HISTORY: 20 year old female presented with 4 years of bilateral (B/L) shin pain. She presented to the clinic after seeing previous physicians two years prior. She had attempted complete rest from activities after being initially diagnosed with "shin splints" two years prior, however the pain was persistent. The patient complained of pain at the B/L anterolateral shins, rated maximumaly 8/10 during running. At rest the pain ranged from either nonexistent to a deep, dull ache rated 4/10. The pain never woke the patient from sleep. She had also tried various NSAIDs without relief. Pt denied radicular pain, vascular insufficiencies, Rheum disorders or any other past medical history. PHYSICAL EXAM: Healthy 20 yo Caucasian female. Visual inspection of the B/L LE was normal without muscle atrophy, vascular changes, swelling, derm lesions. No pretibial swelling/edema was present in the B/L LE, +2 pedal pulses B/L, all muscle strength of B/L LE +5 and equal. Achilles, Patellar reflexes +2 B/L. Dermatomes intact b/l. Palpation along the medial tibial border was tender B/L. Percussion & tuning fork test was moderately tender along the B/L tibiae w/o focality. DIFFERENTIAL DIAGNOSIS: Medial Tibial Stress Syndrome ("MTSS") Tibial Stress Fractures Exertional Compartment Syndrome Ribbing's Disease Other bilateral bone dysplasia's (Engelmann, Van Buchmen, Sclerosteosis) TESTS AND IMAGING: Bone Scan (05/30/08); uniform increased uptake of the B/L midshaft tibiae -Xray (8/7/09). B/L Tib/Fib: Increase Cortical diameter B/L in the midshaft if the Tibia -CT LE (8/12/09): B/L cortical thickening of tibiae and fibulae w reciprocal medullary narrowing, tibiae was more pronounced. Lab Work: CMP: Normal, Alk Phos:44, Ca:9.6; Mag:2.2; Phos:3.4; Vit D 25, OH:34 Surgical Tibia Biopsy: 9/2/09 Pathology: Haversavian channel variability, cortex bone at varying degrees of lamellar conversion. Findings c/w Ribbings disease. FINAL WORKING DIAGNOSIS Ribbings Disease TREATMENT/OUTCOME -After the biopsy results Orthopedic Oncologist referred to Bone and Mineral specialist. -B&M specialist began Bisphosphonate therapy. -1.5 month after initiation on Rx, little change in pain. Typical time frame for efficacy of bisphosphonate is 3-4 months. -Surgical Intramedullary Reaming remains an option. -Requested Genetic Testing