Updated: 11/4/2017

Tibial Stress Syndrome (Shin Splints)

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Introduction
  • Overuse injury or repetitive-load injury of the shin area that includes
    • medial (posteromedial) tibial stress syndrome
      • most common
    • anterior (anterolateral) tibial stress syndrome
  • Epidemiology
    • incidence 
      • 10-15% of running injuries
      • 60% of leg pain syndromes
    • location
      • 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
  • 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
Condition Tissue Origin Characteristics
Anterior tibial stress syndrome Periosteum • Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise, decreases during training
Medial tibial stress syndrome Periosteum • Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, decreases during training
Tibial or fibular stress fracture  Bone • Pain with running, point tenderness over fracture site, "dreaded black line" on lateral xray 
Exertional compartment syndrome  Muscle and fascia • Symptoms begin 10min into exercise and resolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures
Leg Tendinopathy Tendon • May be Achilles tendon, peroneal tendon, or tibialis posterior 
Sural or SPN entrapment Nerve • Dermatomal distribution of symptoms
Lumbar radiculopathy Nerve • Worse with lumbar tension position (sitting)
Popliteal artery entrapment Blood Vessel • Diagnosed with vascular studies
 
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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