Updated: 6/1/2021

Tibial Stress Syndrome (Shin Splints)

Review Topic
https://upload.orthobullets.com/topic/3108/images/dreaded black line.jpg
https://upload.orthobullets.com/topic/3108/images/bone scan shin splints.jpg
https://upload.orthobullets.com/topic/3108/images/mri shin splints.jpg
https://upload.orthobullets.com/topic/3108/images/shin-splints location.jpg
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  • summary
    • Tibial stress syndrome (also known as shin splints) is an overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain.
    • Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. Radiographs or bone scans may be obtained to rule out stress fractures. 
    • Treatment is generally nonoperative with NSAIDs, rest and activity modifications. 
  • Epidemiology
    • Incidence
      • 10-15% of running injuries
      • 60% of leg pain syndromes
    • Anatomic location
      • medial (posteromedial) tibial stress syndrome
        • most common
      • anterior (anterolateral) tibial stress syndrome
      • distal and posteromedial tibia
    • Risk factors
      • runners without enough shock absorption (running on cement or uneven surfaces, improper running shoes)
      • training errors (sudden increase in training intensity and duration)
      • running >20 miles/week
      • hill training early in the season
      • history of previous lower extremity injuries
      • over-pronation or increase internal tibial rotation
  • Etiology
    • Pathophysiology
      • caused by a traction periostitis
        • anterolateral
          • traction periostitis of tibialis anterior on tibia and interosseous membrane
        • posteromedial
          • traction periostitis of tibialis posterior and soleus
    • Associated conditions
      • female athlete triad
        • critical to diagnose and treat
      • tibial stress fractures
        • females have 1.5-3.5 increased risk of progression to stress fractures
  • Presentation
    • Symptoms
      • vague, diffuse pain along middle-distal tibia that decreases with running (early stage)
        • differentiate from exertional compartment syndrome, for which pain increases with running
      • earlier onset of pain with more frequent training (later stages)
    • Physical exam
      • tenderness along posteromedial border of tibia
        • 4cm proximal to medial malleolus, extending proximally up to 12cm
      • pes planus
      • tight Achilles tendon
      • weak core muscles
      • provocative test
        • pain on resisted plantar flexion
  • Imaging
    • Radiographs
      • indications
        • exclude stress fracture
      • findings
        • conventional radiographs are normal in first 2-3weeks
        • long-term changes include periosteal exostoses
          • differentiate from stress fracture, which shows "dreaded black line"
    • 3-phase bone scan
      • indications
        • exclude stress fracture
      • findings
        • diffuse, longitudinal increased uptake along posteromedial border of tibia in delayed phase (Phase 3)
        • normal findings on Phase 1 (flow phase) and blood pool phase (Phase 2)
          • differentiate from stress fracture, which has focal, intense hyperperfusion and hyperemia in Phase 1 and 2, and focal, fusiform uptake in Phase 3
    • MRI
      • indications
        • identify other soft tissue injuries
      • findings
        • periosteal edema
        • progressive marrow involvment
  • Differential
    • Differential Diagnosis for Exertional Leg Pain
      Tissue origin
      Anterior tibial stress syndrome
      • Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise that decreases during training

      Medial tibial stress syndrome
      • Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, that decreases during training

      Tibial/fibular stress fracture

      • Pain with running, point tenderness over fracture site, "dreaded black line" on lateral x-ray


      Exertional compartment syndrome
      • Symptoms begin 10min into exercise andresolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures
      Muscle and fascia

      Leg Tendinopathy
      • May be Achilles tendon, peroneal tendon, or tibialis posterior
      Sural or SPN entrapment
      • Dermatomal distribution of symptoms


      Lumbar radiculopathy
      • Worse with lumbar tension position (sitting)
      Popliteal artery entrapment
      • Diagnosed with vascular studies

      Blood vessel

  • Treatment
    • Nonoperative
      • activity modification with nonoperative modalities
        • indications
          • first line of treatment and successful in vast majority
        • techniques
          • activity modification
            • decreasing running distance, frequency and intensity by 50%
            • use low-impact and cross-training exercises during rehab period
            • regular stretching and strengthening
            • run on synthetic track
            • avoid running on hills, uneven or hard surfaces
          • shoe modifications
            • change running shoes every 250-500miles as shoes lose shock absorbing capacity at this distance
            • orthotics may be helpful in patients with pes planus
          • therapy
            • focus on strengthening of invertors and evertors of the calf
          • other
            • local phonophoresis with corticosteroids may be effective
    • Operative
      • deep posterior compartment fasciotomy + release of painful portion of periosteum
        • indications
          • failed nonoperative treatment
        • outcomes
          • variable results, not likely to cause complete resolution of symptoms
  • Complications
    • Recurrence
      • common after resumption of heavy activity
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