dr. vernon morkel 1996482590 medial tibial stress syndrome “shin splints”

Dr. Vernon Morkel

1996482590

MEDIAL TIBIAL STRESS SYNDROME

“SHIN SPLINTS”

IntroductionHistoryClinical EvaluationSpecial InvestigationsThree stage assessmentProblem list formulationPlan and ProgressionDiscussion

TABLE OF CONTENTS

26 y.o. male, rugby player – backline

Plays rugby for fun, not very fit

Bank clerk

Smoker & social drinker

No chronic medical conditions

INTRODUCTION

Came of rugby field during pre-season practiceIntense pain – over both lower legsStarted gradually during running exerciseHas to stop running for relieveFlared up with increased exercise intensityPrevious h/o ‘shin-splints’

HISTORY

Tenderness over post.med. borders – both tibiasMiddle 3rd of tibias – most tendernessPain – passive ankle dorsiflexionPain – plantar flexion against resistancePain – ‘toe raises’Pain – 4-5 single leg hopsHyperpronation – both feet

CLINICAL EVALUATION

None indicated

None done

SPECIAL INVESTIGATIONS

1. Clinical Medial Tibial Stress Syndrome (Shin Splints) Brought on – intense & repetitive running

exercises

2. Personal Concerned – he frequently has to stop running

or exercise – severe leg pain

THREE STAGE SUMMARY

3. SocialAfraid – miss out on team selectionFriends – ‘sissy’, for quitting exercise

THREE STAGE SUMMARY

1. Active Painful lower legs – Medial Tibial Stress

Syndrome (Shin Splints)

2. Passive Preventing him from completing training

sessions & matches General fitness deteriated

PROBLEM LIST FORMULATION

Iced lower legs – initiallyAnalgesiaRecommended – 10 days rest from runningRefer – innersoles to improve hyperpronationPhysiotherapy

Still in rest period & awaiting innersoles

PLAN AND PROGRESSION

DefinitionMedial Tibial Stress Syndrome (MTSS) is defined as pain along the posteromedial border of the tibia that occurs during exercise, excluding pain from ischaemic origin or signs of stress fracture (Newman and Adams 2012).

DISCUSSION

MTSS – one of the most common causes of exercise-related leg pain

Running & walking activities – most frequently16.8% long distance runners35% - military academies USAFemales twice the risk then menMiddle third mostly, then lower third of tibia

DISCUSSION

Unclear (many theories)Periostitis (inflammation of the periosteum) Tearing of the muscle bone interface

Soleus m, tibialis post & flex digi longus – culpritsStress reaction of the bone (tibia)

PATHOPHYSIOLOGY OF MTSS

History

Patients often c/o painPosteromedial border of tibiaDistal 2/3 of tibiaDuring running activities

Increase in running intensity

Change of running surface

CLINICAL PICTURE

Tenderness over 4 – 6 cm areaPost.med border, middle & distal thirds of tibia

Provocative tests for MTSS

pain with:Passive ankle dorsiflexionResisted plantar flexionToe raises4 – 5 single leg hops

CLINICAL EXAMINATION

abrupt increase in training activitiesinadequate shoeshard or inclined running surfacesprevious MTSSfemale genderincreased BMI

RISK FACTORS FOR MTSS

increased foot pronationincreased varus tendency of the forefoot and/or

hind foothip internal or external rotationincreased muscular strength of plantar flexors

RISK FACTORS FOR MTSS (2)

Stress fractures of the tibia – caused by repetitive loading with resulting microfracture

Chronic exertional Compartment syndrome – is a condition of increased pressure in the fascial compartments of the leg

DIFFERENTIAL DIAGNOSIS

Peripheral Nerve entrapment – most often caused by trauma, the common peroneal, superficial peroneal and saphenous nerves are most commonly at risk for entrapment

 Popliteal artery entrapment syndrome – is an uncommon

overuse injury, frequently caused by compression of the popliteal artery by surrounding musculotendinous structures as it exits the popliteal fossa

 (Brewer and Gregory 2012)

DIFFERENTIAL DIAGNOSIS (2)

X-rays – rarely positive early on. X-rays performed 2 to 3 weeks after onset of pain may reveal periosteal reaction or a radiolucent line (stress fracture)

 Radio isotopic bone scan – can confirm the presence of

MTSS or a stress fracture MRI scan – is the investigation of choice for lower leg pain MRI arteriograph – can confirm popliteal artery syndrome

SPECIAL INVESTIGATIONS

Rest for 7 to 10 days from painful activitiesIcingAnalgesia for pain relieveStretching of calf musculatureStrengthening of calf musculatureActivity modification Orthotics or inner soles to correct foot

hyperpronation

TREATMENT OPTIONS

Extracorporeal Shock Wave Therapy (ESWT) – is a new treatment modality for MTSS. Rompe et al (2010) used low-energy ESWT to treat MTSS. After 15 months 76% of the treatment group were able to return to their sport symptom free, compared to only 37% of the control group. This study showed that low-energy ESWT is safe and effective to treat MTSS

TREATMENT MODALITIES (2)

Bisphosphonates (currently used for treatment of osteoporosis) – Moen at el (2011) administered bisphosphonates to two athletes diagnosed with chronic MTSS. Both athletes returned to their sport in a much shorter time. These case reports raise the possibility that bisphosphonates could decrease the time to return to sport in MTSS patients.

Surgery – only for very severe cases of shin splints that do not respond to conservative treatment. However the effectiveness of surgery remains unclear.

TREATMENT MODALITIES (3)

Shock-absorbent insoles Pronation control insoles (specifically controlling

navicular drop) Graduated running programs

Correcting training errors: – like an abrupt increase in training activity  -Changing to a harder training surface

PREVENTION MEASURES

Abruptly increasing training activities, changing running surfaces and inadequate shoes – ‘shin splints’, correcting these factors and rest are important to manage the condition.

LEARNING EXPERIENCE

1. Brewer, RB., et al, 2012. Chronic lower leg pain in athletes: A guide for the differential diagnosis, evaluation and treatment. Sports Health, 4(2), 121-127

2. Brukner & Khan, 2012. Clinical Sports Medicine, 4th ed, NSW, Australia, McGraw- Hill3. Craig, DI., 2008. Medial Tibial Stress Syndrome: Evidence-Based Prevention. Journal of Athletic

Training, 43(3), 316-3184. Loudon, JK., 2010. Use of foot Orthoses and Calf Stretching for individuals with Medial Tibial Stress

Syndrome. Foot & Ankle Specialist, 3(1), 15-205. Moen, MH., 2011. The treatment of medial tibial stress syndrome with bisphosphonates. Sport &

Geneeskunde, 1, 22-25 6. Newman, P., 2012. Two simple clinical tests for predicting onset of medial tibial stress syndrome:

shin palpation test and shin oedema test. British Journal of Sports Medicine, 1-5 7. Rompe, JD., et al, 2010. Low-Energy Extracorporeal Shock Wave Therapy as a treatment for Medial

Tibial Stress Syndrome. The American Journal of Sports Medicine, 38(1), 125-132 8. Yates, B., 2004. The Incidence and Risk Factors in the development of Medial Tibial Stress

Syndrome among Naval Recruits. The American Journal of Sports Medicine, 32(3), 772-780 

REFERENCES

Dr. VERNON MORKELvmorkel@iway.na

THANK YOU