Shin Pain in a Runner

Abstract

History A 35 year-old athletic female presents to a foot and ankle specialist for evaluation of a six month history of persistent, sharp, and non-radiating right ankle and shin pain with associated numbness. The patient is an avid runner and is currently training for her first marathon with a weekly average of greater than 25 miles. Rest improves her symptoms and activity exacerbates her pain, which occasionally wakes her up at night. Standard three view ankle films are negative for any acute injury, and the patient is diagnosed with shin splints and sent to physical therapy for treatment. Four months later, the patient presents to our clinic with worsening complaints since arduously completing a recent marathon, and she has recently noticed a small painful knot on the anterior portion of her tibia. Physical Examination The patient is a well-developed and well-nourished athletic female with an antalgic gait. On visualization there is no ecchymosis, erythema, or obvious prominence over either tibia. Her right tibia is tender along the anterior and posteromedial borders with focal tenderness over the midshaft. The patient has no neurological deficits or asymmetries in her lower extremities. Her distal pulses are 2+ and equal bilaterally. There is no pes planus or leg length discrepancy. Differential Diagnosis Tibial Stress Fracture Medial Tibial Stress Syndrome Tibial periostitis Chronic Anterior Compartment Syndrome Bone Cyst/Tumor Tests and Results AP and Lateral tib-fib X-rays show dual tibial stress fractures of the anterior cortex in the middle third of the tibia. Bone Densometry is normal. Final Working Diagnosis Dual Tibial Stress Fractures of the anterior cortex in the middle third of the tibia Treatment and Outcomes After extensive counseling and discussion with the patient concerning the need for surgical repair of her tibial stress fractures, she ultimately decided to forego surgical treatment at the time of diagnosis. The patient was made non-weight bearing with crutches and was placed in a pneumatic immobilizer. She was given a bone stimulator with instructions on its use and was sent for formal physical therapy. She was started on Fosamax, OsCal, and a multivitamin, and was given a prescription for a nonsteroidal to use as needed. The patient had two follow up appointments after her diagnosis, and her last follow up X-rays showed minimal interval healing of both fractures at two months.