Transcript Medial Tibial Stress Syndrome “Shin Splints”

MEDIAL TIBIAL STRESS
SYNDROME
“SHIN SPLINTS”
Dr. Vernon
Morkel
1996482590
TABLE OF CONTENTS
 Introduction
 History
 Clinical Evaluation
 Special Investigations
 Three stage assessment
 Problem list formulation
 Plan and Progression
 Discussion
INTRODUCTION
26 y.o. male, rugby player – backline
Plays rugby for fun, not very fit
Bank clerk
Smoker & social drinker
No chronic medical conditions
HISTORY
Came of rugby field during pre-season
practice
Intense pain – over both lower legs
Started gradually during running exercise
Has to stop running for relieve
Flared up with increased exercise intensity
Previous h/o ‘shin-splints’
CLINICAL EVALUATION
Tenderness over post.med. borders – both
tibias
Middle 3 rd of tibias – most tenderness
Pain – passive ankle dorsiflexion
Pain – plantar flexion against resistance
Pain – ‘toe raises’
Pain – 4-5 single leg hops
Hyperpronation – both feet
SPECIAL INVESTIGATIONS
None indicated
None done
THREE STAGE SUMMARY
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. Social
Afraid – miss out on team selection
Friends – ‘sissy’, for quitting exercise
PROBLEM LIST FORMULATION
1. Active
Painful lower legs – Medial Tibial Stress
Syndrome (Shin Splints)
2. Passive
Preventing him from completing training
sessions & matches
General fitness deteriated
PLAN AND PROGRESSION
Iced lower legs – initially
Analgesia
Recommended – 10 days rest from running
Refer – innersoles to improve
hyperpronation
Physiotherapy
Still in rest period & awaiting innersoles
DISCUSSION
Definition
Medial 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
frequently
16.8% long distance runners
35% - military academies USA
Females twice the risk then men
Middle third mostly, then lower third of tibia
PATHOPHYSIOLOGY OF MTSS
Unclear (many theories)
Periostitis (inflammation of the periosteum)
Tearing of the muscle bone interface
Soleus m, tibialis post & flex digi longus –
culprits
Stress reaction of the bone (tibia)
CLINICAL PICTURE
History
Patients often c/o pain
Posteromedial border of tibia
Distal 2/3 of tibia
During running activities
Increase in running intensity
Change of running surface
CLINICAL EXAMINATION
 Tenderness over 4 – 6 cm area
 Post.med border, middle & distal thirds of tibia
Provocative tests for MTSS
pain with:
 Passive ankle dorsiflexion
 Resisted plantar flexion
 Toe raises
 4 – 5 single leg hops
RISK FACTORS FOR MTSS
abrupt increase in training activities
inadequate shoes
hard or inclined running surfaces
previous MTSS
female gender
increased BMI
RISK FACTORS FOR MTSS (2)
increased foot pronation
increased varus tendency of the forefoot
and/or hind foot
hip internal or external rotation
increased muscular strength of plantar
flexors
DIFFERENTIAL DIAGNOSIS
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 (2)
 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 )
SPECIAL INVESTIGATIONS
 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
TREATMENT OPTIONS
Rest for 7 to 10 days from painful activities
Icing
Analgesia for pain relieve
Stretching of calf musculature
Strengthening of calf musculature
Activity modification
Orthotics or inner soles to correct foot
hyperpronation
TREATMENT MODALITIES (2)
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 (3)
 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.
PREVENTION MEASURES
 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
LEARNING EXPERIENCE
Abruptly
increasing
training
activities,
changing running surfaces and inadequate
shoes – ‘shin splints’, correcting these factors
and rest are important to manage the
condition.
REFERENCES
1 . B r e we r, R B . , e t a l , 2 0 1 2 . C h r o n i c l o we r l e g p a i n i n a t h l e t e s : A g u i d e f o r t h e
d i ff e r e n t i a l d i a g n o s i s , e va l u a t i o n a n d t r e a t me n t . S p o r t s H e a l t h , 4 ( 2 ) , 1 2 1 - 1 2 7
2 . B r u k n e r & K h a n , 2 0 1 2 . C l i n i c a l S p o r t s M e d i c i n e , 4 t h e d , N S W, A u s t r a l i a , M c G r a w Hill
3 . C r a i g , D I . , 2 0 0 8 . M e d i a l Ti b i a l S t r e s s S yn d r o me : E vi d e n c e - B a s e d P r e ve n t i o n .
J o u r n a l o f A t h l e t i c Tr a i n i n g , 4 3 ( 3 ) , 3 1 6 - 3 1 8
4 . L o u d o n , J K . , 2 0 1 0 . U s e o f f o o t O r t h o s e s a n d C a l f S t r e t c h i n g f o r i n d i vi d u a l s wi t h
M e d i a l Ti b i a l S t r e s s S yn d r o me . F o o t & A n k l e S p e c i a l i s t , 3 ( 1 ) , 1 5 - 2 0
5 . M o e n , M H . , 2 0 11 . T h e t r e a t me n t o f m e d i a l t i b i a l s t r e s s s yn d r o me wi t h
bisphosphonates. Sport & Geneeskunde, 1, 22-25
6 . N e wm a n , P. , 2 0 1 2 . Two s i m p l e c l i n i c a l t e s t s f o r p r e d i c t i n g o n s e t o f m e d i a l t i b i a l
s t r e s s s yn d r o m e : s h i n p a l p a t i o n t e s t a n d s h i n o e d e ma t e s t . B r i t i s h J o u r n a l o f
Sports Medicine, 1-5
7 . R o m p e , J D . , e t a l , 2 0 1 0 . L o w - E n e r g y E xt r a c o r p o r e a l S h o c k Wa ve T h e r a p y a s a
t r e a t me n t f o r M e d i a l Ti b i a l S t r e s s S yn d r o m e . T h e A m e r i c a n J o u r n a l o f S p o r t s
Medicine, 38(1), 125-132
8 . Ya t e s , B . , 2 0 0 4 . T h e I n c i d e n c e a n d R i s k F a c t o r s i n t h e d e ve l o p m e n t o f M e d i a l
Ti b i a l S t r e s s S yn d r o m e a m o n g N a va l R e c r u i t s. T h e A m e r i c a n J o u r n a l o f S p o r t s
Medicine, 32(3), 772-780
THANK YOU
Dr. VERNON MORKEL
[email protected]