1. Dr. Vernon Morkel 1996482590 MEDIAL TIBIAL STRESS SYNDROME “SHIN SPLINTS”

2. Introduction  History Clinical Evaluation Special Investigations Three stage assessment Problem list formulation Plan and Progression Discussion TABLE OF CONTENTS

3.  26 y.o. male, rugby player – backline  Plays rugby for fun, not very fit  Bank clerk  Smoker & social drinker  No chronic medical conditions INTRODUCTION

4.  Came of rugby field during pre-season practice  Intense pain – over both lower legs  Started gradually during running exercise  Has to stop running for relieve  Flared up with increased exercise intensity  Previous h/o ‘shin-splints’ HISTORY

5.  Tenderness over post.med. borders – both tibias  Middle 3 rd of tibias – most tenderness  Pain – passive ankle dorsiflexion  Pain – plantar flexion against resistance  Pain – ‘toe raises’  Pain – 4-5 single leg hops  Hyperpronation – both feet CLINICAL EVALUATION

6.  None indicated  None done SPECIAL INVESTIGATIONS

7. 1.Clinical  Medial Tibial Stress Syndrome (Shin Splints)  Brought on – intense & repetitive running exercises 2. Personal  Concerned – he frequently has to stop running or exercise – severe leg pain THREE STAGE SUMMARY

8. 3. Social  Afraid – miss out on team selection  Friends – ‘sissy’, for quitting exercise THREE STAGE SUMMARY

9. 1.Active  Painful lower legs – Medial Tibial Stress Syndrome (Shin Splints) 2. Passive  Preventing him from completing training sessions & matches  General fitness deteriated PROBLEM LIST FORMULATION

10.  Iced lower legs – initially  Analgesia  Recommended – 10 days rest from running  Refer – innersoles to improve hyperpronation  Physiotherapy Still in rest period & awaiting innersoles PLAN AND PROGRESSION

11. Definition Medial Tibial Stress Syndrome (MTSS) is defined as pain along the posteromedial border of the tibia that occurs during exercise, excluding pain from ischaemic origin or signs of stress fracture (Newman and Adams 2012). DISCUSSION

12.  MTSS – one of the most common causes of exercise-related leg pain  Running & walking activities – most frequently  16.8% long distance runners  35% - military academies USA  Females twice the risk then men  Middle third mostly, then lower third of tibia DISCUSSION

13. Unclear (many theories)  Periostitis (inflammation of the periosteum)  Tearing of the muscle bone interface Soleus m, tibialis post & flex digi longus – culprits  Stress reaction of the bone (tibia) PATHOPHYSIOLOGY OF MTSS

14. History Patients often c/o pain  Posteromedial border of tibia  Distal 2/3 of tibia  During running activities Increase in running intensity Change of running surface CLINICAL PICTURE

15.  Tenderness over 4 – 6 cm area  Post.med border, middle & distal thirds of tibia Provocative tests for MTSS pain with:  Passive ankle dorsiflexion  Resisted plantar flexion  Toe raises  4 – 5 single leg hops CLINICAL EXAMINATION

16.  abrupt increase in training activities  inadequate shoes  hard or inclined running surfaces  previous MTSS  female gender  increased BMI RISK FACTORS FOR MTSS

17.  increased foot pronation  increased varus tendency of the forefoot and/or hind foot  hip internal or external rotation  increased muscular strength of plantar flexors RISK FACTORS FOR MTSS (2)

18.  Stress fractures of the tibia – caused by repetitive loading with resulting microfracture  Chronic exertional Compartment syndrome – is a condition of increased pressure in the fascial compartments of the leg DIFFERENTIAL DIAGNOSIS

19.  Peripheral Nerve entrapment – most often caused by trauma, the common peroneal, superficial peroneal and saphenous nerves are most commonly at risk for entrapment  Popliteal artery entrapment syndrome – is an uncommon overuse injury, frequently caused by compression of the popliteal artery by surrounding musculotendinous structures as it exits the popliteal fossa (Brewer and Gregory 2012 ) DIFFERENTIAL DIAGNOSIS (2)

20.  X-rays – rarely positive early on. X-rays performed 2 to 3 weeks after onset of pain may reveal periosteal reaction or a radiolucent line (stress fracture)  Radio isotopic bone scan – can confirm the presence of MTSS or a stress fracture  MRI scan – is the investigation of choice for lower leg pain  MRI arteriograph – can confirm popliteal artery syndrome SPECIAL INVESTIGATIONS

21.  Rest for 7 to 10 days from painful activities  Icing  Analgesia for pain relieve  Stretching of calf musculature  Strengthening of calf musculature  Activity modification  Orthotics or inner soles to correct foot hyperpronation TREATMENT OPTIONS

22.  Extracorporeal Shock Wave Therapy (ESWT) – is a new treatment modality for MTSS. Rompe et al (2010) used low-energy ESWT to treat MTSS. After 15 months 76% of the treatment group were able to return to their sport symptom free, compared to only 37% of the control group. This study showed that low-energy ESWT is safe and effective to treat MTSS TREATMENT MODALITIES (2)

23.  Bisphosphonates (currently used for treatment of osteoporosis) – Moen at el (2011) administered bisphosphonates to two athletes diagnosed with chronic MTSS. Both athletes returned to their sport in a much shorter time. These case reports raise the possibility that bisphosphonates could decrease the time to return to sport in MTSS patients.  Surgery – only for very severe cases of shin splints that do not respond to conservative treatment. However the effectiveness of surgery remains unclear. TREATMENT MODALITIES (3)

24.  Shock-absorbent insoles  Pronation control insoles (specifically controlling navicular drop)  Graduated running programs  Correcting training errors: – like an abrupt increase in training activity -Changing to a harder training surface PREVENTION MEASURES

25. Abruptly increasing training activities, changing running surfaces and inadequate shoes – ‘shin splints’, correcting these factors and rest are important to manage the condition. LEARNING EXPERIENCE

26. 1.Brewer, RB., et al, 2012. Chronic lower leg pain in athletes: A guide for the differential diagnosis, evaluation and treatment. Sports Health, 4(2), 121-127 2.Brukner & Khan, 2012. Clinical Sports Medicine, 4th ed, NSW, Australia, McGraw- Hill 3.Craig, DI., 2008. Medial Tibial Stress Syndrome: Evidence-Based Prevention. Journal of Athletic Training, 43(3), 316-318 4.Loudon, JK., 2010. Use of foot Orthoses and Calf Stretching for individuals with Medial Tibial Stress Syndrome. Foot & Ankle Specialist, 3(1), 15-20 5.Moen, MH., 2011. The treatment of medial tibial stress syndrome with bisphosphonates. Sport & Geneeskunde, 1, 22-25 6.Newman, P., 2012. Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test. British Journal of Sports Medicine, 1-5 7.Rompe, JD., et al, 2010. Low-Energy Extracorporeal Shock Wave Therapy as a treatment for Medial Tibial Stress Syndrome. The American Journal of Sports Medicine, 38(1), 125-132 8.Yates, B., 2004. The Incidence and Risk Factors in the development of Medial Tibial Stress Syndrome among Naval Recruits. The American Journal of Sports Medicine, 32(3), 772-780 REFERENCES

27. Dr. VERNON MORKEL vmorkel@iway.na THANK YOU