corticosteroids or
component
the end of the thighbone hyaluronic acid (a lubricating fluid
(femur) and the top of the Patellar that is naturally found in healthy
shin bone (tibia), making component
sure that the bones are cut
joints). Supplements containing
to precisely fit the shape of glucosamine and chondroitin sul-
the replacement pieces. The fate (substances found naturally in
artificial joint is attached cartilage) are often touted for pro-
to the bones with cement Tibial moting joint pain relief, but there
or screws. A small plastic component
is no real evidence they help with
piece goes on the back of
knee arthritis.
the kneecap (patella) to ride
smoothly over the other Pain relievers, however, are
Tibia
parts of the artificial joint only part of the solution. To help
when you bend your knee. strengthen the supporting muscles
around the knee, your doctor will
mal bony outgrowths (bone spurs) caused by joint likely prescribe physical therapy. A physical therapist
damage. If your doctor suspects rheumatoid arthritis, helps you restore and maintain function, usually with
you may have blood tests for signs of inflammation an exercise program that is individually tailored to
and autoantibodies. If gout (another form of arthritis) your needs. The therapist may also apply ultrasound,
is a possibility, you may be tested for elevated uric acid. heat or cold, or a variety of other therapies to help
relieve pain. He or she may also educate you about
Treating knee osteoarthritis posture and body mechanics and suggest assistive
Osteoarthritis has no cure, so doctors focus on three devices to help protect your knees.
things when treating the condition: relieving pain, Assistive devices can help you get around more
protecting joints from further damage, and improving easily when your knees are sore. Placing special insoles
muscle tone to help stabilize joints. Losing weight if into your shoes redistributes your weight, shifting the
you are overweight or obese is essential to getting knee load off your knees. An unloader brace also moves
osteoarthritis under control. With each step you take, weight off the painful part of the knee. A cane or
you put one-and-a-half times the force of your body walker can be invaluable for helping you get around
weight onto your knees. Climb stairs, and the force on without falling (see “Finding the assistive device that
your knees will reach double that of your body weight. fits you,” page 12).
Increasing your physical activity level and changing If you’ve tried a number of treatments and are still
your diet can help you get to your desired weight. dealing with debilitatingly stiff, achy knees, your doc-
For pain relief, over-the-counter nonsteroidal tor might suggest one of these surgical procedures:
anti-inflammatory drugs (NSAIDs)—such as aspi- Cartilage grafting removes a piece of healthy car-
rin, ibuprofen, or naproxen—play an important role. tilage from another part of your body and uses it to
However, NSAIDs may cause stomach bleeding or plug a small area of damaged cartilage in your knee.
other side effects. Acetaminophen (Tylenol) is easier This procedure is best suited to younger people who
on the stomach, but it may be less effective for osteo- have minimal cartilage damage.
arthritis; if you take it, be sure not to exceed the maxi- Osteotomy takes a small piece of bone from either
mum dosage of 3,000 milligrams per day. Some of the tibia or femur and uses it as a bolster to shift your
these drugs also come in rub-on versions that avoid weight off the damaged part of your knee.

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 Total or partial knee replacement removes dam- Diagnosing patellofemoral pain syndrome
aged cartilage and bone and replaces them with an During the exam, your doctor will ask what you’ve
artificial metal or plastic joint or components (see been doing that might have triggered knee pain and
Figure 15, page 34). what activities make the pain worse. The doctor will
gently press on your knee to identify areas of tender-
ness and will look at your leg and knee alignment,
Patellofemoral pain syndrome strength, and flexibility while you bend and straighten
Patellofemoral pain syndrome is a catchall term for the joint. You may be asked to move in different
pain around the kneecap (patella) that’s caused by a ways—for example, walking, squatting, or lunging—
variety of factors. Inflammation and pain in this area so the doctor can assess your knee and leg strength
is sometimes referred to as “runner’s knee,” but it can and look for any changes in your gait. An x-ray can
also occur during non-athletic activities. About 22% help rule out arthritis or other bone problems, while
of people over all, and 29% of teenagers, develop this an MRI or CT scan will reveal any cartilage loss, liga-
condition each year. Patellofemoral pain syndrome is ment problems, and meniscal tears.
the leading cause of knee pain in female athletes.
Although the syndrome may have any of several Treating patellofemoral pain syndrome
causes (including tendinitis in the knee; see page 36), The treatment your doctor recommends depends on
the term frequently refers to pain stemming from the cause of your knee pain. You’ll want to take a break
a misalignment in the kneecap. Instead of moving from the activity that caused the pain. Rather than
back and forth inside the trochlear groove when the jogging or climbing stairs, do non-impact exercises
knee bends, the patella moves out to one side of the like biking or swimming to avoid putting pressure on
groove, which increases pressure on the soft tissues your knee. Use the RICE (rest, ice, compression, eleva-
of the knee. This abnormal movement may be caused tion) method to give your knee time to recover (see
by muscle weakness, tightness, or imbalance; a larger- “Treating a hamstring strain or tear,” page 19). Take
than-normal Q-angle (see Figure 12, page 31); or an an over-the-counter anti-inflammatory pain reliever
overly tight tendon that pulls the patella out of place. such as aspirin, ibuprofen, or naproxen to bring down
Overuse—for example, from running or climb- swelling and ease your pain. Exercises to strengthen
ing stairs frequently—is one of the most common your quadriceps, hamstrings, and core muscles will
causes. Suddenly jacking up your workouts or using provide more stability to your knee. You can do these
the wrong technique can also lead to pain. Repeatedly exercises on your own or with a physical therapist.
bending and straightening your knee increases pres- Your doctor might also recommend wearing
sure between the patella and femur, and it irritates the orthotics, special shoe inserts that put your leg into
patella. Damage to the tendons, cartilage, or bones of better alignment to take pressure off your knee. You
the knee can also contribute to this condition. can buy these inserts over the counter or have them
specially ordered for you at your doctor’s office. A
knee brace or taping will help stabilize the painful
Symptoms of patellofemoral pain joint whenever you exercise or participate in sports.
syndrome It can take six weeks or more to notice an improve-
• Dull, aching pain in the front of the knee, especially ment, but it’s important to see your therapy through to
during activities like running, climbing stairs, jumping, the end. Inadequate treatment is one reason why more
kneeling, or squatting than half of people with patellofemoral pain syndrome
• Pain when you get up after sitting for several hours still complain of pain five or more years after they are
with your knees bent, such as on a long airplane trip first diagnosed.
• Popping or crackling sounds when you move your knee Surgery is rarely needed unless your pain is severe
and it does not improve with conservative treatments.

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Doctors can remove damaged cartilage and bone the joint and restore full range of motion. Mild strains
from the surface of the kneecap or adjust tendons to should heal within six weeks. It may take more than
correct the misalignment arthroscopically (through four months for a more severe tear to heal, and some
small incisions). will require surgery to fix. Most of these procedures
are done arthroscopically, through small incisions
using tiny instruments.
Strains
A knee strain is a stretch or tear in a muscle or ten-
don that supports the knee. It is typically caused by an Tendinitis
accident such as a fall or twisting motion that stretches Tendinitis is inflammation in a tendon. In the case of
the tissues of the joints past their limits. Strains are the knee, the damage typically occurs to the patellar
common among people who play football and other tendon, the bridge between your kneecap (patella) and
contact sports, but they can also occur as the result of shin bone (tibia). Patellar tendon disease or inflam-
poor form, overuse, tight or weak muscles, or wearing mation is sometimes referred to as “jumper’s knee,”
the wrong footwear. because athletes in sports that involve a lot of jumping
on hard surfaces, such as basketball and volleyball, are
Diagnosing knee strain more likely to develop this injury.
Distinguishing sprains from strains may be chal- Repeated stress from the weight of your body
lenging because of the number and complexity of while running or jumping may cause inflammation
structures that make up your knee (see “Sprains and and tiny tears to form in the patellar tendon. As the
strains: What’s the difference?” on page 30). Your doc- number of tears increases, the tendon progressively
tor will use your symptoms and a description of the weakens and becomes more painful. You are more
injury that caused them as a guide to pinpoint which likely to develop knee tendinitis if you have tight thigh
of the two problems you have. Strains are graded in muscles or an imbalance of stronger to weaker mus-
much the same way as sprains, and the grade of your cles in your knees, both of which can increase pressure
injury can help determine which treatment you need on your patellar tendon.
(see “Diagnosing ligament injuries,” page 30). MRI The quadriceps tendon can also be injured, but
may aid in the diagnosis by revealing tears in muscles, this is not as common.
ligaments, or cartilage.
Diagnosing tendinitis in the knee
Treating knee strain After asking about your symptoms and any activi-
Most people can self-treat knee strains with the RICE ties that might have caused this injury, your doctor
(rest, ice, compression, elevation) method. Wearing will gently press on your knee to see where the pain
a brace on your knee will help support the injured is centered. Discomfort just below your kneecap is a
joint while it heals. After an injury, it’s common for sign of tendinitis. You may need an x-ray to see if your
the knee to become stiff and difficult to move. Doing
exercises with a physical therapist will help strengthen
Symptoms of tendinitis in the knee
• Pain and tenderness in the front of your knee, just
Symptoms of knee strain below your kneecap
• A popping noise when • Swelling • Pain when you walk, run, or jump, which may improve
the injury occurs when you rest
• Bruising
• Pain • Swelling
• Weakness
• Stiffness • A cracking sound when you move the knee

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pain stems from a bone or joint problem in the knee. cises to stretch and lengthen the muscles of your knee,
Ultrasound or MRI can reveal tears or other damage and to strengthen these muscles to take pressure off
in your patellar tendon. your patellar tendon. One exercise that’s often recom-
mended for patellar tendinitis is the eccentric drop
Treating tendinitis in the knee squat, which involves rapidly dropping into a quarter-
Ice, rest, and over-the-counter pain relievers can help squat (but don’t drop lower than that) and then slowly
you manage discomfort in your knee until it heals. In standing back up. Another is the straight-leg raise
the meantime, a physical therapist can teach you exer- (see Figure 16, at left). Your physical therapist might
recommend an orthotic device called a patellar ten-
don strap, which applies compression to your tendon
Figure 16: Straight-leg raise to redistribute some of the pressure off of it and onto
Strong muscles around a damaged knee can help support the other parts of your knee.
joint. For example, a strong quadriceps can take over the shock- If these measures don’t work, a corticosteroid
absorbing role usually played by the meniscus or cartilage in the
injection in the knee can help relieve pain. A newer
knee. This exercise, called a straight-leg raise, helps strengthen the
quadriceps.
treatment injects the sugar dextrose into the knee.
Dextrose acts as an irritant, which is believed to stim-
To do this exercise:
ulate collagen growth and connective tissue repair.
• Lie on your back with your legs outstretched in front of you. Bend
one knee into a 90° angle, keeping your foot on the floor.
However, its overall effectiveness is uncertain. Plate-
• In this position, slowly lift the other leg about six to 12 inches off
let-rich plasma (PRP) injection (see “Treating a ham-
the floor. Hold for 10 seconds. Slowly lower your leg. string strain or tear,” page 19) is also being investigated
• Repeat until your thigh feels fatigued, then switch to the other as a treatment for knee tendinitis. Early studies show
leg. promise, but the research is still preliminary.
Tendinitis should improve within a few weeks.
Your doctor will likely recommend taking a break
from whatever activity caused the injury until the
tendon heals. If you don’t see any improvement, your
doctor might recommend arthroscopic surgery to
remove damaged tissue from the knee (a procedure
called debridement).

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 Lower leg pain

Y our lower legs take a lot of

wear and tear. Despite their
comparatively small size in rela-
Muscles
Muscles in the lower leg are inte-
gral to movements of the ankle,
tion to your upper legs, they carry foot, and toes.
a greater weight, and they must Gastrocnemius. The main calf
contend with the difficult job of muscle (gastrocnemius) is the larg-
pumping blood back up toward the est muscle in the back of the lower
heart. The sources of pain in your leg, and the one that bulges out
lower legs can range from muscle if you regularly strengthen your
and tendon issues to blood ves- calves by bike riding or climb-
sel problems and skin sores. This ing stairs. This diamond-shaped
chapter elaborates on some of the muscle begins at the bottom of the
main problems that can affect your femur and attaches to the Achilles
calves and shins (listed in alpha- tendon at the heel. It allows you

© shakzu | Getty Images

betical order). It starts with a look to extend your foot downward, as
at the anatomy of the lower leg. well as to run and jump.
Soleus. Underneath the gas-
The Achilles tendon is the thick, fibrous band
trocnemius is a smaller, flatter
Lower leg anatomy 101 of tissue that connects your calf muscles to muscle called the soleus, which
Bones, muscles, tendons, and your ankle. Achilles tendinitis is a common pulls tightly to help your body
blood vessels in the lower leg have affliction among runners. remain upright. You also use this
a lot in common with their coun- muscle whenever you walk or run.
terparts in the upper leg, yet their position near the Plantaris. In between the gastrocnemius and
body’s extremities poses some additional challenges. soleus is a pencil-thin muscle called the plantaris that
works with the Achilles tendon to allow you to rise
Bones up onto your toes or point your foot. Interestingly
The lower leg has just two bones. enough, 10% to 20% of people are born without a
The tibia (shin bone) is the larger of the two bones plantaris muscle. In those who lack a plantaris muscle,
in the lower leg. It is actually the second largest bone the gastrocnemius takes over its work.
in the body (only the thighbone is bigger) and the one
that supports most of your weight. It connects to the Tendons
thighbone at the knee, and to the bones of the foot at The Achilles tendon attaches all three muscles in
the ankle joint. the lower leg—the gastrocnemius, plantaris, and
The fibula (calf bone) runs parallel to the shin soleus—to the heel bone. It is the main connection
bone, but it is thinner and weaker. Whereas you can point between the leg and foot, and it gives you the
easily feel the shin bone by running your hand down ability to run and jump. Because the structures of the
the front of your lower leg, you may not even be aware legs and feet are so closely connected, a problem with
of the existence of the calf bone. Still, it provides one can lead to problems with the other. For exam-
essential stability for the shin bone. ple, when your feet hurt, you may adapt the way you

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walk to avoid discomfort. Changing your gait alters
the mechanics of your ankle joint, which can lead to Symptoms of Achilles tendinitis
ankle pain. Pain in your ankle makes you adjust your • Pain in the back of the lower leg, just above the heel,
that gets worse after long periods of running, walking,
leg movements, which can potentially lead to knee or
or stair climbing
hip issues. Continuing to move in an unnatural way
• Swelling
can contribute to ongoing pain.
• Stiffness that may improve with activity
• Reduced range of motion, especially difficulty flexing
Blood vessels
your foot or standing up on your toes
As in the rest of the body, the arteries deliver blood
from the heart, and the veins ferry it back. But arter- Symptoms of Achilles tendon tear
ies in the lower leg are particularly vulnerable to cir- • A popping sound
culation problems (see “Peripheral artery disease and • Swelling
claudication,” page 43), and the hydraulic challenge of • Sudden pain in the heel
pumping blood upward is greatest in the lower legs
(see “Edema,” page 41).
Achilles tendinitis is divided into two types, based
on the part of the tendon that is inflamed:
Achilles tendinitis and tendon tear • Non-insertional Achilles tendinitis affects fibers in
The Achilles tendon is the thick, fibrous band of tissue the center of the tendon. This type is more common
that runs down the back of your lower leg. It connects among young, active people.
your calf muscles to your heel and helps you run, • Insertional Achilles tendinitis affects the bottom of
jump, and walk. This tendon, the largest in your body, the heel, in the spot where the tendon attaches (the
gets its name from Achilles, the mythological Greek technical term is “inserts”) into the heel bone. An
hero of the Trojan war. Achilles was exceptionally abnormal piece of extra bone, called a bone spur
strong, but he had one vulnerability—a tiny area on (osteophyte), may also grow on the heel. This type
his heel where his mother had held him while dipping of tendinitis can affect people of any age, but it often
him into the river Styx to make him invincible. If you occurs after years of running or other overuse.
play sports frequently enough to injure this tendon, Tendon weakness—or an injury from too much
it could turn into your own “Achilles’ heel,” causing force on the heel—can also rip the Achilles tendon.
pain and inflammation severe enough to limit your This is known as a tendon rupture or tear. You’ll
activities. know your tendon has ruptured by signs like a pop-
Achilles tendinitis primarily affects people who ping sound, swelling, and sudden pain in the heel. If
overwork this tendon when they run, walk, or jump you hear that telltale popping sound, get medical help
excessively. This is a common affliction among run- right away. Waiting too long to see a doctor can make
ners, particularly if they suddenly increase the inten- surgical repair more difficult if you ultimately need it.
sity or duration of their training sessions or frequently
run up hills. Some 66% of joggers complain of pain in Diagnosing Achilles tendinitis and tendon tear
their Achilles tendon at one time or another. Repeti- Your doctor will ask about your symptoms and activi-
tive stress causes fibers in the Achilles tendon to break ties before examining the back of your heel to look for
down, making the tendon swell. However, you don’t swelling, pain, and thickening of the Achilles tendon.
need to be an athlete to develop Achilles tendinitis. You may be asked to stand on your toes. An inability
Age also weakens this structure and makes it more to do so is a sign you’ve injured this tendon.
prone to strain or tears. Certain physical character- To determine whether you’ve ruptured your ten-
istics, including flat feet and tight calf muscles, also don, your doctor may do the Thompson test. You’ll lie
increase the likelihood of tendinitis. face down with your feet hanging off the end of the

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table. When the doctor squeezes your calf muscle, age to the tendon. Knowing how badly the tendon is
your big toe should flex. A lack of movement indicates injured can help your doctor plan surgery, if needed.
a tendon rupture.
In addition to the exam, your doctor might send Treating Achilles tendinitis and tendon tear
you for x-rays to look for calcium deposits where the The first step in treatment is to stop the activity that
tendon attaches to the heel (indicating calcific tendi- caused your Achilles tendinitis. Avoid high-impact
nitis) or an MRI scan to reveal the severity of dam- exercises such as running or stair climbing that put
pressure on the tendon. Switch to
non-impact exercises like biking,
Stretches for your lower legs swimming, and elliptical training.
Use an ice pack on the affected ten-
T hese exercises stretch the Achilles
tendon and the muscles of your
calves.
against your left upper thigh.
• Lean forward and gently grasp your
don for 15 to 20 minutes at a time,
a few times a day. (Never place ice
left foot, pulling it toward you (use a
Standing calf stretch strap if you can’t reach your foot). directly on the skin. Place a thin
• Hold the position for 10 to 30 towel between your skin and the
seconds. Repeat on the other side. ice pack.) An over-the counter pain
Do the stretch on both sides for a reliever such as aspirin, ibupro-
total of two to four times.
fen (Advil, Motrin), or naproxen
Standing soleus stretch (Aleve) can also help reduce swell-
ing and pain.
Physical therapy is an effective
treatment, especially for non-inser-
tional tendinitis. The therapist will
teach you exercises to strengthen
muscles around the heel. One spe-
To do this stretch: cific program used to treat Achilles
• Start by standing up straight. Hold
tendinitis is called eccentric train-
the back of a chair or press your
hands against a wall, arms extended
ing, or the Alfredson protocol. It
at shoulder height. involves contracting the muscles
• Extend your right leg straight back and tendons around your heel as
To do this stretch:
and press the heel into the floor. you lengthen the muscle. An exam-
Allow your left knee to bend as • Stand up straight. Hold the back of
ple of this technique involves stand-
you do so, while keeping that heel a chair or press your hands against
a wall, arms extended at shoulder ing on the edge of a stair and then
grounded on the floor. Feel the
stretch in the back of your calf. Hold height. slowly lowering one or both heels
this position for 10 to 30 seconds. • Extend your right leg slightly behind below the edge, while holding on
Return to the starting position, then you and press the heel into the floor. to the banister for balance. You will
repeat with your left leg. Do the Allow your left knee to bend as also be given stretches for the calf
stretch on both sides for a total of you do so, while keeping the heel
two to four times.
and Achilles tendon (see “Stretches
grounded on the floor. Now bend
your right knee as much as possible, for your lower legs,” at left) to help
Variation: Seated calf stretch
pressing into your heel until you feel prevent tightness that could lead to
To do this stretch:
a stretch low in your calf. Hold for 10 future injuries.
• Sit on the floor with your left leg out to 30 seconds. Return to standing.
straight.
Special shoes and orthotic
Do this one to three times more,
• Bend your right leg in so that the then repeat the entire sequence with
devices can make you more com-
sole of the right foot is pressed your other leg. fortable while your injury heals.
Soft-backed sneakers or shoes will

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prevent any rubbing against the already irritated heel.
Shoe inserts called heel lifts raise the heel, moving it Symptoms of cellulitis
away from the back of the shoe to prevent rubbing. • Swelling and redness of • Warmth
the skin on one leg (the • A fever
Whatever you do, avoid “rocker” shoes, which have a
redness may gradually
higher forefoot than heel, because they put too much • Blisters
expand)
stress on the Achilles tendon. • Pain and tenderness
• Dimpling of the skin
These treatments should improve Achilles ten-
dinitis, but it can take up to six months to notice a
difference. Diagnosing cellulitis
If you have a tendon tear, your doctor may suggest See a doctor right away if you have a large area of red
surgery. In debridement surgery, the surgeon removes swollen skin and a fever, or if you notice skin symp-
the damaged part of the Achilles tendon and then toms like these and you have diabetes or a weakened
repairs the tear with sutures. Any bone spurs will also immune system. Cellulitis is a potentially serious
be removed during this procedure. If more than half condition that needs to be treated as soon as possi-
of the Achilles tendon is damaged, the surgeon may ble. Your doctor should be able to diagnose it just by
remove a piece of tendon from the big toe and use examining your skin.
it to shore up the Achilles tendon to prevent it from
rupturing again. (This procedure shouldn’t affect your Treating cellulitis
ability to walk or run.) Cellulitis is treated with an oral antibiotic, which you
After surgery, you’ll need physical therapy for up will take for 10 to 14 days. Your symptoms should
to a year to fully recover. improve within one to two days, but be sure to finish
the entire prescription anyway. Stopping the medicine
too soon allows the strongest bacteria to survive, con-
Cellulitis tributing to the development of antibiotic-resistant
Cellulitis is a bacterial infection of the skin. Although superbugs—and setting up the possibility that your
you can get it in any part of your body, it’s most likely infection will come roaring back. If you don’t feel
to affect your lower legs. Bacteria that normally live on better or if your symptoms get worse while on oral
your skin—most commonly Streptococcus or Staphylo- antibiotics, you may need to be treated with stronger
coccus—enter your body through a cut, burn, scrape, intravenous (IV) antibiotics in a hospital. Severe cases
or surgical wound; a skin condition like eczema or may be treated with IV antibiotics from the start.
athlete’s foot; or another open sore. Increasingly, meth- When you treat cellulitis early, it usually clears
icillin-resistant Staphylococcus aureus (MRSA) bacte- up completely without causing any long-term com-
ria cause cellulitis. This “superbug” is tough to treat plications. However, once you’ve had cellulitis, you
because it’s resistant to many commonly used antibiot- are more likely to develop it again. To prevent a
ics. Once inside your body, the bacteria can spread to future occurrence, keep your skin clean and, if you
your lymph nodes and bloodstream, where they can have any wounds, be sure to properly disinfect and
cause a life-threatening infection called sepsis. cover them.
Although anyone can get cellulitis, you’re more
likely to develop this infection if you have one of the
following conditions: Edema
• a weakened immune system from a disease, or from Edema occurs when fluid becomes trapped in the
chemotherapy or another medical treatment body’s tissues, causing them to swell. The word
• a chronic illness such as diabetes “edema” comes from the Greek word oidein, meaning
• a skin condition such as eczema or shingles “to swell.” Although edema can occur anywhere in the
• obesity. body, it’s most likely to affect the legs, ankles, and feet.

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 that prevents them from pushing enough blood up
Symptoms of edema to the heart, causing blood to leak backward and
• Swelling or puffiness in • Pitting of the skin when pool in the legs.
the legs you press on it for five
In addition, sitting or standing for long periods
• Skin that looks stretched seconds or more
of time can produce this symptom, as gravity causes
or shiny in the swollen • Difficulty walking due to
blood to pool in the legs. Too much sodium in your
area heaviness or enlargement
of the legs diet can lead to fluid buildup. During pregnancy, extra
blood and fluid in the body, along with the additional
pressure of the expanding uterus on blood vessels, can
Leg swelling caused by excess fluid buildup is known make the legs swell. Some medications—including
as peripheral edema. nonsteroidal anti-inflammatory drugs, certain blood
Many different medical conditions can cause pressure medications, steroid drugs, female hor-
peripheral edema, including mones, and blood pressure medications—may cause
• cardiomyopathy—a disease of the heart muscle that edema as a side effect.
makes it harder for your heart to pump enough
blood to your body Diagnosing edema
• chronic kidney disease or kidney failure—damage See your doctor if you have symptoms of peripheral
to the kidneys that can cause extra fluid and sodium edema. If you have symptoms like shortness of breath,
to build up in your bloodstream, leading to swelling trouble breathing, or chest pain, get medical attention
• cirrhosis—scarring of the liver due to excessive right away. These could be signs of fluid buildup in
alcohol use or diseases such as hepatitis that can your lungs (pulmonary edema)—which, like edema in
cause fluid to build up in the body the lower legs, can indicate heart failure—or a blood
• heart failure—an inability of the heart to pump clot in the lungs (pulmonary embolism; see “Deep-
blood effectively, which can vein thrombosis,” page 17).
make blood pool in the legs and Your doctor may be able to
feet diagnose peripheral edema based
• nephrotic syndrome—kidney on your symptoms and medical
disease that causes excessive history alone, but imaging tests
protein loss in urine, which may or blood and urine tests are often
in turn lead to a buildup of fluid helpful. Blood tests can reveal
in the body heart, liver, or kidney disease.
• pericarditis—inflammation of Ultrasound can identify a DVT.
the membrane around the heart And tests like an echocardiogram
that can prevent the heart from (which uses high-frequency sound
pumping enough blood, causing waves to create images of your
blood to build up in the legs heart) are helpful for diagnosing a
• thrombophlebitis—a condition heart condition.
in which a blood clot (thrombus)
© vchal | Getty Images

forms in one or more superficial Treating edema

veins, usually in the lower leg, Some cases of edema may improve
causing inflammation of the vein on their own if you simply restrict
(phlebitis) and preventing nor- Edema can occur anywhere in the body, but your salt intake and keep your
mal blood flow it’s most common in the legs, ankles, and legs propped up on a pillow (ide-
• venous insufficiency—weaken- feet. Many conditions, including venous ally above the level of your heart)
ing or damage in the leg veins insufficiency and heart failure, can cause it. when you sit or lie down. This

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encourages blood flow out of your legs and back to tor, with cramps becoming more frequent in middle
your heart. Try not to sit or stand for too long at a age and beyond. Older muscles tire more easily, and
time. Wearing compression stockings also prevents they become increasingly sensitive to lower fluid vol-
blood from pooling in your legs. Limiting sodium umes in the body. Cramps can also be a side effect of
and fluid sometimes prevents fluid buildup, especially medicines like statins, which are used to treat high
if you have a condition like heart failure that hinders cholesterol.
your heart’s pumping ability.
For severe edema, your doctor may prescribe a Diagnosing muscle cramps
diuretic, or “water pill,” which helps to remove extra You should be able to treat a cramp on your own, but
fluid and sodium through your urine. You’ll also need see a doctor if your cramps are severe, you get them
to treat the cause of edema, which may include ther- often, or you have other symptoms (like numbness or
apy to control kidney, liver, or heart disease, or chang- weakness) along with them. Rarely, cramps can signal
ing medications if one of your drugs causes edema. a problem with the spine, blood vessels, or liver.

Treating muscle cramps

Muscle cramps Most cramps will go away on their own within a few
The muscles in your legs are made up of bundles of seconds to minutes. Stretching or massaging the mus-
fibers that alternately contract and expand to produce cle will help it relax. Heat is soothing to tense muscles.
movement. A cramp is a sudden, involuntary contrac- Apply a heating pad or warm wet washcloth to help
tion (tightening) of one of these muscles, typically in loosen up the muscle.
your calf. Cramps can last anywhere from a few sec- To avoid leg cramps in the future, drink plenty of
onds to several minutes. They can be mild, or intense fluids before and during exercise. Muscles need fluid
enough to wake you out of a sound sleep. A sudden, to contract and relax properly. Prevent tightness by
painful muscle spasm in the leg is called a charley warming up your leg muscles before you work out with
horse, which legend has it is named after baseball some walking in place or a slow jog. After each work-
player Charlie “Hoss” Radbourn, who reportedly suf- out, stretch out your leg muscles for a few minutes (see
fered from frequent cramps back in the 1880s. “Stretches for your lower legs,” page 40). Do another
Sometimes there is no obvious cause for a cramp. set of stretches before bed if you tend to get cramps
Exercise is a common trigger, especially after you’ve while you sleep. For cramps that are especially severe,
exercised for a long period of time or in the heat. frequent, or disruptive to sleep, a prescription muscle
Muscles that are tired or dehydrated become irri- relaxant like cyclobenzaprine (Flexeril), metaxalone
tated and are more likely to cramp up. A deficiency (Skelaxin), or methocarbamol (Robaxin) may help.
of electrolytes such as magnesium or potassium in
your diet can lead to more frequent cramping, by
preventing your muscles from fully relaxing. The Peripheral artery disease (PAD) and
risk of a cramp increases during pregnancy, possibly claudication
because of circulatory changes and increased stress on Peripheral artery disease (PAD) is a narrowing of
the muscles from a growing belly. Age is another fac- arteries in the legs (and sometimes the arms)—that
is, the body’s periphery, or outer areas. Like coronary
artery disease, it is caused by the buildup of arterial
Symptoms of muscle cramps plaques (deposits of fat, cholesterol, and other sub-
• Sudden pain and • A temporary hard lump or stances that collect in your arteries). The blood ves-
tightness in a muscle, twitching under the skin sels stiffen as a result and are unable to dilate (widen)
typically in your calf as the muscle contracts enough to deliver sufficient oxygen and nutrients dur-
ing physical activity.

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 The main symptom of PAD is claudication (pain
when you walk or exercise). But in the most serious Symptoms of peripheral artery disease
cases, reduced blood flow can lead to tissue death (PAD)
(gangrene). • Pain in one or both legs that appears when you walk
PAD is an incredibly common condition, affect- or climb stairs and disappears when you rest (called
intermittent claudication)
ing some 8.5 million Americans. Up to one out of
• An aching or heaviness in the affected leg
every five people over age 60 has it, and only about
• Weakness or numbness in the leg
a quarter of people who are affected realize they are
living with PAD. • Cold areas on your lower leg or foot

Having heart disease risk factors such as obesity, • Sores on your legs or feet that don’t heal

high blood pressure and cholesterol, and diabetes • Reddish-blue color to your leg
raises your odds of developing peripheral artery dis- • Hair loss on your leg
ease. Smoking is the leading risk factor and the one • Shiny skin
that increases your chances the most of having serious • A weak pulse in your legs and feet
complications like gangrene in your legs from poor
blood flow.
blood pressure that is lower in your leg than in your
Diagnosing PAD arm may indicate narrowed blood vessels in your legs.
Your doctor will examine you, using a stethoscope to Doppler ultrasound uses a small device called a trans-
listen through the skin over your arteries. A whoosh- ducer, which emits high-frequency sound waves as
ing sound (called a bruit) or weak pulse are signs that a technician rolls it over your leg. The test measures
blood isn’t flowing properly through these vessels. blood flow through the vessels of your legs to identify
Your primary care doctor can do the initial exam, any narrowing or blockages.
but for a more comprehensive diagnosis and treat- Several tests involve injecting a contrast dye (a
ment, you may need to see a vascular surgeon or a substance visible on a particular type of imaging scan)
cardiologist. into your bloodstream. Your doctor can watch the
Doctors use a variety of tests to diagnose PAD. dye’s progress through your arteries using any of these
The ankle-brachial index compares the blood pres- types of imaging:
sure readings from your upper arm and your ankle; • x-rays (in a test called angiography)
• MRI, which uses magnets and radio waves (in a test
called magnetic resonance angiography, or MRA)
• CT, which combines x-rays from multiple angles
(in a test called computerized tomography angiog-
raphy, or CTA).
Injecting the dye through a catheter (narrow tube)
passed into a blood vessel is a more invasive way to
find the source of the problem, but the advantage is
that once the narrowed artery is located, the doctor
© skynesher | Getty Images

may be able to widen it immediately using medication

or by inflating a small balloon inside it.

Treating PAD
One approach to diagnosing peripheral artery disease involves inject- If you have PAD, it’s very important to control your
ing a contrast dye into your bloodstream, then using imaging to see vascular disease risk factors. Just as artery narrowing
how the dye (along with your blood) is flowing through your arteries. limits blood flow to your legs, it could also disrupt

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blood flow to your heart or brain. A piece of plaque that particular nerve controls. The result is periph-
can eventually break open and cause a blood clot to eral neuropathy, which causes symptoms like numb-
form, triggering a heart attack or stroke. Poor blood ness, weakness, pain, or a loss of sensation in the
flow from PAD can lead to the death of tissue in the affected area, such as the legs and feet. An estimated
leg, which could ultimately require amputation. 20 million Americans have some type of peripheral
To prevent PAD—or to avoid complications if you neuropathy, although it’s difficult to get a precise fig-
already have it—lose excess weight, quit smoking, and ure because of the overlap in symptoms with other
adjust your diet and exercise routine with your doc- conditions.
tor’s help. If you can’t control your cholesterol, blood Damage to a single nerve is known as mononeu-
sugar, and blood pressure with these lifestyle measures ropathy. When two or more nerves are damaged, doc-
alone, ask your doctor whether you need medications tors refer to it as polyneuropathy.
to improve your numbers. A number of problems can damage the nerves,
For PAD that causes claudication, a few medical including
procedures are available to open up the blocked area • diabetes (up to 70% of people with diabetes have
of artery: some kind of neuropathy, making this the leading
• In angioplasty, the doctor threads a catheter cause in the United States)
through the femoral artery in your groin and • an injury from a fall, repetitive use, accident, or
advances it to the site of the blockage. A hair- sporting activity that compresses, stretches, or
thin wire inserted through this tube allows your damages the nerve
surgeon to see inside the artery. Then, a tiny bal- • autoimmune diseases such as Sjögren’s syndrome,
loon on the end of the catheter is inflated inside rheumatoid arthritis, and lupus
the artery to widen it, and sometimes a mesh tube • blood vessel problems that reduce blood flow to the
called a stent is put in place to hold the artery peripheral nerves
open. • kidney and liver diseases
• In atherectomy, the doctor uses a catheter with a • medications, such as chemotherapy for cancer
sharp blade at the end to cut out the blockage. • viral infections such as Lyme disease, shingles,
• In bypass surgery, the doctor places one of your chickenpox, Epstein-Barr, HIV, and hepatitis C
own blood vessels or an artificial graft to direct • excessive alcohol use
blood around the blocked artery. • exposure to chemical toxins such as acrylamide, eth-
ylene glycol (antifreeze), dioxins, lead, or mercury
• tumors that press on nerves
Peripheral neuropathy • B vitamin deficiencies
Your peripheral nervous system is an interconnected • hereditary disorders such as Charcot-Marie-Tooth
network of motor and sensory nerves that transmit disease.
messages to and from your central nervous system
(your brain and spinal cord) and the rest of your body.
Signals from motor nerves tell your leg muscles to Symptoms of peripheral neuropathy
move so that you can walk and jump. Sensory nerves • Numbness, tingling, or a pins-and-needles sensation in
transmit signals that help you feel the heat of the sun your feet and legs
on your bare legs, or the pain from a cut on your shin. • Burning, sharp, stabbing, electric, or throbbing pain

Autonomic nerves control functions you don’t nor- • Muscle weakness

mally think about, such as breathing, digestion, heart • Extreme sensitivity to touch
rate, and blood pressure. • Muscle cramps or twitches
Damage to peripheral nerves interrupts or dis- • Difficulty with balance and coordination
torts these messages, disrupting whatever function

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Diagnosing peripheral neuropathy and pregabalin (Lyrica) can help relieve nerve pain.
Your doctor will ask about your medical history, • Topical pain relievers, such as patches or creams
including what medical conditions, injuries, or containing lidocaine or capsaicin, can block the
medicines might have caused nerve damage. These sensation of pain in the area where you apply them.
questions will most likely be followed by a neuro- • Opioid medications may be tried if other treat-
logical exam in which the doctor checks your muscle ments haven’t worked. Because of the risk of depen-
strength, reflexes, balance, coordination, and the sen- dence and side effects, however, these drugs should
sation in your legs and feet. be used sparingly and only under the close supervi-
Blood tests are helpful in detecting an autoim- sion of a doctor.
mune disease, diabetes, or a vitamin deficiency. A CT A noninvasive treatment called transcutaneous
or MRI scan may be done to look for an injury such as electrical nerve stimulation (TENS) can be helpful for
a herniated disc or a tumor that is putting pressure on peripheral neuropathy, especially when diabetes is the
a nerve. Your doctor might also perform nerve con- cause. You place electrodes attached to a battery-oper-
duction velocity and electromyography tests, which ated unit onto your skin for about 30 minutes a day.
measure nerve strength and speed and detect the elec- The electrodes emit a gentle current, which is believed
trical activity in your muscles to identify a potential to work by interfering with the transmission of pain
nerve problem (see “Nerve studies,” page 25). Some- signals to the brain and stimulating the release of pain-
times the diagnosis requires a nerve biopsy, in which relieving chemicals in the body. Although research
the doctor removes a small piece of a sensory nerve hasn’t confirmed that TENS is effective for peripheral
from your lower leg and sends it to a lab to check for neuropathy, it is unlikely to cause side effects other than
any problems. A skin biopsy (removal of a small piece mild skin irritation where the electrodes are placed.
of skin for testing) can detect problems with nerve If a nerve is compressed—for example, by a her-
fibers in the skin. niated spinal disc or a tumor—surgery may be per-
formed to release the nerve.
Treating peripheral neuropathy
The primary goal of treatment is to control the
underlying condition that is causing the nerve dam- Pseudoclaudication (lumbar spine
age. That could entail taking medications for diabe- stenosis)
tes or an autoimmune disease, or removing a tumor Like claudication (see “Peripheral artery disease and
or spinal disc that’s putting pressure on a nerve. The claudication,” page 43), pseudoclaudication causes
hope is that addressing the problem will relieve the pain in the legs while walking, but for different reasons.
pain, numbness, and tingling. Rather than being caused by poor blood flow, pseu-
In addition, your doctor may recommend a drug doclaudication results from nerve compression in the
to relieve symptoms. Drugs that are used to treat spine. It is a symptom of spinal stenosis, a narrowing
peripheral neuropathy include the following: of the spinal canal—the hollow space through which
• Over-the-counter pain relievers—either acetamin- the spinal cord runs as it extends down the back. As the
ophen (Tylenol) or nonsteroidal anti-inflammatory spinal canal narrows, it compresses the nerve roots that
drugs such as aspirin, ibuprofen, or naproxen— branch off the spinal cord. The narrowing is often due
may work for mild nerve pain. to osteoarthritis (which may lead to the growth of bone
• Tricyclic antidepressants, such as amitriptyline spurs) or a bulging disc. Degenerated discs and bone
(Elavil) or nortriptyline (Pamelor), and serotonin- spurs can put pressure on nerves of the spine, causing
norepinephrine reuptake inhibitors (SNRIs), such symptoms like pain, numbness, and weakness. If spi-
as duloxetine (Cymbalta), can alter the brain sig- nal stenosis affects the nerves that control feeling and
nals that cause you to feel pain. movement in your lower legs, that’s where you will feel
• Antiseizure drugs such as gabapentin (Neurontin) the symptoms.

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 fen, or naproxen can help bring down inflammation
Symptoms of pseudoclaudication and relieve pain in the spine and legs. Corticosteroid
• Pain in your legs that gets worse when you stand or injections into the spine (called epidural injections)
walk, and improves when you sit down or bend forward can also reduce swelling and pain, but they carry a
• Numbness, tingling, and weakness in the legs small risk of infection or bleeding and they aren’t
• Lower back pain always effective. Also, you shouldn’t have more than
• Loss of control over your bowels or bladder (rarely) a few injections a year.
• Difficulty with sexual function If your symptoms interfere with your daily life, are
severe, or continue to worsen with treatment, you may
want to consider a surgery called decompression lami-
Because osteoarthritis is so often the cause, pseu- nectomy. During this procedure, the surgeon removes
doclaudication is more common in older adults. Most any bone spurs, along with the roof (lamina) of one or
people over age 60 will have at least some degree of more vertebrae, to create more space for your spinal
spinal stenosis. In people ages 50 and younger, the nerves. This procedure can be done as open surgery
cause is likely congenital spinal stenosis—that is, a or laparoscopically (using miniature tools inserted
narrowing that was present at birth. through smaller incisions). A spinal fusion, which
connects or fuses two or more vertebrae to stabilize
Diagnosing pseudoclaudication your spine, may be done at the same time.
Your doctor will ask about your symptoms and exam-
ine your back and legs, as well as do a thorough neu-
rologic exam to rule out other conditions. He or she Restless legs syndrome (RLS)
may also use various types of imaging to help pinpoint A creepy, crawly sensation in your legs at night that
a diagnosis: prevents you from falling asleep could be restless legs
• An MRI or CT scan may be used to get more syndrome (RLS), also known as Willis-Ekbom dis-
detailed images of the spinal cord and confirm that ease. Doctors don’t know what causes these strange
you have spinal stenosis. sensations, but they may stem from an imbalance of
• An x-ray can reveal bone spurs, damage to the the brain chemical dopamine, which helps to control
discs, and narrowing of your spine. muscle movement.
• A myelogram, in which the doctor injects a con- Up to 10% of Americans have this condition.
trast dye into the spine before performing an x-ray Although RLS can affect people of both genders and
or CT scan, will show the nerves of your spine more all ages, it is more common in women, especially dur-
clearly than either type of imaging alone. ing pregnancy. The frequency also increases with age.
In addition, two tests—electromyography and
nerve conduction studies—can evaluate the speed and Diagnosing RLS
strength of nerve impulses and determine how well Your doctor will ask about your symptoms. The hall-
your nerves are signaling the muscles of your legs (see mark criterion for a diagnosis of RLS is a crawling or
“Nerve studies,” page 25). other sensation in your legs at night that makes you
want to move your legs, and which improves when you
Treating pseudoclaudication walk or stretch. You may also have a neurological exam
Treatment often starts with physical therapy exer- and blood tests to rule out other possible causes for your
cises to strengthen the muscles of your legs and symptoms, such as nerve damage or an iron deficiency.
belly, and stretches to relieve pain. The purpose is to
open up the spinal canal, although it may not help Treating RLS
much for spinal stenosis. An over-the-counter anti- Simple, nonmedical measures may be enough to re-
inflammatory pain reliever such as aspirin, ibupro- lieve RLS and help you sleep through the night. Take

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a warm bath and massage your lower legs before help you fall asleep, although they don’t treat the
bedtime to relax your muscles. You can also place a abnormal leg sensations.
heating pad or ice pack on your legs. (Always place These drugs can cause side effects, including day-
a cloth or towel between the ice pack and your skin, time drowsiness and dizziness. Use them only when
to avoid damaging the skin.) Exercise daily, but do it necessary and under the direction of your doctor.
early in the day to avoid disrupting your sleep even
more. Try to get to bed early each night, and keep
your bedroom comfortably dark and cool to pro- Shin splints
mote better sleep. Avoid caffeine and alcohol, espe- Your shin bone (tibia) runs down the front of your
cially before bed. Both can worsen RLS symptoms. If lower leg, from your knee to your ankle. The term
you’re low on iron, your doctor might suggest taking “shin splints” refers to pain and inflammation of your
a supplement. tibia and its associated muscles and tendons, caused
In addition, the FDA has recently cleared a cou- by overworking this region. You are most likely to
ple of devices to treat RLS. One is a foot wrap called get shin splints if you increase your activity level; for
Restiffic that goes around the middle of your foot. It example, if you switch from a daily 30-minute walk
relieves RLS symptoms by putting gentle pressure on to an hour walk, or you add more hills to your runs.
muscles in the bottom of your foot. The other device, Runners face the highest risk for shin splints, followed
called Relaxis, is a vibrating pad that you place under by dancers and military recruits. Running or dancing
your lower legs for about 30 minutes at a time. Studies on a hard surface like concrete increases the risk for
suggest that Relaxis improves the ability to sleep, but shin splints.
the evidence is not compelling for either device. Both You’re more likely to develop this problem if you
devices are available only with a prescription from have flat feet, because without the proper arches, your
your doctor. Restiffic costs about $200, while Relaxis feet don’t provide adequate shock absorption for your
costs about $700, and neither is typically covered by lower legs. Wearing inappropriate shoes or worn-out
insurance. sneakers increases your likelihood of developing this
The following medicines, primarily used for other condition.
conditions, can also help with RLS:
• Parkinson’s drugs such as pramipexole (Mirapex), Diagnosing shin splints
ropinirole (Requip), and rotigotine (Neupro) ease Your doctor will ask about your symptoms and
RLS symptoms by increasing dopamine levels in examine your lower legs. An x-ray, MRI, or other
the brain. imaging test can help rule out conditions with simi-
• Antiseizure drugs like gabapentin, gabapentin ena- lar symptoms, such as tendinitis or a stress fracture
carbil (Horizant), and pregabalin may help with in your tibia.
RLS symptoms.
• Muscle relaxants like clonazepam (Klonopin) can Treating shin splints
Because overuse is the main cause of shin splints, rest
is often the solution. Avoid the activity that caused
Symptoms of restless legs syndrome your pain. If you are a frequent walker or jogger, sub-
(RLS) stitute a non-impact activity such as swimming or bike
• A crawling, throbbing, creeping, aching, tingling, or riding. To bring down swelling and reduce pain, hold
other abnormal sensation in your legs, often occurring an ice pack to your shin for about 20 minutes at a time,
at night, that is relieved by movements like walking or several times a day. An over-the-counter anti-inflam-
stretching
matory pain reliever such as aspirin, ibuprofen, or
• An urgent need to move your legs
naproxen may also help with both swelling and pain.
Stretch your lower leg muscles a few times a day

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 which can damage the valves in your veins. If you
Symptoms of shin splints don’t treat chronic venous insufficiency, blood can
• Throbbing, dull, or sharp pain in the front of your lower eventually spill over into the tiny capillaries of your
legs legs and quickly overwhelm them to the point where
• Pain that gets worse when you exercise they burst open. The broken blood vessels weaken
and damage the skin above them, producing an
open sore.
to keep your muscles limber. Wear good, supportive While problems with veins are the most com-
shoes with adequate cushioning throughout the day mon cause of leg ulcers, poor blood flow in the arter-
to reduce the stress on your shins. (If you’re a runner, ies of the legs can also cause them. A lack of blood
see “How to find the right running shoes,” page 22.) flow compromises the quality of the skin and its ability
Orthotic shoe inserts can help realign your foot and to withstand minor injuries and heal properly. Other
ankle and take pressure off your shins. These inserts possible causes include
may be particularly useful if you have flat feet, or if • diabetes, due to a combination of poor blood flow
you frequently get shin splints. (from blood vessel damage) and nerve damage
Shin splints can take up to six months to heal. (which prevents people from feeling injuries when
Don’t return to the activity that caused them until they occur); however, ulcers from diabetes are more
you’ve been pain-free for at least two weeks, and then likely to form on the feet than on the legs
only gradually ease back into your program. Rushing • kidney failure—in rare cases, from calcium buildup
back into your sport or activity could lead to another in the small blood vessels that deprives the skin of
injury. oxygen and nutrients
• rheumatoid arthritis and other inflammatory
diseases—sometimes because of inflammation
Skin ulcers (leg ulcers) in blood vessels supplying the skin, sometimes
A skin ulcer is a medical term for a sore or opening in because of infection, and other times because of
the skin. Ulcers caused by an injury are typically one- venous insufficiency
time occurrences. However, when they result from an • cellulitis (see page 41)
underlying medical problem, these sores can be slow • an injury that breaks the skin and leaves a sore or
to heal, putting you at risk for infections if bacteria or opening
other germs make their way into your body through • lying down for long periods of time, such as follow-
the opening. You can also develop pressure sores if ing surgery.
you are bedridden; in the lower legs, these may occur
on the heels. Diagnosing leg ulcers
By far the most common cause of leg ulcers is For a thorough diagnosis and treatment, you may
chronic venous insufficiency (improper function- need to see a wound specialist, vascular surgeon, or
ing of the valves in leg veins), which is responsible both. To diagnose venous insufficiency, your doctor
for about 80% of all leg ulcers. As discussed earlier
(see “Leg anatomy: An overview,” page 2), veins are
the blood vessels that carry oxygen-depleted blood Symptoms of leg ulcers
from your legs back up to your heart. However, • One or more open sores on the leg
aging and inactivity can cause the one-way valves in • Red, brown, or purple skin (a sign that blood has
leg veins to malfunction, so that blood pools in the pooled beneath the skin)
legs rather than continuing to move back up toward • Dry, scaly skin around the ulcer
the heart. You’re more likely to develop this condi- • Swelling of the leg
tion after having deep-vein thrombosis (see page 17),

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may use a test called a vascular ultrasound. A trans- valves to help keep blood flowing in the right direc-
ducer releases sound waves, which bounce off of tion. If these valves malfunction or if they are dam-
blood vessels and other structures in your leg to pro- aged, blood can pool inside the veins and cause them
duce an image on a monitor. to swell. Phlebitis is the term used to describe an
inflamed vein.
Treating leg ulcers Varicose veins are swollen veins close to the sur-
The goal in treating skin ulcers is to encourage wound face of the skin—generally in the lower leg, although
healing and prevent infection. To these ends, your they can occur in the upper leg, too. Backed-up blood
doctor may prescribe special wound dressings and stretches the walls of these veins, turning them thick
antibiotics. You will need to keep the dressing clean and ropey. As the enlarged veins try to squeeze into the
and dry. Change it as often as your doctor recom- same space they’ve always inhabited, they twist up. For
mends. Compression, which is accomplished by wear- many people, varicose veins are primarily a cosmetic
ing special stockings or wrapping a bandage around issue, but they can cause pain, too—particularly after
the leg, can help bring down swelling. you’ve been sitting or standing for a long time. Some-
Chronic venous insufficiency is treated with regu- times a blood clot forms in a varicose vein or another
lar exercise and loss of excess weight. Try to avoid sit- surface vein—a painful and annoying but rarely seri-
ting or standing for long periods of time. Every few ous condition called superficial thrombophlebitis.
minutes, get up and walk to encourage blood flow in Twice as many women develop varicose veins as
your legs. Wearing compression stockings can also men, in part because of hormonal changes that occur
help keep blood flowing in the right direction. during life transitions such as pregnancy and meno-
Ulcers are notoriously slow to heal. It may take pause. Aging itself can cause wear-and-tear on the
four months or longer for the wound to completely veins that eventually makes their walls and valves
clear up. Once it has healed, you will need to take weaken. Being overweight puts added pressure on
good care of your legs, and possibly continue to wear these veins.
compression stockings to prevent another ulcer from
forming. Many people find off-the-shelf compression Diagnosing varicose veins
stockings uncomfortable; however, a doctor can help Although your primary care doctor can make the initial
make sure you have the correct size with the proper diagnosis based on your symptoms and the appearance
amount of compression. of veins in your legs, you may need to see a vascular
It’s important to carefully clean and inspect the specialist, dermatologist, or plastic surgeon if the diag-
skin of your legs and feet every day, especially if you nosis is unclear. Doppler ultrasound is a test commonly
have diabetes. Diabetic nerve damage can prevent you used to diagnose varicose veins. It uses sound waves to
from feeling an injury if one occurs. Wash your legs create images of the veins, which can help your doctor
and feet with a mild soap and warm water, then gently identify weak veins and blockages in blood flow. Less
pat them dry. Apply moisturizer to your skin to pre- commonly, your doctor might order a test called a veno-
vent cracks that can open up into sores. gram, in which a dye is injected into a vein, so it will
show up more clearly on an x-ray image.

Varicose veins
Veins are the networks of blood vessels that carry Symptoms of varicose veins
blood from your legs back to your heart. From the legs • Thick, ropey blue or purple veins just under the surface
to the heart is a long trip that requires blood to flow of the skin
against the downward pull of gravity. Along with the • Aching, throbbing, or heaviness in your legs
leg muscles, which squeeze the veins to push blood • Itching in your lower legs and ankles
upward, the leg veins come equipped with one-way

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This Harvard Health Publication was prepared exclusively for Kathleen M Kimball - Purchased at https://www.health.harvard.edu
 Treating varicose veins typically done once every four to
Varicose veins are typically six weeks until the affected veins
more annoying than harmful. If have faded away.
they don’t bother you or cause Thermal ablation therapy.
symptoms, you don’t have to do The doctor makes a small cut in
anything to treat them. You can the skin and places a thin tube
bring down swelling with the called a catheter inside the vein.
following strategies: Laser or radiofrequency energy
• Stand up and walk around passed through the catheter heats
every hour or so through- and seals off the vein.
out the day to keep the blood Ambulatory phlebectomy.
flowing in your legs. The doctor makes small cuts in
© Fertnig | Getty Images

• Elevate your legs above the the skin and uses special hooks
level of your heart—for exam- to pull the veins out of your legs.
ple, by propping them on a pil- This procedure can remove vari-
low—three or four times a day. Varicose veins are primarily a cosmetic issue, but cose veins that are close to the
• Lose weight if you are over- sometimes they can cause pain—particularly after surface.
weight or obese, to take pres- you’ve been sitting or standing for a long time. Vein stripping and liga-
sure off your veins. tion. This procedure ties off and
• Don’t wear leggings or other tight pants that could removes the damaged veins through small openings
inhibit the blood flow in your legs. in the skin. It is typically reserved for severe varicose
• Wear compression stockings, which are designed to veins.
squeeze the veins in a way that keeps blood moving
upward and prevents it from pooling in your legs.
You can buy these stockings over the counter at a Care for your legs, protect your health
drugstore. If you find the store-bought stockings The conditions highlighted in this report illustrate
too uncomfortable, have some custom-fit for you the relationship between your leg health and overall
with a prescription from your doctor. health. When something is wrong with your legs—a
Several medical procedures treat varicose veins, nagging ache, muscle weakness, swelling, or numb-
either by sealing off or removing them. Once a vein ness—it could signal a more serious problem that
is closed or removed, the blood flow simply reroutes needs your attention. Give just as much care and con-
around it. cern to your legs as you would to your heart, lungs,
Sclerotherapy. This is the most common treat- brain, and other vital organs. Your legs are key to
ment for varicose veins. The doctor injects a chemical maintaining your independence as you age. The bet-
into the vein, which irritates and scars it to the point ter you care for them, the more likely they’ll be able to
where the vein eventually closes. This procedure is support you for the rest of your life.

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This Harvard Health Publication was prepared exclusively for Kathleen M Kimball - Purchased at https://www.health.harvard.edu
 Resources
Organizations National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS)
American Academy of Orthopaedic Surgeons (AAOS) 1 AMS Circle
9400 W. Higgins Road Bethesda, MD 20892
Rosemont, IL 60018 877-226-4267 (toll-free)
800-626-6726 (toll-free) www.niams.nih.gov
https://orthoinfo.aaos.org
This division of the National Institutes of Health deals with
The American Academy of Orthopaedic Surgeons is a national arthritis and other diseases of the musculoskeletal system. Its
organization of orthopedic specialists. The AAOS has a website includes a variety of informational resources.
comprehensive website, called OrthoInfo, filled with informative
articles about arthritis, fractures, tendon and muscle injuries, and Publications from Harvard Medical School
other conditions affecting the musculoskeletal system.
The following Special Health Reports and Online Guides from
American College of Rheumatology (ACR) Harvard Medical School go into greater detail on various topics
2200 Lake Blvd. NE mentioned in this report. You can order them by going to www.
Atlanta, GA 30319 health.harvard.edu or calling 877-649-9457 (toll-free).
404-633-3777
www.rheumatology.org Finding Relief for Sciatica (2018). This online-only guide
This website for rheumatology professionals includes a consumer- explains the causes of and treatments for sciatica, including medi-
friendly section, complete with overviews of rheumatic diseases cations, surgery, and physical therapy. Includes home remedies and
such as arthritis. It includes information on what to do when the importance of good posture and getting enough sleep.
you’re newly diagnosed, how to manage your medications, and Healthy Feet: Preventing and treating common foot
how to live better with these conditions. problems (2018). This Special Health Report covers 30 different
problems that can affect your feet, from bunions to toenail
American Orthopaedic Society for Sports Medicine fungus. It includes a Special Section on keeping your feet healthy.
(AOSSM)
9400 W. Higgins Road, Suite 300 The Joint Pain Relief Workout: Healing exercises for your
Rosemont, IL 60018 shoulders, hips, knees, and ankles (2018). The expert-designed
877-321-3500 (toll-free) workouts in this report are intended to strengthen the muscles
www.sportsmed.org that support your joints, increase flexibility, and improve range
This organization of sports medicine professionals offers a of motion. Done regularly, these exercises can ease your pain,
patient-focused newsletter as well as an online directory of improve mobility, and help prevent injury.
specialists on its website. You’ll also find tip sheets and resources
to help prevent sports injuries in both children and adults.
Knees and Hips: A troubleshooting guide to knee and hip
pain (2018). This Special Health Report describes the most com-
American Physical Therapy Association mon knee and hip problems and the best treatments for them. A
1111 N. Fairfax St. Special Section provides in-depth information on joint replacement.
Alexandria, VA 22314
Living Well with Osteoarthritis: A guide to keeping your
800-999-2782 (toll-free)
joints healthy (2019). Osteoarthritis—the most common type of
www.apta.org
arthritis—can interfere with your quality of life. This Special Health
This professional organization represents more than 100,000 Report covers the many ways you can protect your joints, reduce
physical therapists around the country. On its consumer website, discomfort, and improve mobility.
www.moveforwardpt.com, you can read patient stories and find a
physical therapist in your area. Stretching: 35 stretches to improve flexibility and reduce
pain (2017). Several of the stretches illustrated in Healing Leg
Arthritis Foundation Pain were drawn from Stretching. This Special Health Report
1355 Peachtree St. NE, 6th Floor includes stretches that can help you increase your flexibility,
Atlanta, GA 30309 improve your balance, and reduce pain and stiffness.
404-872-7100
844-571-HELP (toll-free) Total Hip Replacement: What you need to know about
www.arthritis.org getting a new joint (2018). This online-only guide walks you
through the process of deciding if a hip replacement is right for
The website of this national nonprofit organization has you, sorting through the various options, and handling rehab.
educational materials on arthritis, joint surgery, pain control, and
standard and complementary therapies, as well as exercise videos Total Knee Replacement: What you need to know about
and a directory of local offices and events. Local chapters may getting a new joint (2018). This online-only guide helps you sort
offer joint-health exercise classes, including water-based classes. through the options and prepare for surgery.

52 Healing Leg Pain  w w w.h ealt h .ha r va r d.e du

This Harvard Health Publication was prepared exclusively for Kathleen M Kimball - Purchased at https://www.health.harvard.edu
 Glossary
acetabulum: The cuplike socket of the hip joint, in which the head medial collateral ligament (MCL): A band of tissue on the
of the femur sits. inside of the knee that prevents the knee from bending inward.
Achilles tendon: The strong, fibrous cord that attaches the meniscus: A thick, rubbery pad of cartilage that acts as a shock
muscles in the back of your calf to your heel bone. absorber between the tibia and femur in the knee. There are two
menisci in each knee—the medial meniscus on the inside of the
anterior cruciate ligament (ACL): A strong band of tissue in the
knee joint, and the lateral meniscus on the outside of the joint.
center of the knee that helps to stabilize the joint and control the
forward and backward movement of the knee. meralgia paresthetica: Numbness, tingling, and burning in the
outer thigh due to compression of a nerve that supplies feeling to
arthroscopy: A surgical procedure performed through small inci-
that area.
sions using a camera for guidance.
articular cartilage: The smooth tissue that covers the ends of osteoarthritis: The most common type of arthritis, in which the
cartilage in a joint wears down, causing pain and stiffness.
bones in joints and helps prevent friction between the bones.
avascular necrosis: The death of bone tissue because of a block- osteophyte: An abnormal bony growth, which can be caused by
age in the blood supply. arthritis damage in a joint. Also called a bone spur.

avulsion fracture: An injury in which a tendon or ligament tears patella (kneecap): The small bone at the front of the knee joint.
at its connection to a bone, pulling off a piece of the bone with it. peripheral artery disease (PAD): A problem with blood flow
that prevents the legs from getting enough blood supply.
bursa: A fluid-filled pouch that acts as a cushion around a joint to
prevent bone and soft tissue from rubbing against each other. peripheral neuropathy: Damage to nerves that carry messages
from the brain and spinal cord to the rest of the body and back.
bursitis: Inflammation of a bursa.
cellulitis: A bacterial infection of the skin. plantaris: A small muscle in the back of the leg that sits in
between the soleus and gastrocnemius muscles of the calf.
claudication: Pain in the legs, often during exercise, which is
typically caused by reduced blood flow. posterior cruciate ligament (PCL): A strong band of tissue in
the center of the knee that helps to stabilize the joint and control
crepitus: A crackling or grating sound from the friction between the forward and backward movement of the knee.
bones where cartilage has been damaged.
pseudoclaudication: Pain in the legs while walking; caused by
debridement: A surgical procedure to remove damaged tissue nerve compression in the spine.
from a joint or another injured area of the body.
quadriceps: The strong group of muscles in the front of the thigh.
deep-vein thrombosis (DVT): A condition in which a blood clot
forms in one of the deep veins in the legs. If the clot breaks free sciatic nerve: A nerve that extends from the lower back, through
the buttocks, and down the back of each leg.
and travels to the lungs, it’s called a pulmonary embolism.
edema: Swelling due to fluid buildup in the body’s tissues. sciatica: Pain, numbness, tingling, and other symptoms in the
lower back and legs that’s caused by pressure on the sciatic nerve.
femur (thighbone): The bone of the upper leg.
soleus: The small, flat muscle behind the gastrocnemius in the calf.
fibula (calf bone): The smaller bone that sits behind the tibia
(shin bone) and provides stability for the lower leg. sprain: A stretch or tear in a ligament.

gastrocnemius: The main calf muscle in the back of the lower leg. strain: A stretch or tear in a muscle or tendon.

greater trochanter: A bony protuberance on the hip joint to synovium: Tissue that lines joints such as the hip and knee and
produces fluid that lubricates the joint.
which muscles of the buttocks and upper legs attach.
hamstrings: A group of three muscles in the back of the thigh that tendinitis: Inflammation in a tendon.
enable you to bend your knee and extend your leg. thrombophlebitis: A blood clot that blocks a vein in the leg and
prevents blood from flowing normally.
iliopsoas: A powerful muscle formed from the joining of the psoas
and iliacus muscles in the front of the upper hip. tibia (shin bone): The bone that runs down the front of the lower
leg and connects the knee with the ankle bone.
iliotibial (IT) band syndrome: Inflammation of the band of
tissue that runs down the side of your upper leg, typically caused ulcer: As relates to the leg, an open sore, often caused by poor
by overuse. blood flow.
labrum: A rim of cartilage around the hip socket that helps keep varicose veins: Swollen, twisted, blue or purple veins close to the
the upper thighbone in place within the socket. skin that are caused by a pooling of blood inside them.
lateral collateral ligament (LCL): A band of tissue on the venous insufficiency: Weakening or damage in the leg veins,
outside of the knee that prevents the knee from bending outward. causing blood to flow backward and collect in the legs.

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 Harvard Health Publishing
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