Shin Splints and Bone Injuries Flashcards
What are the most common structure involved in shin splints?
- Tibialis Posterior, medial tibial shaft, and Soleus
- MORE common than anterior type (4-19% in athletes)
What anterior structures are involved in shin splints?
Tibialis Anterior and lateral tibial shaft
What is the MOST densely innervated tissue involved in shin splints?
Periosteum: connective tissue that surrounds bone except on articular surfaces
What is Posterior or Medial Tibial Stress Syndrome (MTSS)?
- Another name for shin splints, involving the tibialis posterior, medial tibial shaft, and soleus.
- MORE common than anterior type (4-19% in athletes)
What are risk factors for Medial Tibial Stress Syndrome (MTSS)?
- Biological female (Dietary/ Hormonal)
- High BMI
- Previous running injury
- Training errors
- Impaired LE control
- Excessive pronation: Increased Navicular drop and Pronation
- Increased PF ROM: unclear contributions; possibly
indicating ankle instability leading to excessive pronation - Greater hip ER ROM: NOT well understood
- NO meaningful association with shoe wear
Pronation is eccentrically controlled PRIMARILY by what muscle?
Tibialis Posterior
What are the pathomechanics of Medial Tibial Stress Syndrome (MTSS)?
- Excessive tibial bending stresses exceed opposing mm. supply
- Increased load on deeper posterior leg mm, particularly Tibialis Posterior and Soleus
- Traction and inflammation of periosteal tissue
What are symptoms of Medial Tibial Stress Syndrome (MTSS)?
- Gradual onset of medial shin P!
- Generally worsened with exercise and NOT ADLs
- NO cramping, burning, or tingling
- 1/3 have co-existing leg injuries
What might you observe with MTSS?
- Overstriding leading to greater heel strike
- Impaired LQ control
- Possible excessive pronation
- Increased pelvic drop… so impaired hip abduction mm.
- Increased LE IR
PF directly oppose what motion?
The bending of your tibia
What might you see with resisted/ MMT with MTSS?
- Weak and possibly P!ful PFs
- Hip weakness and lack of endurance
- Ext/abd
- ERs
- Possibly weak and P!ful IV
What special tests will you have the patient preform for MTSS?
- P! with hop on ball of foot due to plantar flexion of Tib Post
- Possible foot and/or ankle instability
What motions do you want to see when you do heel raises?
Want to see PF and INV (INV at calcaneus)
Where will the patient be tender with MTSS?
TTP over postero-medial tibial border ≥ 5 cm or 2 in. in length
Is POLICED helpful for MTSS?
Yes
What basic patient education should you provide for MTSS?
- Soreness rule
- Load management
- LQ control
What kind of movement pattern training education should you provide your patient?
- NOT changed by strengthening alone
- Reduce LE IR with cues to tighten glutes
- Decrease heel strike with cueing for shorter/faster steps
What kind of shoe wear (general instruction for all runners) should you provide your patient?
- Light, supportive, and cushioned
- Rotate shoes- 39% lower injury risk
- Change running shoes every 250-500 miles
What kind of taping/ orthotics should be done for MTSS?
- Taping to assist Tibialis Posterior
- Foot orthotic
- For excessive pronation use pre-fabricated orthotic
- For heavy heel striker use
- Cushioned inserts
- Gel heel cups
- Air-cast for functional support that allows ankle motion (Unloading bone)
- Walking boot in severe cases
What is manual therapy good for with MTSS?
Any joint dysfunctions like limited DF
What is the MET primary focus for MTSS?
Unloading Tibia and Tibialis Posterior
What else is MET good for with MTSS?
- Improve hip Ext/ER/Abd strength
- Improve PF and IV strength
- Soleus- supports up to 8x BW
- Gastroc/ Soleus- counters distal tibial bending
- Tibialis posterior is primary invertor
- Address spinal stabilization prn
What differential diagnosis do you need to reason through with MTSS?
- Bone stress injuries of Tibia: Stress reaction (periosteal and/or marrow inflammation) or Stress fracture (cortical break)
- Compartment Syndrome
What is the prevalence/ incidence for bone stress injuries?
- Up to ~16% in recreational or competitive athletes
- Biological females 3.5x the risk vs. males
- Most common for runners
What are the characteristics of stress fractures in athletes less than 20 years of age?
- Peak at 16 yrs.
- Basketball MOST common sport
- Tibia MOST common bone
- 70% participated 6-7 days/wk.
What is the most common bone stress injury for runners?
Tibia… progression of MTSS
What is the most common area for a bone stress injuries in the fibula?
Distal region
What is the most common foot injury?
Bone stress injury of the metatarsals
What is the most common metatarsal prone to AVN?
Base of the 5th
What are the 3 zones of injury in the metatarsals?
- Zone 1- 90% of fxs and MOSTLY with sprains
- Zone 2- MOST susceptible to AVN
- Zone 3- typically due to repetitive stress with possible lack of pronation
What are risk factors for bone stress injuries?
- High forces worse than more frequent
- Repetitive jumping/landing
- Impaired LQ control
- Longer stride length leads to greater heel strike
- LE weaknesses
- Poor load management
- Diet and hormonal dysfunction
What is the pathogenesis of bone stress injuries?
- Increasing load and frequency without recovery
- Osteoclastic activity exceeding osteoblastic activity
What are symptoms of a bone stress injury?
Generally worsening P! with ADLs AND exercise, and
may become constant
What are signs of bone stress injuries?
- Typical fx findings
- Bone P! also reproduced with hop test on heel within 10 reps for Tibial stress fx
What might you see on a radiograph (x-ray) with a bone stress fracture?
- fx may NOT appear for 2-6 weeks
- Unlikely that anything will show up to tell this individual not to participate in their activity … if they continue they will most likely get worst, call doctor… worried about bone!
What might you see on a MRI with a bone stress fracture?
Gold standard for earlier detection bc of periosteal and bone marrow changes;
NOT reflective of healing
Why do diet and hormonal limitations need to be addressed with bone stress injuries?
- Due to possible
decreased bone mass density (BMD): meeting energy expenditure, Vit. D, Calcium, regular menstrual cycles (estrogen helps absorb calcium) - Well managed sleep, stress, and BMI
- Medications i.e., antacids prevent gut absorption of Calcium
Adolescent bone does NOT =
Adult bone
BMD decreases just before growth spurts and then takes up to _____ to increase afterwards
4 yrs.
What is the average growth spurt timing for a biological female and male?
- Biological females- 11.9 yrs.
- Biological males- 13.6 yrs.
What is the average age of menarche?
12 years
Why does it make sense that these adolescence are getting stress fractures?
- There is a period of skeletal weakness around growth spurts
- They are also are dealing with hormonal and skeletal changes in addition to increasing physical activity
What kind of PT Rx can you do with someone with a bone stress injury?
- Graded unloading to ambulate without pain
- Gradual and progressive return to activity while addressing risk factors and etiologies
- If it hasn’t been 2 weeks begin treating with caution, if it has been 2 weeks send for x-ray
What is the prognosis for tibial stress fractures?
- BMD lowest at 3 mths. post fx in both injured > uninjured leg
- BMD returned to baseline between 3 and 6 mths.
- Reinjury to either LE more likely prior to 3 mths. !!!
- All were at baseline BMD by 6 mths
- BMD @ 12 mths. surpassed baseline
What is the etiology of compartment syndrome?
- Blunt Trauma (ex: kicked in the shin)
- Overuse
What is the pathogenesis of compartment syndrome?
Increased swelling with limited fascial extensibility,
particularly compressing neurovascular structures in the anterior leg compartment
What are signs and symptoms of compartment syndrome?
- Recent blunt trauma or overuse to anterior compartment
- Primarily cramping, burning, tingling
- Any lengthening or use of DFs adds to compression and P!
- Possible DF weakness
What are the 6 Ps in compartment syndrome?
- Pain- severe and persistent
- Palpable tenderness
- Pulselessness
- Pallor- blanching
- Paresthesias
- Paralysis
If a patient is experiencing “unrelenting 6 Ps” what does this mean?
Medical emergency due to neurovascular
compromise and need for surgical fasciotomy to prevent tissue death
If you can modify the 6 Ps what does this mean in regards to PT?
- PT should be directed at the source of inflammation and fascial extensibility
- Surgery may be necessary
What is a bi-malleolar ankle (aka Pott’s) fracture?
Distal tibia and distal fibula
What is a tri-malleolar ankle (aka Pott’s) fracture?
Tibia, fibula, and posterior tibial rim
What is the most common rearfoot tarsal fracture?
Calcaneus MOST common tarsal fx
Are fractures in the midfoot common?
Rare except the navicular
What is the most common foot region of fractures?
Forefoot
What is the PT Rx for fractures?
Primarily treating consequences of
immobilization of other tissues
