WHAT ARE SHIN SPLINTS?
- Medial tibial stress syndrome (MTSS), more commonly known as shin splints, is a common overuse injury of the anterior lower leg, which occurs when the shin bone becomes inflamed resulting in pain.
- Shin splints are typically seen in repetitive, high-impact sports such as running, dancing and basketball, as well as in the military recruit population with an incidence ranging from 4% to 35% [Moen et al, 2009; Reshef & Guelich, 2012].
WHAT CAUSES SHIN SPLINTS?
- Certain factors may increase your risk of developing shin splints, such as flat feet, excessive foot pronation, rigid arches or wearing worn out or unsupportive shoes while being physically active [Moen et al, 2009; Reshef & Guelich, 2012].
- Histological studies have not supported the theory of traction periostitis, instead suggesting that the condition is related to bone overload and microdamage [Moen et al, 2009; Winters et al, 2019]. If left untreated, shin splints may develop into stress fractures of the tibia.
HOW DO YOU KNOW IF YOU HAVE SHIN SPLINTS?
- Symptoms of shin splints include dull or sharp pain along the lower two-thirds of the shin, and pain that worsens during or immediately following physical activity that improves with rest. Pain may be felt along one or both shins.
- Pain along the tibia can also be made worse by pushing or palpating along the bone. MTSS is characterized by diffuse pain along the posteromedial border of the tibia, while tibial stress fractures present with more localized pain and may include edema.
- The progression from MTSS to a stress fracture is supported by the continuum of stress response in bone, and studies suggests that MTSS is an early stage of a stress response that, if left untreated, may progress to a stress fracture [Yagi et al, 2013; Anderson et al, 1997].
HOW ARE SHIN SPLINTS DIAGNOSED?
- Diagnosis is based on detailed history, physical examination, and imaging. While a patient’s history and findings on physical exam often provides adequate information for the clinical diagnosis of shin splints, imaging may be utilized to rule out other similar lower extremity injuries and determine whether a more severe stress injury is present.
HOW DO YOU TREAT SHIN SPLINTS?
Conservative Treatment
- Initial treatment of shin splints consists of rest, ice, NSAIDs, and physical therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief and physical therapy may be utilized to improve strength and flexibility of the surrounding musculature. Orthotics and supportive, appropriate footwear may help address contributing mechanical issues.
Shockwave therapy
- Shockwave therapy may be used as an adjunctive therapy for shin splints. Shockwave therapy initiates the body’s natural healing process by improving circulation and speeding up healing and tissue regeneration with the aim of reduction in pain and increase in function.
- Extracorporeal shockwave therapy (ESWT) has been investigated as a treatment for medial tibial stress syndrome (MTSS) with several studies providing evidence for its efficacy.
- One cohort study by Rompe et al. of 47 subjects with chronic recalcitrant MTSS who received low-energy radial ESWT found that the shockwave group had a significantly higher success rate compared to the control group that consisted of a home training program at 1 month (30% vs. 13%), 4 months (64% vs. 30%), and 15 months (76% vs. 37%) post-treatment. Additionally, 40 out of 47 subjects in the treatment group returned to their preferred sport at their pre-injury level, compared to 22 out of 47 in the control group [Rompe et al, 2010].
- In another study, Moen et al.
conducted a prospective controlled study of 42 athletes with MTSS that compared a gradual running
program alone to the same running program with the addition of 5 focused shockwave treatments over 9 weeks. The shockwave group achieved
full recovery significantly faster than the control group (59.7 ± 25.8
days vs. 91.6 ± 43.0 days, p=0.008). The shockwave group on average recovered over 30 days faster than with a graded return to running program alone, suggesting that shockwave can expedite
recovery [Moen et al, 2012].
- Finally, Newman et al.
performed a randomized double-blind sham-controlled trial with 28
active adults with MTSS. The study found no statistically significant
differences between the standard dose of shockwave and sham groups in terms
of pain, however, the sham
dose may have had a clinical effect suggesting that we need a better understanding of shockwave dosing and further
investigation [Newman et al, 2017].
Surgical Management
- In instances where conservative management is unsuccessful and the injury persists or worsens, surgical management may become necessary. Surgical interventions may include:
- Fasciotomy and Periosteal Stripping: This procedure involves releasing the fascia and stripping the periosteum along the medial tibia. Yates et al. reported that this surgery reduced pain levels in patients with chronic MTSS, with 69% of patients achieving excellent or good results [Yates et al, 2003].
- Partial Fasciectomy: This involves the removal of a portion of the fascia to relieve tension and reduce symptoms. Järvinen et al. showed good to excellent results in 79% of patients with MTSS. [Jarvinen, 1993].
- Curettage: This technique involves scraping the periosteum and cortical bone to stimulate healing. This is a less commonly used technique.
- Endoscopic Surgery: Minimally invasive endoscopic techniques have been explored to reduce recovery time and surgical morbidity. These techniques aim to achieve similar outcomes to open procedures with less tissue disruption.
REFERENCES
- Anderson MW, Ugalde V, Batt M, Gacayan J. Shin splints: MR
appearance in a preliminary study. Radiology. 1997 Jul;204(1):177-80.
- Järvinen M. Lower leg overuse injuries in athletes. Knee Surg Sports Traumatol Arthrosc. 1993;1(2):126-30.
- Moen
MH, Rayer S, Schipper M, Schmikli S, Weir A, Tol JL, Backx FJ.
Shockwave treatment for medial tibial stress syndrome in athletes; a
prospective controlled study. Br J Sports Med. 2012 Mar;46(4):253-7.
- Moen
MH, Tol JL, Weir A, Steunebrink M, De Winter TC. Medial tibial stress
syndrome: a critical review. Sports Med.2009;39(7):523-46.
- Newman
P, Waddington G, Adams R. Shockwave treatment for medial tibial stress
syndrome: A randomized double blind sham-controlled pilot trial. J Sci
Med Sport. 2017 Mar;20(3):220-224.
- Reshef N, Guelich DR. Medial tibial stress syndrome. Clin Sports Med. 2012 Apr;31(2):273-90.
- Rompe
JD, Cacchio A, Furia JP, Maffulli N. Low-Energy Extracorporeal Shock
Wave Therapy as a Treatment for Medial Tibial Stress Syndrome. The
American Journal of Sports Medicine. 2010;38(1):125-132.
- Winters
M, Burr DB, van der Hoeven H, Condon KW, Bellemans J, Moen MH.
Microcrack-associated bone remodeling is rarely observed in biopsies
from athletes with medial tibial stress syndrome. J Bone Miner Metab.
2019 May;37(3):496-502.
- Yagi S, Muneta T, Sekiya I.
Incidence and risk factors for medial tibial stress syndrome and tibial
stress fracture in high school runners. Knee Surg Sports Traumatol
Arthrosc. 2013 Mar;21(3):556-63.
- Yates B, Allen MJ, Barnes
MR. Outcome of surgical treatment of medial tibial stress syndrome. J
Bone Joint Surg Am. 2003 Oct;85(10):1974-80.
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