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Orthopaedic Consultants of Cincinnati, Inc.
Suite 110 | 4701 Creek Road | Cincinnati, Ohio 45242 | USA

Standardized by: 
Denver T. Stanfield, MD



OVERUSE INJURIES
of the LEG

For many years discomfort in the anterior aspect of the leg associated with athletic activity has been called "shin splints." We now classify exercise related lower leg pain according to specific location, severity, and duration of symptoms.

The mildest form is often associated with activity at the beginning of training, after a relatively inactive period or a dramatic increase of training intensity. The location is usually along the lateral border of the tibia, or shin bone, at the muscle-bone interval. This syndrome is frequently seen in runners and has been called Anterior Compartment Syndrome, Anterior Shin Splints or Lateral Shin Splints. The etiology is felt to be local overuse of the lateral compartment muscles. This overuse may be related to a change in training technique such as hill sprinting, interval training, stair climbing, plyometrics, or changing to a overly flexible shoe. All of these can overload the anterior compartment muscles, producing pain along the extensor border of the tibia. Decreased flexibility can also be a cause of Anterior Compartment Syndrome. An adult starting an exercise program without proper warm-up and pre-exercise stretching or a teenager with poor flexibility during periods of rapid growth, is at increased risk of developing an overuse syndrome such as this.

The second obvious location is along the medial or inside border of the tibia. This is usually termed Medial Tibial Stress Syndrome, Medial Compartment Syndrome or Medial Shin Splints. The most common location is along the lower or distal two thirds of the medial tibial at the bone-muscle interval. Medial Tibial Stress Syndrome is often associated with increased force such as running on hard surfaces, poorly supportive shoes, or jumping (volleyball, basketball, long jumping, rope jumping). Mechanical abnormalities have also been identified as potential causes. Hyperpronation of the foot, increased eversion of the heel, external tibial rotation, external hip rotation or even prolonged running on a banked surface are the primary mechanical factors felt to be involved in Medial Tibial Stress Syndrome. The pain increases with running and decreases with rest. Pain is often present, even without exercise, when the medial edge of the tibia is touched. The area is often exquisitely tender. The painful area will be more symptomatic after exertion.

Attempts to exercise through the initial symptoms without treatment will often lead to a more severe condition known as Tibial Periostitis. Periostitis is an inflammatory reaction of the outer covering of the bone. The area of pain or tenderness involves at least one third the length of the tibia. The pain is reproduced by tapping on the border of the bone. Often the reaction by the bone periosteum will be visualized on an x-ray. A bone scan also will be positive and involve a diffuse area of the shaft of the tibia.

The most severe overuse injury involving the lower leg is the Tibial Stress Fracture. Stress fractures of the tibia in the athlete account for approximately 20% of all stress fractures. Most Tibial Stress Fractures involve the proximal (upper) or distal (lower) one third of the bone. These heal relatively quickly, and are seen primarily in joggers and runners. Young athletes seem prone to proximal tibial fractures. Stress fractures involving the upper or lower portions of the tibia usually present with activity related pain. Point tenderness may be noted. In contrast, periostitis or muscle strain commonly presents as a larger area of tenderness.

Anterior mid-shaft Tibial Stress Fractures are caused by a different type of force on the leg and are often slow to heal. They are classically seen in ballet dancers and basketball players. Fortunately, anterior stress fractures account for less than 5% of all

Tibial Stress Fractures in athletes. They have a propensity for delayed healing, progression to a complete fracture, and recurrence after healing.

Treatment

Treatment usually involves a decrease in activity for Anterior Compartment Syndrome and Medial Tibial Stress Syndrome. Efforts to reduce local inflammation include the use of oral antiinflammatory agents and the local application of ice. Taping, strapping or the use of elastic sleeves may reduce the stress on the local soft tissues. More supportive and well cushioned shoewear is suggested. Training techniques should be evaluated along with running surfaces and altered as necessary. The gait should be evaluated for possible mechanical abnormalities which may require changing to a specific type of shoewear or the use of orthotics. Treatment by a Physical Therapist trained in Sports Medicine may be indicated.

Of primary importance is the implementing of a regular warm-up and cool-down stretching program to increase flexibility and reduce the tension on local tissues. The use of such a program is the single most important factor in alleviation of symptoms and the prevention of recurrence. After resolution of symptoms a strengthening program should be added to improve overall power and endurance and decrease the risk of injury.

The initial treatment of Tibial Periostitis includes the conservative measures above and REST. Cross-training activities may be necessary briefly to maintain general aerobic
condition and strength. When asymptomatic, the patient can slowly resume running.

The x-ray will remain abnormal for several months despite symptomatic improvement.

The treatment for Tibial Stress Fractures is dependent upon the location of the fracture along the shaft of the bone. If the fracture is located either proximal or distal, near the knee or ankle, activity restriction for 4 to 6 weeks is usually successful in obtaining complete healing of the fracture. Casting is rarely indicated. During this period cross-training is absolutely necessary.

Anterior Tibial Stress Fractures involve the mid shaft of the bone with a tendency towards slow healing and the potential for complete fracture. Most recommend initial immobilization in a walking cast or brace. If healing is not evident by 4 to 6 months consideration can be given to bone grafting or electric stimulation.