Leg and Ankle

From a shattered tibia bone to a sprained ankle, this area of the body represents one of the most common injuries for children of all ages.

Shin Splints

Shin splits are a common overuse injury among teen athletes. It causes a dull or aching pain and tenderness along the inside of the lower leg or shin bone.

What are shin splints?

Medial tibial stress syndrome, more commonly known as shin splints, is an overuse condition that develops gradually and causes lower leg pain in runners and other athletes. Some causes of shin splints include:

  • Running downhill
  • Running on uneven or hard surfaces
  • Improper running form
  • Increasing mileage or running intensity too quickly
  • Old or worn-out shoes
  • Over pronation, or flat feet
  • Sports requiring repetitive activity, like soccer, basketball or cross country running

An athlete may first notice the pain along the inside of the shinbone after running. Without taking a break from activity, the pain can progress to occurring both during and after running and could develop into a stress fracture.

How we diagnose shin splints

At Children’s, we conduct a thorough physical exam, which may include running on a treadmill to look for mechanical flaws and X-rays to rule out other problems, such as fractures.

How to treat shin splints

Treatment of shin splints may include:

  • Rest - Take a break from running and other high-impact activities.
  • Ice - Relieve pain with ice. Try an ice massage: freeze a styrofoam cup of water, tear off the rim of the cup and using a gentle circular motion to massage the leg with ice for five to ten minutes.
  • Medicine - Anti-inflammatory medicine (like ibuprofen) can help relieve pain.
  • Rehabilitative exercises - Lower leg stretches and heel walking can help manage the condition.
  • Physical therapy - Sports therapists can show athletes ways to properly warm up, stretch and strengthen leg muscles to recover from shin splints and prevent the injury from coming back. Children’s also offers a Running Program that helps athletes who are injured, who want to prevent injury or who want to enhance their performance.

How to return to sport after shin splints

The recommended period of rest for shin splints is usually four to six weeks. During this time, some cross-training such biking, swimming or using a low-impact elliptical machine may be allowed. When the pain goes away, running activities may be resumed.

How to prevent shin splints

When starting a new running program, returning after an injury or simply taking steps to prevent shin splints, make sure you:

  • Increase your mileage gradually (no more than 10 to 15 percent per week).
  • Run on soft, level surfaces.
  • Wear well-cushioned, supportive shoes and replace them every year or every 350 miles.
  • Use shin sleeves or a compression wrap while you run.
  • Do exercises to strengthen your legs.
  • Stop activity at the first sign of pain.

Never try to run through the pain, it will only get worse and could cause further injury.

Lower Leg Pain

How to diagnose lower leg pain

Radiology tests, such as X-rays or an MRI, may be used to help determine a diagnosis or rule out other causes of leg pain.

How to prevent lower leg pain

When starting a new running program, returning after an injury or simply taking steps to prevent shin splints, make sure you:

  • Increase your mileage gradually (no more than 10 to 15 percent per week).
  • Run on soft, level surfaces preferably on a rubberized cushioned track or a grassy cross-country trail. Running hills, stadiums, bleachers or on hard pavement may increase the risk of developing shin splints.
  • Keep your running shoes in good repair. They should be replaced every 350 miles or each year, whichever comes first.
  • Add some extra shock absorption to your shoes in the form of cushioned arch supports, especially if you have low arches or pronate.
  • Try a compressive wrap such as an ace bandage or a weave-type tape job over your shins while running. Some athletes get relief with this.
  • Do exercises to strengthen your legs.
  • Stop activity at the first sign of pain.

Never try to run through the pain, it will only get worse and could cause further injury.

How to return back to sport after lower leg pain

The recommended period of rest is usually four to six weeks. During this time, some cross-training such biking, swimming or using a low-impact elliptical machine may be allowed. When the pain goes away, activities may be resumed.

Ankle Sprain

Ankle sprains are injuries to a ligament (tissue that connects one bone to another) and are a common sports injury. Nearly half of all ankle sprains occur in children and adolescents, likely because of their participation in sports.

Sprains are graded as mild, moderate or severe (or as 1, 2 and 3):

  • Grade 1 - the ligament fibers are stretched, but minimally torn
  • Grade 2 - partial tear of the ligament
  • Grade 3 - complete tear of the ligament

Most ankle sprains are inversion (lateral) sprains, which happen when the ankle turns toward the outside or "rolls over.” When this happens, the ligaments on the outside of the ankle are injured. Pain may be felt immediately and swelling could happen within hours. The degree of swelling depends on the severity of the sprain and how quickly it’s treated.

How to treat ankle sprains

Luckily, sprains can be treated at home with:

Rest

Immediately remove your child from the activity - whether they are in a game, in practice, or just playing with friends. Continuing to play will worsen the ligament damage and increase the severity of the injury. Do not remove your child’s shoe until ice can be applied—a tight shoe will act as a compression wrap and limit the initial swelling.

Ice

Apply crushed or chipped ice in a plastic bag directly over the skin for 20 minutes, every one to two hours. Bags of frozen peas or corn also work well. Another method is to massage your child’s ankle with a Styrofoam cup filled with frozen water. Ice should be applied four to five times a day for the first 48 to 72 hours, or as long as the ankle is swollen.

Compression

Tightly wrap an ACE bandage from the toes up (do not allow skin to show). You may also use a stirrup brace for support and compression.

Elevation

Keep your child’s ankle elevated while on the bench or at home. Proper elevation is when the ankle is kept above the level of the heart.

Medication

Acetaminophen (Tylenol) can be used in the first two to three days to relieve your child’s pain. But we recommend waiting to administer medicines like ibuprofen (Motrin, Advil) and naproxen (Aleve). Since it’s very important for the body to be allowed to initiate its own inflammatory process in response to the injury, and since it signals the body to clean up debris from the injury and start repairing the injured ligament, anti-inflammatory medications can slow this process. For this reason, we recommend you wait 48 to 72 hours after the injury to give your child these medications.

Rehab

Begin range of motion exercises the next day to prevent stiffness during the first phase of healing. While your child is seated, have them imagine the big toe is a pen and trace all the capital letters in the alphabet as large as possible. This can be done three times in the air or in a large bucket of ice water or slush (keep the foot in the bucket for five to seven minutes). Once your child has done the exercise, re-apply a compression wrap and elevate their ankle.

You should have your child evaluated by a doctor if:

  • There is immediate or severe swelling.
  • Your child cannot put weight on their ankle.
  • There is pain in the bones above the knee.
  • If the treatment described above doesn’t result in improvement within 5-7 days.

Recovery

Your child can return to competition or resume their normal physical activities when:

  • Most swelling is gone
  • They have full range of motion
  • Their strength is 90 percent or better than the uninjured side
  • They are able to balance on the injured ankle
  • They can perform the tasks required of their sport (sprinting, cutting, jumping, etc.) with no pain, swelling, or limp.

Recovery time will depend on the grade of your child’s ankle sprain:

  • Grade 1: Recovery time of 2 - 3 weeks
  • Grade 2: Recovery time of 4 - 6 weeks
  • Grade 3: Recovery time of 10 - 12 weeks

Remember: Returning to play is best determined by function (range of motion, strength, balance) and not by time. The above time frames should only serve as a guide.

When to consider physical therapy

A physical therapist with experience in sports injuries and rehabilitation can help in all phases of your child’s recovery. Athletes with ankle sprains who see physical therapists will return to their sport sooner and stronger, and have less of a chance of re-spraining their ankle. Once the initial pain and swelling is under control, a therapist can develop a customized program to improve range of motion, flexibility, strength and balance. When your child is ready to return to play, the therapist can also offer guidance on using bracing, ankle supports or ankle taping.

The best predictor of future ankle sprains is a past ankle sprain. Untreated ankle sprains or insufficient physical therapy may result in chronic ankle instability. Recognizing an injury and appropriate rehabilitation are critical for a young athlete’s muscle and bone health.

Achilles Tendon Bursitis

What is Achilles tendon bursitis?

The Achilles tendon is the large tendon that connects the calf muscles to the heel bone and is used to walk, run and jump. The bursa—a fluid-filled sac located at the back of the heel under the Achilles tendon—contains a lubricating fluid that acts as a cushion to reduce friction between muscle and bones. Achilles tendon bursitis is a painful condition caused by swelling of the bursa.

How to spot Achilles tendon bursitis

Achilles tendon bursitis is caused by overuse of the ankle, which results in irritation and inflammation of the bursa. Common causes include excessive walking, jumping or running. Achilles tendon bursitis can also occur in combination with Achilles tendinitis, which is inflammation of the Achilles tendon.

The most common symptom is pain and tenderness at the back of the heel—especially while walking or running—which increases when standing on tiptoes. In some cases, the skin at the back of the heel may also become red and warm to the touch.

How we diagnosis Achilles tendon bursitis

Achilles tendon bursitis is usually diagnosed through a physical examination and consideration of symptoms. Radiology tests, such as x-rays and MRIs, may be required if treatment does not improve the symptoms.

How to treat Achilles tendon bursitis

Treatment for Achilles tendon bursitis can include:

  • Rest - Restrict activities that cause pain.
  • Ice - Apply ice on the injured area to help reduce swelling. Ice should be wrapped in a cloth rather than being applied directly to skin.
  • Medicine - Nonsteroidal anti-inflammatory medications (such as ibuprofen) may help reduce inflammation and pain.
  • Foot support - Custom heel wedges can be used to reduce stress on the heel.
  • Injections - Corticosteroid injections may be given to reduce swelling and pain.
  • Physical therapy - Physical therapy may be recommended to help restore and improve the flexibility and strength of the muscles, tendons and joints around the ankle.

If the injury is associated with Achilles tendonitis, it may be necessary to cast the ankle for several weeks. Bursectomy is a surgical procedure done to remove an inflamed or infected bursa. Surgery is considered only when all nonsurgical treatment fails to resolve pain and inflammation.

How to prevent Achilles tendon bursitis

To prevent Achilles tendon bursitis:

  • Maintain proper form during exercise.
  • Warm up before beginning rigorous exercise.
  • Gradually build up to increased levels of exercise.

Distal Fibula Fractures

Ankle fractures happen when the ankle turns in, causing pain and swelling on the outer portion of the ankle, and often involving the growth area of the small fibula bone. In children, the bone’s growth areas are made of cartilage and are weaker than the bone or surrounding ligaments, making ankle fractures a common childhood injury. Thankfully, they heal easily without much lasting impact, and growth arrest is extremely rare.

Typically, your child will be placed in either a walking boot or a short walking cast for several weeks. When the cast comes off, the bone is usually healed and your child is ready for activities as soon as their strength and range of motion improve. Physical therapy is sometimes recommended based on the severity of the injury and the activity level of your child.

Triplane Fractures

What are triplane fractures?

Triplane fractures usually happen during some type of twisting maneuver. They are also commonly called transitional fractures since they only happen in adolescents during the period of time when the growth area of the distal tibia bone is closing.

If the bones are not separated from each other, then the fracture can likely be treated with a cast alone. The cast, however, is often a long cast above the knee for three to four weeks, followed by a short cast for two weeks—making the total cast time six weeks.

If the bones are displaced (separated), surgery will likely be recommended so the bone to heal in a straight position. After surgery, your child will likely be in a short cast for four to six weeks.

After triplane fractures, physical therapy is often recommended to help regain ankle strength and range of motion. And, since there is a risk of permanent injury to the growth area, your child will need a follow-up visit at least one year after the injury to ensure the ankle continues to grow straight.

 

Tillaux (Ankle) Fracture

What is a tillaux fracture?

Children and teens can often twist their ankles by rolling them. Twisting can result in a tillaux fracture (pronounced till-o), which is a fracture that goes through the joint and the growth plate. It is most common in children between the ages of 12 and 14, as the growth plate is beginning to close.

Tillaux fractures are seen exclusively in adolescents since there is approximately an 18-month window of time for this type of fracture to occur. This distal (bottom) tibia growth area closes asymmetrically. The center part closes first, then the medial (inner portion), and lastly the lateral (outer portion) of the growth area as follows:

  • Central: closes between ages 13 to 14 years
  • Medial: closes between ages 14 to 15 years
  • Lateral: closes between ages 14 to 16 years 

Tillaux fractures happen when the ankle is twisted outward. At this time, only the lateral (outer) growth area is still open, and the other growth area sections are fused to the remainder of the tibia bone. The growth area is made of weaker cartilage, and when a child turns his ankle in just the right fashion, a ligament pulls this piece away from the tibia bone.

How to spot a Tillaux fracture

  • Severe pain in the ankle
  • Difficulty in bearing weight
  • Limp
  • Swelling
  • Bruising
illustration showing how ankle roll can break ankle

How we diagnose a Tillaux fracture

In a Tillaux fracture, the injury to the growth plate disrupts the ankle joint. Failure to properly and promptly treat this growth-plate injury can lead to a deformed joint and early arthritis. These fractures can be misdiagnosed as an ankle sprain. The cause of injury and appearance are similar.

Tillaux fractures are not always visible on an X-ray because a large part of the fracture goes through the growth plate, which is still cartilage. Our pediatric-trained radiologists and orthopaedic specialists can identify this kind of fracture through imaging, patient history and a physical examination.

How we treat a Tillaux fracture

The treatment of a Tillaux fracture depends on the extent of the injury. Minor cases can be handled with a closed reduction. The doctor places the ankle in the proper position and then casts it.

If the fracture is displaced, surgery is necessary. The procedure involves placing a screw across the fracture site to help properly align the ankle joint.

pediatric ankle repair illustration