Exercise induced lower limb pain
Shin Splints…………………this is an outdated term and generally needs to be avoided as it merely describes shin pain with exercise and is not a diagnostic term. Sometimes referred pain eg from the back, may cause lower limb pain and often needs to be excluded as a cause in the clinical assessment. Rare vascular causes may also need to be excluded.
The three types of exercise induced lower limb that I see most commonly are Medial Tibial Periostitis, Chronic Exertional Compartment Syndrome and Tibial Stress fractures.
Medial tibial periostitis
This common condition usually presents with exercise induced bilateral shin pain, often exacerbated by hard surfaces or overload. Pain may occur during activity and often persists for many hours following cessation of the activity. The pain is usually located on the inside of the middle / distal shins in a linear distribution. Usually this area is tender to touch. A full lower limb examination needs to be conducted to look for contributory biomechanical factors. Sometimes a podiatrist may be needed to prescribe insoles. Investigations are not usually required. Surgery is rarely required. With appropriate diagnosis and rehabilitation the majority of these problems will settle uneventfully.
Chronic Exertional Compartment syndrome (CECS)
Whilst this is an uncommon condition, I do see cases on a regular basis at the military rehabilitation unit that I work in. Soldiers present with worsening shin or calf pain (depending upon the compartment affected eg anterior, lateral, posterior) with exercise, often carrying significant amounts of weight. The pain is describes as a build-up of pressure within the leg. When the activity is stopped the pain usually subsides within a few minutes. Clinical assessment is often normal. It is important to examine the circulation to the legs both at rest and after exercise to exclude a rare vascular cause. These cases do not generally respond well to rehabilitation programmes. Usually, intra-compartment pressure testing is performed prior to a possible surgical fasciotomy release procedure, followed by careful, early post-operative rehabilitation.
Tibial stress fracture
Again these cases are more common in the military setting due to the large amount of impact activities performed often carrying significant amounts of weight. Diagnosis of such fractures is important as undiagnosed they can lead to complete fractures of the tibia and associated complications.
Stress fractures occur because the bone turnover is unable to keep pace with the impact it is being exposed to. Dietary issues, osteoporosis, menstrual problems in females and family history are important factors to discuss as certain groups are more at risk of developing stress fractures than others. Usually, tibial stress fractures present with gradual onset local tibial pain, worse with impact activities and relieved by rest. Usually there is a history of increasing the speed or distance too quickly preventing the body from adapting to the increased loads. It can occur on one side or both. Whilst there may be some contributing biomechanical issues eg foot mechanics which may need to be addressed, an early diagnosis needs to be made. Clinical examination usually reveals a local area of bony tenderness in the mid shaft of the tibia. Plain x-rays may show the stress fracture but are often normal, particularly in the early stages. MRI scans may be required. Once the diagnosis is made Dr Davies will guide you through a safe, structured rehabilitation programme to enable you to return to your normal activities.