PT Tip of the Month

Tibial Stress Injuries

Tibial stress injuries can have a wide variety of causes. The two most common causes are shin splints and tibial stress fractures. Shin splints, (aka, tibial fasciitis, medial tibial stress syndrome) is a commonly used term to refer to pain along or just behind the tibia bone of the lower leg. It is a condition that occurs during physical activity such as running, basketball, soccer, tennis, or dancing. The most common complication of shin splints is a tibial stress fracture. The tibia is the most common bone in which stress fractures occur, accounting for between 35% and 56% of all stress fracture injuries. Tibial stress fractures typically occur over the medial tibial border, with rare occurrences in the anterior tibia. Tibial stress fractures occur when an increase in load first causes a stress reaction to occur (as in running). With continued load, the stress reaction turns into a stress fracture. A bone scan is a useful diagnostic tool to assess the presence of a stress fracture. Both shin splints and tibial stress fractures occur when the body is unable to heal properly as a result of repetitive muscle contractions and tibial strain, such as what is required in running and other sports. There are multiple contributing factors to shin splints and tibial stress fractures, including but not limited to: inappropriate training, poor technique, inappropriate footwear, and low bone mineral density.

Intro/Anatomy

There are a number of hypotheses regarding the pathophysiology of tibial stress injuries, including: tendinopathy, periostitis (inflammation of the outer covering of the bone), periosteal remodeling, and stress reaction of the tibia. Muscular dysfunctions of the tibialis posterior, tibialis anterior, and soleus muscles have also been investigated as causes of tibial stress injuries. Whatever the cause, the result is altered tibial loading with abnormal strain and bending of the tibia.

Risk Factors

Recent changes in training regimens (frequency, duration, intensity) and new footwear are often the most common factors involved in tibial stress injuries. Individuals with previous lower extremity injuries and those who run more than 20 miles/week are more susceptible to these types of injury. Research also indicates that females are 1.5 to 3.5 times more at risk for a stress fracture. Females often have a higher incidence of diminished bone mineral density and osteoporosis, placing them at increased risk to develop these injuries. Biomechanical abnormalities at the knee, hip, or foot as well as abnormal motions anywhere in the lower extremity are often associated with tibial stress injuries. Overpronation is one of these biomechanical abnormalities. This is when the foot rolls too far medially as one walks or runs. Tightness and/or weakness in the triceps surae muscle group may also contribute to altered biomechanics and increased strain on the tibia. Weakness in thigh, hip, and abdominal musculature can likewise affect proper mechanics. Type of running surface has also been suggested to contribute to tibial stress injury. Lastly, abnormal running kinematics, particularly at the hip and at the foot, have also been linked to tibial stress fractures, especially in female runners.

Symptoms

Patients often describe pain from tibial stress reactions and fractures during the heel strike portion of running, when running downhill, and when running on hard surfaces. In the early stages, pain is generally worse at the beginning of exercise, which gradually subsides during activity and with cessation of exercise. As the injury progresses, pain may become more constant, and physical activity may be stopped due to the severity of pain. Pain may also be present at rest. Upon examination, localized pain over the medial tibial border is experienced with hopping or jumping activities. Tenderness to palpation may also be experienced over the tibialis posterior or soleus muscles.

Treatment

Although shin splints are often not serious, it can be quite disabling and painful and may progress to a more serious condition, such as a tibial stress fracture, if not treated properly. Your physical therapist is highly trained to identify the contributing factors related to your shin pain and formulate an appropriate treatment plan to restore you to your prior level of activity. During the acute and subacute phases, rest and modalities may be suggested to decrease the inflammation. As your symptoms subside, various stretching, ROM, proprioceptive, and strengthening exercises may be implemented into your plan of care, with a gradual return to exercise. Manual therapy may also be utilized by your physical therapist if appropriate. If you are experiencing shin pain either as a result of shin splints or a tibial stress fracture and would like to be scheduled for a physical therapy evaluation, please contact 617-232-PAIN (7246) for our Brookline office and 617-325-PAIN (7246) for our West Roxbury office.

References

  1. Galbraith RM and Lavallee ME. Medial tibial stress syndrome: conservative treatment options. Curr Reve Musculoskelet Med. 2009;2:127-133.

  2. Hubbard TJ, Carpenter EM, and Cordova ML. Contributing factors to medial tibial stress syndrome: a prospective investigation. Med Sci Sports Exerc. 2009;41:490-496.

  3. Pohl MB, Mullineaux DR, Milner CE, Hamill J, and Davis IS. Biomechanical predictors of retrospective tibial stress fractures in runners. J Biomech. 2008;41:1160-1165.

  4. Thacker SB, Gilchrist J, Stroup DF, and Kimsey CD. The prevention of shin splints in sports: a systematic review of  literature. Med Sci Sports Exerc. 2002;34:32-40.

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