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Shin Splints

Clinical Vignette. A 16 year old female presents to the office after three weeks of track practice complaining of shin pain. She says it was a gradual pain on both sides while pointing to the posteromedial surface of the tibia and has progressively gotten worse. She thinks these are shin splints and wants to know what to do about them?.

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Shin Splints

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    1. Shin Splints Aaron McGuffin, M.D.

    2. Clinical Vignette A 16 year old female presents to the office after three weeks of track practice complaining of shin pain. She says it was a gradual pain on both sides while pointing to the posteromedial surface of the tibia and has progressively gotten worse. She thinks these are shin splints and wants to know what to do about them?

    3. Clinical Vignette What if she had said, As soon as I put my foot down now to bear weight it hurts and running and jumping are unbearable. It is deep and aching. Stress Fracture What if she had said the pain comes on gradually over 5-10 minutes, gradually increases and lasts several hours after exercise. Compartment syndrome

    4. Clinical Vignette What if she had said, I have burning pain and numbness over front of my ankle and top of my foot. Superficial peroneal nerve entrapped

    5. Shin Splints What is another name for shin splints syndrome? Medial tibial stress syndrome What is the pathophysiology? Periosteal edema ? marrow involvement ? cortical stress fracture

    6. What is the typical distribution of pain? Lower half of the posteromedial border of the tibia Anterior tibial compartment (containing the tibialis anterior and extensor hallucis longus muscles) Tibia Interosseous membrane region of the foreleg

    9. What is the natural progression? Patients typically complain of a dull ache followed by a gradually worsening pain. Symptoms are at first relieved by rest, but later become continuous. Accompanying numbness, or loss of sensation over the fourth toe may be noted. Pain usually is confined to the posteromedial portion of the leg, although the site of involvement may be more diffuse Much less localized than the pain of stress fractures.

    10. Physical examination Tenderness can usually be elicited over symptomatic sites Mild swelling and induration may also be evident at the site of tenderness. Sensory or motor nerve deficits suggest a compartment syndrome rather than shin splints

    11. Diagnosis Main diagnostic dilemma: distinguishing shin splints from a stress fracture What diagnostic test would you order? Plain films are normal in patients with shin splints syndrome, but may also be normal in those with stress fractures Stress fractures do not usually produce radiographic changes for two to three weeks, at which time periosteal changes may be seen. Callus formation is typically not apparent until at least four to six weeks after injury

    12. Diagnosis Technetium bone scans may show changes within few days of injury in patients with either disorder. Often increased uptake focally in area of stress fracture Uptake in patients with shin splints syndrome is less localized and is usually longitudinal involving the posteromedial tibia cortex .

    13. Diagnosis Fat-suppressed MRI may discriminate between stress fracture and shin splints. Study of 22 athletes with pain in middle or distal part of their leg during or after sports activity. (Clin Orthop Relat Res 2004 Apr;(421):260-7.) Result of MRI were compared to those of serial radiographs. Stress fractures were diagnosed when consecutive radiographs showed local periosteal reaction or a fracture line, and shin splints were diagnosed in all the other cases.

    14. Diagnosis In all eight patients with stress fractures, an abnormally wide region of high signal localized to the bone marrow noted in the coronal fat-suppressed MRI scan. MRI changes were present prior to periosteal changes on plain radiographs. None of 11 patients with shin splints had this type of bone marrow signal. Instead there were narrower linear high signal areas noted either along the medial posterior surface of the tibia or along the medial bone marrow adjacent to the cortical bone.

    15. Diagnosis Periostitis (often evident on triple phase bone scan or MRI), tears of musculotendinous structures, or ischemic compartment syndromes are additional important diagnostic considerations. Pain out of proportion to the clinical findings is suggestive of a compartment syndrome.

    16. Treatment RICE: Rest, Ice, Compression of injured tissue, and Elevation. Leg elevation and application of ice packs for 15 minutes at a time are initial treatment measures. Stretching (lengthening) followed by strengthening exercises directed to the musculature of the involved site of the leg are helpful. Pelvic, spinal, and lower extremity structure and alignment should be checked for imbalances if the injury is recurrent.

    17. Treatment Manual techniques such as massage, myofascial release, and pressure applied to trigger/tender points have also been helpful. The runner should decrease weekly mileage, avoid hard surface running, and shorten the running stride to reduce impact. Changing to shoes with waffle soles and using orthoses with alteration of the heel counter (the hind part of the shoe surrounding the heel) may also be useful in some cases.

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