Shin Splints

In an effort to remain active and continue to support social distancing initiatives, many of us have stopped going to the gym and started going for jogs in our communities. As I was partaking in such activity, a young, adolescent reminded me of how great it is to be youthful. As she sprinted past me, only glancing briefly over her shoulder to ensure herself that she didn’t need to contact 911 for the old man who was breathing awkwardly and horrifically diaphoretic, I recalled the days when I was once so energetic and nimble. I also recalled the days of having terrible shin pain often after training. What was that about? Let’s take a minute to review what was causing my terrible leg pain (and potentially the reason I run so slowly now … ok… maybe not) – Shin Splints:

Pediatric Shin Splints: Basics

  • “Shin splints” is not a specific term … but more often used to describe an overuse injury of the tibia. [Korsh, 2017]
    • More accurately called “Tibial Stress Syndrome.”
    • Stress reaction may involve:
      • Periosteum
      • Bone
      • Tendon
    • Most will have symptoms for > 3 weeks (even as long as 6 months).
  • Overuse Injuries are common in adolescents (particularly athletes). [Korsh, 2017, Wu, 2016]
    • More prevalent in children who “specialize” in only one sport.
    • Highest incidence in gymnastics and cross country running.
    • High-impact activities also place children at greater risk:
      • Running
      • Basketball
      • Cheerleading
      • Gymnastics
  • Shin Splints / Tibial Stress Syndrome Presentations: [Korsh, 2017]
    • Onset of pain is usually insidious.
    • Pain is exacerbated by weight-bearing activities.
    • Pain is improved with rest.
    • No overt traumatic injuries.
    • May describe calf “tightness” or pain as well.
    • No significant skin changes.
    • May have had recent change in training routine.
  • Location of pain may vary with activity: [Korsh, 2017]
    • Distal third – activities that involve sprinting
    • Middle third – activities that involve jumping
    • Posteromedial – activities that involve long distant running
    • Proximal – more often seen with pre-adolescents (but not Osgood-Schlatter’s)

Pediatric Shin Splints: Evaluation

  • Shin pain may be due to other conditions so keep Ddx open: [Korsh, 2017; Wu, 2016]
    • Exercise-induced compartment syndrome
    • Osteosarcoma and Masses
    • Tibial stress fractures
      • Uncommon
      • Considered High-risk stress fractures
      • Have relatively high rate of nonunion.
      • May require surgery.
      • X-rays may show thickened anterior cortex with a lucent fracture line (“Dreaded Black Line“).
  • Physical exam will often be normal for Shin Splints. [Korsh, 2017]
    • Focus on not “ruling in” shin splints, but trying to exclude other conditions.
    • Some maneuvers can help raise concern for stress fractures: [Korsh, 2017]
      • Tap Test – Percuss length of tibia with 2 fingers. If bone pain increases, then test is positive and concerning for stress fracture.
      • Single Leg Hop Test – Patient hops on 1 leg 10 times. If completing this is difficult or there is increased landing time or decreased height (compared to unaffected side), then this is abnormal.
      • Fulcrum Test – While holding the ankle, apply perpendicular force with your other palm to the leg. If this is painful, it is concerning for stress fracture.
  • Imaging: [Korsh, 2017]
    • Plain radiographs have limited utility in making the diagnosis of Tibial Stress Syndrome.
    • Should be reserved to evaluate concern for other entities (ex, occult mass?) or for refractory cases.
    • MRI can show stress reaction (periosteal edema, bone marrow edema, subtle fracture lines), but should not be done routinely to make the diagnosis.
  • Bone Health is important! [Korsh, 2017]
    • Ensure the patient is consuming enough calcium and vitamin D for bone health!
    • Screening for eating disorders also reasonable.
  • Management: [Korsh, 2017]
    • The mainstay is activity modification (which can be challenging).
    • Crutches:
      • Posterior pain – lower risk to develop stress fractures – use crutches for comfort
      • Anterior (mid-tibial) – higher risk for development of stress fractures – non-weight bearing, crutches, consider fracture boot.
    • Reinforce and educate about healthy diets!

Moral of the Morsel

  • FOMO – Rest is important… but… The anterior shin pain may be, in fact, less painful than the thought of missing out on the athletic season … and this may cause persistent issues.
  • Make some maneuvers! Look for signs of other problems!
  • Image gently… and with reason. Do not get an X-ray for shin splints… but if you are worried for an occult mass, that is a reasonable reason to image (gently).

References

Korsh J, Matijakovich D, Gatt C. Adolescent Shin Pain. Pediatr Ann. 2017 Jan 1;46(1):e29-e32. PMID: 28079916. [PubMed] [Read by QxMD]
Wu M1, Fallon R, Heyworth BE. Overuse Injuries in the Pediatric Population. Sports Med Arthrosc Rev. 2016 Dec;24(4):150-158. PMID: 27811514. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. donorcure says:

    The pain of shin splints is also more generalized than that of a stress fracture. Press your fingertips along your shin, and if you can find a definite spot of sharp pain, it’s a sign of a stress fracture.

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