Inflammatory Shin Pain - Tibial Stress Injuries
Shin pain is a common complaint among Athletes. This may range from a mild inflammatory process to a tibial stress fracture.
The patient with inflammatory shin pain may complain of pain along the medial border of the tibia, which usually decreases with warming up.
The athlete may complete the training session, but the pain returns after exercise. Inflammation of the shins can be more common among athletes who may change the type of surface they are training or competing on, changing the type of foot wear they train and or compete in, or have technique flaws in their performance. (Workola and Annuniato 2001) report that cases of exertional leg pain are not always easily determined but are often linked to repetitive stress and that exercise induced leg pain is a common condition in both the competitive and recreational athlete. Many terms have been used for description of exercise induced leg pain. These include shin splints, tibial stress syndrome, recurrent exercise induced ischemia, and chronic exertional compactment syndrome. “Shin splints" has often been used as an all encompassing term for many of these disorders. However, with the advent of imaging techniques such as isotope bone scans and MRI, we are now able to make more precise anatomical and pathological diagnosis of patients with shin pain. Brokner and Khan 2001 describe how the terms "medial tibial stress syndrome” and "shin splints" become somewhat meaningless and that the terms, inflammatory shin pain or exercise induced leg pain are often preferred. Exercise induced leg pain in athletes accounts for an estimated 10 to 20% of all injuries in runners and up to 60% of all overuse injuries of the leg.
An acute history and examination is essential and will differentiate stress fractures from other stress reactions (Maitra 1997).
In any assessment of possible stress induced shin injury, factors contributing should be assessed. These include extrinsic fractures such as training methods, the type of running surface and type of footwear worn by the athlete. With training methods, athletes can develop symptoms after rapid increases in intensity, frequency and duration of training as well as changes in technique.
The type of surface can influence the amount of tibial stress. Banked, irregular and hard surfaces all increasing the risk of injury. Poor or worn footwear and lack of orthodic support can greatly increase the risk of exercise induced tibial stress. There are also intrinsic factors, unique to the individual athlete, which will influence an athlete's susceptibility to tibial stress injury. These include muscle strength and flexibility, bone mineral density and existence of previous injuries. Stress injury occurs more frequently in female athletes who have menstrual disturbances. (Brukner, Bradshaw and Bennell 1998) Showed that in females, lower bone density, a history of menstrual disturbance, less lean mass in the lower limb, a discrepancy in leg length, and a low-fat diet were significant risk factors for stress injury. Often a combination of factors is involved, for example, a sudden increase in training with amenorrheic women who had excessive subtalar pronation.
(Yates & White 2002) Concluded that identifying pronated foot type prior to training may help reduce the incidence of “Medial Tibial Stress Syndrome” by early intervention to control abnormal pronation.
Some specific conditions that cause shin pain include:
tibial stress fractures
“Medial tibial stress syndrome” or exercise induced shin pain. Courture and Karlson (2002) describes that with “tibial stress syndrome” patients report diffuse pain along the middle and distal thirds of the posteromedial tibia. Early in the disorder the pain occurs at the commencement of a run then may resolve during a workout and reoccur after the training session. In the early stages the pain resolves quickly, while in later stages the pain is more persistent and sharper and more severe. In more advanced stages, the pain can even occur at rest. With tibial stress fractures, the symptoms may be similar to ‘tibial stress syndrome’. Patients may have pain at the posteromedial margin of the tibia, though it tends to be more focal. Examination reveals localized tenderness over the tibia. Most stress fractures of the tibia are located on the medial border with very obvious tenderness. Inflammatory shin pain and tibial stress fractures can be differentiated on the basis of physical examination. Inflammatory shin pain is marked by tenderness along the posteromedial tibia, usually the middle and distal thirds. However, patients with tibial stress fractures commonly have more local tenderness at the posteromedial margin of the tibia near the junction of the middle and distal thirds of the bone.
(O'Connor, Howard, Fieseler, Nirschl 1997) Describe how an accurate diagnosis in most overuse injuries require a good history, physical examination and selected radiographs. A typical clinical feature of a stress injury is an exercise related localized pain that increases with activity that abates or becomes less intense with rest. (Bradshaw 2001) describes how taking a good history is essential for correct diagnosis of athletes with shin pain. The most important aspect being the relationship between pain and exercise. If the pain improves after the warm up and exercise, then it is most likely due to periostel problems. If pain gets worse with exercise and there is also a 'tight' feeling, then compartment syndrome must be considered. Chronic compartment syndrome is probably the entity most likely to be confused with tibial stress injuries. Athletes may describe tightness or pain in the muscles of the anterior leg after exercising for a specific amount of time. They may also have distal numbness in the region. Pain is usually relieved with a brief rest period with often no tenderness elicited on exam. Diagnosis is made by direct compartment pressure measurement immediately after exercise.
If the pain is worsened by jumping, or pain continues at rest, then a stress fracture is a possibility. (Courture and Karlson 2002) Report how plain x-rays of patients who have tibial stress syndrome are almost invariably normal, although posterior cortical widening consistent with chronic remodeling may be seen. Likewise, patients with early stage tibial stress fractures typically have normal radiographs.
Plain x-rays may show a stress fracture of the tibia that has been present for a number of weeks. But, generally plain radiographs are not that useful in diagnosis of shin pain.
Radioisotopic bone scan is a more sensitive indicator of bone stress. It is particularly useful for establishing an early diagnosis and for directing appropriate management. Depending on the extent of the injury the bone scan may remain positive for up to a year.
There has been conflicting views of the use of magnetic resonance imaging (MRI) for diagnosis of tibial stress injuries. However, tibial stress fractures can be clearly delinated on the MRI. In patients with acute symptoms of tibial stress, the MRI can show changes consistent with bone stress injury, although in patients with chronic symptoms the images tend to be normal.
The MRI has the advantage of displaying excellent anatomic visualization and lack of radiation exposure.
With tibial stress injury, most athletes respond to conservative treatment. This involves rest followed by a gradual return to precipitating activities after symptoms subside.
(Hutchinson, Cahoon and Atkins 1998) describes rest as a relative decrease in the exacerbating activity to a level that no longer produces pain. Patients who have mild tibial stress may require only a few days of rest, but those who have tibial stress fractures often require up to six weeks before return to activity. With inflammatory shin pain initial treatment is to reduce inflammation. Courture and Karlson described how ice massage is the most effective adjunctive treatment is the acute stage. Bradshaw describes how reduction of inflammation is initially treated by rest, non steroid anti-inflammatories, ice and electrotherapeutic medalities. Podiatric assessment and development of a stretching program are also an essential component in management. Deep massage therapy is also an effective treatment element. Specific muscle strengthening exercises are often prescribed after the diagnosis of tibial stress injury. On re-commencement of training, an adequate stretching program with warm-up and cool down is essential. Custom orthoses may benefit patients who have excessive pronation or subtotal mobility. As the athlete returns to training from injury, a gradual increase in intensity and duration is necessary to minimize the chance of injury re-occurrence. The physician and/or the coach should closely monitor the athletes' recovery. Any hyper-pronation or other malalignments would benefit from orthodics and or physical or manipulative therapy techniques. For female athletes with menstrual disturbances possible hormonal therapy may be indicated. With tibial stress fractures an initial period of rest is usually necessary before pain is settled. Basic treatment for patients who have uncomplicated stress fractures is rest from the aggravating activity for four to six weeks. It has been shown with the use of a pneumatic leg brace a speedier return to a full activity can be made. (Hutchinson, Cahoon and Atkins 1998) describe how when impact activities can be performed in the brace without pain, a gradual return to the activity is permitted. However, if the pain recurs or the fracture is resistant to healing, casting or complete abstinence from impact activities may necessary. The progress of stress fracture healing is monitored clinically, with patients resuming exercise when healing is evident. That is, when the athlete is pain free with no localized pain under normal day to day activities. The athlete should make a gradual return to sporting activity. Commencing with simple walking with a gradual increase in pace until being able to run at normal pace.
While recovering from injury, the athlete will need to change their sport or activity to one that does not worsen the condition. For example, the athlete may need to bicycle or swim rather than be involved in running activities. The best management of tibial stress injuries is prevention based. Athletes should be aware of correct techniques to avoid training errors. Running should begin on level, moderately firm surfaces. Training intensity should increase gradually and other changes like repetitive jumping need to be re-introduced very carefully with a slow, gradual increase in intensity and quantity. Couture and Karlson (2002) present a strategy for long term management and the prevention of Tibial Stress injuries. In this strategy an athlete must firstly avoid any training errors. Using a ‘start slow and go slow’ introduction to activities with concentration on good technique. Changes in intensity of training and changes in terrain or running surfaces should be gradual. Flexibility of calf muscles must be maintained. The athlete should also develop adequate anterior tibial strength. The athlete must wear correct footwear and replace worn shoes when necessary. Any imbalances such as hyperpronation must be corrected with necessary orthodics. The athlete should ensure that they have adequate calcium intake, (although some studies [Gillespie and Grant] concluded that there was no evidence at present for the use of calcium supplements to prevent stress fractures). Any menstrual dysfunction should also be addressed, if applicable. Athletes are also advised to maintain flexibility of the gastrocnemius and soleus muscles with thorough stretching regimes. O’Connor, Howard, Fieseler and Nirschl (1997), discuss the use of effective control of tissue overload. This involves firstly improving the athletes sport technique. This is seen as critical as abnormal and incorrect biomechanical movement will predispose a reoccurrence of an injury. It also involves attention to training errors, that is, excessive frequency, intensity and duration. Athletes should be encouraged to follow basic training principles of progression and periodisation, which implies a gradual increase in workload and training cycles that emphasise programmed rest. Control of tissue overload also involves modification of equipment. This requires paying attention to foot wear as well as training and competing surfaces. Even a slight abnormality in an athletes foot biomechanics can contribute to stress injuries. These abnormalities need to be corrected through rehabilitation, use of proper footwear and custom orthodics. Gillespie and Grant (2003) evaluated evidence from controlled trials of treatments and programs for prevention and management of lower limb stress injuries. They found that the best available evidence indicated that the provision of ‘shock absorbing’ insoles reduces the overall incidence of stress fractures and stress reactions of bone. They also found that it was possible that controlling the amount of medium distance running in the context of an overall fitness programme is also effective. Hacker, Gilchrist, Stroup and Kimsey (2002) also found that the most encouraging evidence for effective prevention of ‘shin splints’ involves the use of shock absorbing insoles. Yeung and Yeung (2003) in their review, found evidence for the effectiveness of the modification of training schedules in reducing lower limb, soft tissue running injuries. Difiori (1999) suggested that the prevention of these injuries could begin at an early age by encouraging children to be involved in a variety of different sports. This would allow the young athlete to adapt to a wider range of surfaces, activities and types of footwear. As Brunkner and Khan (2002) describe in their general principles of injury prevention, that these types of injuries can be minimised following basic principles of injury prevention.
Firstly, correct biomechanics is a major factor in injury prevention and every effort must be made to ensure that the athlete maintains correct technique. Adequate warm up and stretching should be performed. The type of exercise to be performed should determine the type of warm up. The most effective warm up consists of both general and specific exercises. In stretching programs, static, dynamic and proprioceptive neuromuscular faciliation stretching may be performed depending on the needs of the athlete and the event. Suitable equipment is another basic area for prevention of tibial stress injuries. The optimum shoe for a runner is one that matches the athlete's specific mechanical characteristics. This applies to the running shoe as well as the competition spikes that may be used in actual competition. With running spikes, the calf muscles may be subject to greater eccentric load due to the negative heel lift as the tibia is required to dorsiflix over the foot through a greater range.
Also, the small heel in the running spike provides little stability for the lowering of the heel by the calf muscle. This can lead to the development of inflammatory shin pain in runners. Running spikes can be modified to prevent this by providing the heel stability. The other area for prevention of tibial stress injury is the choice of an appropriate surface. The type of surface being used can influence the risk of an injury; for example, a hard surface such as concrete generates greater force through the musculoskeletal system than a forgiving surface such as grass. It has shown that maximal forces when walking approach up to twice that of body weight, this can increase to up to twelve times body weight with jumping. Training errors are perhaps the most common predisposition factors in the development of sporting injuries. Applying the general principles of training such as periodization, specificity, overload and individuality will assist in the prevention of both tibial stress injuries as well as numerous other sporting injuries.
Exercise induced shin pain is one of the most common injuries in runners. These injuries can be assessed accurately with thorough examination and history. The use of selected radiographs including radioisotope bone scans and MRI can assist greatly in the diagnosis of the conditions. These injuries usually respond well to conservative treatment. The athlete needs to take great care with the re-introduction to training with a gradual and cautious approach to increasing intensity and volume. Tibial stress injuries can be minimized by following basic principals of injury prevention such as following correct warm-up, wearing suitable footwear, running on suitable surfaces, maintaining correct technique and following a suitable approach to training loads.
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by Dr Martin Lynch