1. It’s not all shin splints
Marc Silberman, M.D.
Gillette, New Jersey

2. Disclosure
I declare no conflict of interests I do not have any financial disclosures

3. Exercise induced leg pain
1. CECS %
2. Tibia Stress Fracture 25%
3. MTSS %
Clanton T, Solcher B. Chronic leg pain in the athlete. Clin J Sport Med. 1994;13:

4. Chronic Exertional Compartment Syndrome (CECS)

5. CECS
Pain, tightness, cramping, numbness, burning, swelling with exertion
Pathophysiology not understood
High pressure within myofascial space resulting in decrease tissue perfusion
Historical treatment is fasciotomy

6. The Compartments

7. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

8. Pedowitz Criteria At rest > 15 mm Hg
1 minute post exercise > 30 mm Hg
5 minutes post exercise > 20 mm Hg
Pedowitz RA, Hargens A, Mubarak SJ. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35-40

9. Continuous Pressure Measurement Anterior Compartment
Phase 1 Military 15kg backpack walking 6.5km/hour
Phase 2 Military 15kg backpack walking incline 5%
Phase 3 No backpack running 9.5km/hour incline 5%
Elevated pre-exercise standing state in subjects
Diagnostic cut off of 105 mm Hg
Roscoe et al. Am J Sports Med 2015.

10. Surgical Outcomes Packer reports a 19% failure rate
Post college age satisfaction of 66%
50% military symptomatic, 25% failed to return to full duty
17% had to be discharged
Success rates of 30% to 65% for posterior compartment

11. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

12. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

13. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

14. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

15. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

16. Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada.
Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

17. Forefoot Running
Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2011;6:
Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:
Helmhout et al. The Effectiveness of a 6-Week Intervention Program Aimed at Modifying Running Style in Patients With Chronic Exertional Compartment Syndrome. The Orthopaedic Journal of Sports Medicine.

18. Diebel et al 10 patients enrolled in a 6 week running program
Running distance significantly increased by 300%, from 1400 ± 600 m to 4800 ± 500 m
Mean post exercise anterior pressure decreased by 51%, from 78.4 ± 32.0 to 38.4 ± 11.5 mm Hg
Improvements of 81% for SANE, 21% for LLOS, 96% for VAS; scores higher at 1 year follow-up
Vertical ground reaction force decreased
Decreased step length and increased step rate

19. Helmout et al. 19 participants in the Dutch Military
6 weeks learning Pose Technique
Running distance increased by 43%
Post exercise ICP decreased by 36%
Self reported outcomes increase in SANE, LLOS, and PSC of 36%,18%, 60%
74% had no elevation of pain
Decreased step length and increased step rate

20. Helmout et al.

21. Pose Technique
The support foot is pulled from the ground to allow the body to fall
forward, while the other foot drops down freely, in a change of support

22. Reduced Eccentric Loading with Pose Technique
Shorter stride lengths
Smaller vertical oscillations of the sacrum and heel
Neutral ankle joint at impact
Lower magnitude of vertical impact forces
Lower eccentric work at the knee
Greater eccentric work at the ankle
Arendse et al. MSSE

23. Vertical Ground Reaction Force
Higher loading rates are found in those who sustained stress fractures
Higher loading rates are found in those who sustained all running related injury types, studies are limited
Hank van der Worp et al. BJSM 2015.

24. Botulinum toxin A 16 patients 25 anterior compartments
17 lateral compartments
Follow-up lasted 3 to 9 months
15 patients pain was eliminated
5 patients the strength remained normal
Isner-Horobeti ME. Am J Sports Med. 2013;41:2558–2566.

25. Botulinum toxin A
Isner-Horobeti ME. Am J Sports Med. 2013;41:2558–2566.

26. Onabotulinum toxin A 20 year old, left anterior-lateral CECS
Onabotulinum toxin A 20 units proximally and 20 units distally
Within one week, pain 1/10 with no paresthesias, jogging within 2 weeks
14 month follow-up
Neuromuscular junction affect lasts 2 – 6 months
Known antinociceptive effects independent of its neuromuscular action
Barria at al. Clin J Sport Med 2016;0:1–3.

27. CECS References
Arendse et al. Reduced eccentric loading of the knee with the Pose running method. MSSE 2004; (36)
Barria MR. Botulinum Toxin for Chronic Exertional Compartment Syndrome: A Case Report With 14 Month Follow-Up. Clin J Sport Med 2016;0:1–3.
Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2011;6:
Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:
Helmhout et al. The Effectiveness of a 6-Week Intervention Program Aimed at Modifying Running Style in Patients With Chronic Exertional Compartment Syndrome. The Orthopaedic Journal of Sports Medicine.
Isner-Horobeti ME, Dufour SP, Blaes C, et al. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. Am J Sports Med. 2013;41:2558–2566.
Pedowitz RA, Hargens A, Mubarak SJ. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35-40
Roscoe D et al. Intramuscular Compartment Pressure Measurement in Chronic Exertional Compartment Syndrome:New and improved diagnostic criteria. Am J Sports Med : 392

28. Stress Fracture

29. “A high school athlete with shin pain has a stress fracture until proven otherwise”

31. Definition
“A fracture caused not by a direct blow, twist, or fall, but
by cyclical loading that exceeds the bones natural repair capacity”

32. Stress fracture hypothesis
“Bone remodeling is a balance between osteoclastic resorption and osteoblastic reconstruction” As loading increases, additional bone resorption occurs Time lag between the two is 2 to 3 weeks

33. Stress fracture hypothesis
When activity is increased, local weakness and microdamage may be caused by increased osteoclastic activity Stress fractures occur when muscle becomes fatigued and unable to absorb added force Impact forces are transferred to bone which causes overload and stress fracture

34. Female Athlete Triad
Risk of stress fractures in athletes with menstrual disturbance is 2 to 4 times that of eumenorrheic athletes
Disordered eating, amenorrhea, and osteoporosis
Functional Hypothalamic Amenorrhea from insufficient energy intake
Decreased leptin levels, decreased gonadotropins, hypoestrogenic state lead to reduced calcium absorption, increased bone resorption, suppressed bone formation

35. True or False
A stress fracture is a small crack in a bone

36. False

37. False

38. True or false
Stress fractures are caused by weak bones

39. False 1. Abnormal stress on normal bone
Not weak bones but weak or fatigued muscles
2. Normal stress on abnormal bone
3. Abnormal stress on abnormal bone

41. Clinical tests
There are no clinical tests to diagnose a stress fracture
The diagnosis is made by radiological imaging
Schneiders AG et al. The Ability of Clinical Tests to Diagnose Stress Fractures: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther 2012;42(9):

42. X-ray “While X-ray can rule in a stress fracture,
X-ray can not rule out a stress fracture”
X-ray sensitivity of 10 to 50%

43. X-ray First Visit

44. X-ray First Visit

45. X-ray 1 month

46. X-ray 3 month

47. X-ray 3 month

48. MRI
“MRI can rule out a stress fracture and MRI can grade a stress fracture”
Sensitivity 88%, Specificity 100%
Gaeta M et al. Radiology May; 235(2):553–561.

49. Grading
Grade
X-ray
MRI 1
Normal
Positive STIR 2
Positive STIR and T2 3
Positive T1 and T2 4
Fracture,
Periosteal reaction
Positive T1 and T2, Fracture line
Adapted from Arendt et al. Clin Sports Med (2):

50. Grade 1

51. Grade 2
Nattiv et al. Am J Sports Med August ; 41(8): 1930–1941.

52. Grade 3
Nattiv et al. Am J Sports Med August ; 41(8): 1930–1941.

53. Grade 4

54. High Risk vs Low Risk High Risk Low Risk Lateral Femoral Neck
Medial Femoral Neck
Femoral Head
Femoral shaft
Patella
Pelvis*
Anterior tibia cortex
Posterior medial tibia
Medial Malleoli
Fibula
Talus
Cuboid
Navicular
Cuneiform
Second metatarsal base
Calcaneus*
Fifth metatarsal base
Other metatarsals
Sesamoid medial

55. Return to Play
Mean days
Median days
Q25 days
Q75 days
LowRiskLowGrade 61 50 35 78
LowRiskHighGrade
153 86 64
164
HighRiskLowGrade
135 70 63
132
HighRiskHighGrade
131 89 72
124
Prolong healing time at high risk fracture sites and at low risk sites with high grade lesion.
Take home message: Need a fast and reliable diagnosis.
Dobrindt et al. BMC Musculoskeletal Disorders 2012, 13:139.

56. NCAA Time to return to sport
Nattiv et al. Am J Sports Med August ; 41(8): 1930–1941.

57. NCAA Time to return to sport
Femoral neck, sacrum, pelvis
Nattiv et al. Am J Sports Med August ; 41(8): 1930–1941.

58. Stress Fracture References
Arendt et al. Clin Sports Med (2):
Dobrindt et al. BMC Musculoskeletal Disorders 2012, 13:139
Gaeta M et al. Radiology May; 235(2):553–561.
Nattiv et al. Am J Sports Med August ; 41(8): 1930–1941.
Schneiders AG et al. The Ability of Clinical Tests to Diagnose Stress Fractures: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther 2012;42(9):

59. Medial Tibial Stress Syndrome (MTSS)

60. Diagnosis Yates et al Exclusion criteria (Edwards et al):
distal third
Exclusion criteria (Edwards et al):
Stress Fracture: focal tender, focal pain, abrupt onset
CECS: burning, cramping, pain in compartment with exertion
that will disappear after cessation of exercise

61. Pathophysiology Bone overload theory Myofascial Strain Enthesopathy
DEXA showed decreased bone density at site (Magnusson)
High resolution CT revealed osteopenia (Gaeta)
Myofascial Strain
Enthesopathy
Large variation in attachment of the deep crural fascia, FDL, TP
Periosteal inflammation
Few histological studies have demonstrated any inflammation

62. Risk Factors of MTSS Navicular drop 10mm RR 1.99 Orthotic use RR 2.31
Previous MTSS RR 3.74
Female gender RR 1.71
Higher BMI
Decreased running experience
Pronated foot type NOT associated
Solues tightness NOT associated
Gastrocnemius tightness NOT associated
Newman et al. Journal of Sports Medicine

63. Risk Factors of MTSS
Newman et al. Risk factors associated with MTSS in runners: systemic
review and meta-analysis. Journal of Sports Medicine. November 2013.

64. Prospective study of young female athletes
95 athletes, 20 developed “EMTP”
Decreased hip abductor concentric strength
Verrelst et al. Br J Sports Med 2013.

65. MTSS Treatment in Athletes
Only ONE randomized control study
74 athletes
14 did not complete due to no progress
3 treatment groups:
Graded running program
Graded running program with stretch and strengthening
Graded running program with compression stockings
Mean time to run 18 minutes at intensity was 105 days in all 3 groups
Moen et al.

66. MTSS Treatment No intervention has been proven to be effective
Low energy laser, stretching, strengthening, compression stockings, leg braces, and pulsed electromagnetic fields showed no effect
Iontophoresis, phonophoresis, ice massage, ultrasound, periosteal pecking, and ESWT studies all have methodological bias and can not be recommended
Winters et al. Sports Med 2013.

67. MTSS References
Edwards et al. A practical approach to the differential diagnosis of chronic leg pain in athletes. Am J Sports Med 2005, 33(8);
Gaeta et al. CT and MRI findings in athletes with early tibia l stress injuries. Radiology 2005, 235 (2)
Magnusson et al. Abnormally decreased regional bone density in athletes with medial tibia stress syndrome. Am J Sports Med 2001, 29(6);
Moen et al. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2012, 4:12.
Verrlst R et al. The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study. Br J Sports Med 2013, 00: 1-7.
Winters et al. Treatment of Medial Tibial Stress Syndrome: A systemic review. Sports Medicine December 2013.
Yates et al. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med 2004,32(3);

68. Injury Prevention

69. “The causes of injuries are multifactorial,
you can’t blame one thing”

70. Calcium “There is more to bone health than calcium”
The scientific literature is conflicting regarding calcium supplementation on stress fracture prevention and overall bone mineral density
Calcium supplementation may cause an increase in cardiovascular events

71. Vitamin D Appears more important than calcium
Vitamin D level < 40 mg/mL is associated with stress fracture
Supplementation of up to 4000IU/day appears to be safe
Miller JR et al. The Journal of Foot and Ankle Surgery 55 (2016) 117 – 120.
Inklebarger J et al. J R Amry Med Coprs 104;160:61-63.

72. “Running injuries are
caused by running”

73. Training Error Too much too soon Not enough recovery
Takes less than 2 weeks for a fracture to occur

74. Nutrition
“It’s not about calcium, it’s about food, or rather the lack of” “Edible food like substances” - Michael Pollan

75. Medications
“More children are taking medications than in any other time in the history of mankind”
Bad To The Bone
NSAIDs
SSRIs and Tricyclics increase fracture risk by two-fold
Isotretinoin , Retinoids, and Vitamin A
Progesterone, Progesterone-Estrogen
Proton pump inhibitors
Hidden medications in our food and water (flouride)

76. Sleep
How stress fracture incidence was lowered in the Israeli army: a 25 year struggle
Imposing a sleep regimen of at least 6 hours and reducing cumulative marching lowered the incidence by 62%
(30.8 % to 11.6% annually)
Shoe modifications, orthotics, and Risedronate had no effect
Med Sci Sports Exerc Nov; 40(11 Suppl):S623-9

77. Where do we go from here?
"What we must do is change the physical habits of millions of Americans and that is far more difficult than changing their tastes, their fashions or even their politics." President Kennedy, December 5, 1961

78. Thank you
Marc Silberman, M.D.