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

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

Exercise induced leg pain 1. CECS 34% 2. Tibia Stress Fracture 25% 3. MTSS 13% Clanton T, Solcher B. Chronic leg pain in the athlete. Clin J Sport Med. 1994;13:743-759

Chronic Exertional Compartment Syndrome (CECS)

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

The Compartments

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.

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

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.

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

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.

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.

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.

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.

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.

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.

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;6:312-321. 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;40:1060-1067. 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.

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

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

Helmout et al.

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

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. 2004.

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.

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.

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

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.

CECS References Arendse et al. Reduced eccentric loading of the knee with the Pose running method. MSSE 2004; (36)2 272-277. 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;6:312-321. 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;40:1060-1067. 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 2015 43: 392

Stress Fracture

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

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

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

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

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

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

False

False

True or false Stress fractures are caused by weak bones

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

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):760-771.

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%

X-ray First Visit

X-ray First Visit

X-ray 1 month

X-ray 3 month

X-ray 3 month

MRI “MRI can rule out a stress fracture and MRI can grade a stress fracture” Sensitivity 88%, Specificity 100% Gaeta M et al. Radiology. 2005 May; 235(2):553–561.

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 1997. 16(2): 291-306

Grade 1

Grade 2 Nattiv et al. Am J Sports Med. 2013 August ; 41(8): 1930–1941.

Grade 3 Nattiv et al. Am J Sports Med. 2013 August ; 41(8): 1930–1941.

Grade 4

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

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.

NCAA Time to return to sport Nattiv et al. Am J Sports Med. 2013 August ; 41(8): 1930–1941.

NCAA Time to return to sport Femoral neck, sacrum, pelvis Nattiv et al. Am J Sports Med. 2013 August ; 41(8): 1930–1941.

Stress Fracture References Arendt et al. Clin Sports Med 1997. 16(2): 291-306 Dobrindt et al. BMC Musculoskeletal Disorders 2012, 13:139 Gaeta M et al. Radiology. 2005 May; 235(2):553–561. Nattiv et al. Am J Sports Med. 2013 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):760-771.

Medial Tibial Stress Syndrome (MTSS)

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

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

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. 2013.

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.

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

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.

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.

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);1241-1249. Gaeta et al. CT and MRI findings in athletes with early tibia l stress injuries. Radiology 2005, 235 (2) 553-561. Magnusson et al. Abnormally decreased regional bone density in athletes with medial tibia stress syndrome. Am J Sports Med 2001, 29(6);712-715. 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);772-80.

Injury Prevention

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

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

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.

“Running injuries are caused by running”

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

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

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)

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. 2008 Nov; 40(11 Suppl):S623-9

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

Thank you Marc Silberman, M.D.