PEDIATRIC ANNALS • Vol. 46, No. 1, 2017 e29

FEATURE ARTICLE

Adolescent Shin PainJeremy Korsh, MD; Douglas Matijakovich, BA; and Charles Gatt, MD

ABSTRACTShin pain is a common complaint in adolescent athletes. The term “shin splints” has his-

torically been applied to these patients. Shin splints, more often than not, refers to a stress

reaction of the tibia from overuse. Overuse injuries occur when repetitive microtrauma to

the bone exceeds the biologic healing potential. Diagnosis is based on typical history and

physical examination findings. Plain radiographs and advanced imaging are rarely neces-

sary but can provide valuable prognostic information. Treatment consists of adequate rest

and exercise modification. Time to return to sport depends on injury location and severity.

Stress fractures have long-term implications on bone health, so modifiable risk factors

should be addressed. It is important for primary care physicians to understand the signifi-

cance of these injuries. [Pediatr Ann. 2017;46(1):e29-e32.]

Shin pain is a common complaint in adolescent athletes. The term “shin splints” has traditionally

been applied to patients complaining of shin pain with activities. However, most patients with shin splints, known clini-cally as tibial stress syndrome, have an underlying stress reaction of the tibia from overuse. This stress reaction may involve bone, periosteum, and tendon. History and physical examination find-ings can differentiate tibial stress re-actions from other causes of leg pain, such as exercise-induced compartment syndrome and popliteal artery entrap-ment syndrome. Depending on its loca-tion and severity, the stress fracture may

require a prolonged period of activity modification or risk progression to com-plete fracture. Most of these injuries occur in youth, but there are long-term implications on bone health.

EPIDEMIOLOGYOveruse injuries are common in

high school athletes.1 Stress fractures represent an overuse injury in which repetitive microtrauma to the bone ex-ceeds the biologic healing potential in a period of time.2 Increasing youth par-ticipation in sports, as well as the trend toward specialization in only one sport, have increased the prevalence of this injury.3 The highest incidence occurs in

the sports of cross country running and gymnastics, with girls having nearly twice the risk as boys.4 Girls with a de-layed age of menarche, family history of osteoporosis, or high-impact activity (eg, running, basketball, cheerleading, and gymnastics) have the highest risk.5

HISTORYPatients typically present with an

insidious onset of leg pain. The pain is exacerbated by weight-bearing activity and alleviated by rest. There is usually no history of trauma.

The evaluation of an adolescent with shin pain includes key screening ques-tions regarding the duration, severity, and progression of symptoms (Table 1). A history of pain for longer than 1 week, any pain causing a limp, or progression of pain severity is suspicious for stress fracture. Changes in training regimen (eg, surface, intensity, type) or increased hours spent per week participating in sports increases risk. It is important to include questions regarding nutrition (ie, daily dairy or calcium and vitamin D in-take), gastrointestinal absorption issues (ie, celiac or Crohn’s disease), and men-strual dysfunction when taking a patient history.

PHYSICAL EXAMINATIONShin pain causes no or minimal

skin changes, no ecchymosis, and no edema. The examiner must palpate the entire length of the tibia and note any areas of bony tenderness. It is impor-tant to palpate both the anterior crest and the posteromedial side of the tibia

Jeremy Korsh, MD, is a Senior Resident, Department of Orthopaedic Surgery, Rutgers-Robert

Wood Johnson Medical School. Douglas Matijakovich, BA, is a fourth-year Medical Student, Rutgers-

Robert Wood Johnson Medical School. Charles Gatt, MD, is the Chairman, Department of Orthopaedic

Surgery, Rutgers-Robert Wood Johnson Medical School. Address correspondence to Jeremy Korsh, MD, Department of Orthopaedic Surgery, Rutgers-Robert

Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB 422, New Brunswick, NJ 08903; email: korshjm@scarletmail.rutgers.edu.

Disclosure: The authors have no relevant financial relationships to disclose.doi: 10.3928/19382359-20161209-01

e30 Copyright © SLACK Incorporated

FEATURE ARTICLE

to distinguish between compression and tension-sided injuries. Complaints of calf tightness or pain are frequently referred pain from the tibia. Location of injury varies based on type of sport and age of the patient. Injuries to the ante-rior, middle third of the tibia are more common in jumping athletes. Most long- distance runners have posteromedial pain. The distal third of the tibia is more frequently injured in sprinters or in those who compete in sports with sprinting activity. The proximal third of the tibia is commonly involved in preadolescent athletes.

Physical examination maneuvers in-clude the fulcrum test, tap test, and sin-gle leg hop test (Table 2).6 Positive find-ings are consistent with stress fracture.

IMAGINGDiagnosis is based on typical history

and physical examination findings. Plain radiographs have limited diagnostic util-ity and should be reserved for refrac-tory or high-risk cases. Only a minority of initial radiographs will have positive findings. Follow-up radiographs have in-creased sensitivity, but one-half of stress fractures will never show abnormal

radiographic findings.7,8 An antero-posterior and lateral view of the tibia should be obtained for suspected ante-rior tibial stress fractures or for those cases having failed at least 3 weeks of conservative treatment. Radiographs should be scrutinized for a periosteal reaction or “dreaded black line” on the anterior tibia cortex, signifying a high-risk tension side injury (Figure 1).9

Advanced imaging is not recom-mended for most patients but can be considered in select cases where di-agnosis confirmation or prognostic information is essential. Magnetic resonance imaging (MRI) has replaced bone scan in the evaluation of stress fractures because it provides more information without the need for ra-diation exposure and the findings are predictive of recovery time.10,11 Stress reactions appear as periosteal edema, bone marrow edema, and subtle frac-ture lines on MRI (Figure 2). The se-verity of these findings strongly corre-lates with recovery time.12

PROGNOSIS Most patients will have symptoms

that persist for longer than 3 weeks, and a significant proportion of patients will have symptoms that persist for longer than 6 months.4,13 The postero-medial tibia or compression side of the bone is the most common site of in-jury and carries a low risk for fracture

progression. However, the anterior or tension side is considered high risk, as stress fractures here may progress to complete fractures. A delay in presen-tation, which is common, may increase the risk for a prolonged recovery.14

Patients with mild-to-moderate symptoms and no significant findings on a radiograph can expect to return to their sport in 1 to 2 months. If there is periosteal reaction on the radiograph or higher-grade MRI findings, recov-ery may take 3 to 5 months. A patient with a high-risk anterior mid-tibial stress fracture should expect a pro-longed period of waiting, upwards of 5 months.12,15,16

TREATMENTUp to 99% of stress fractures are

treated nonoperatively.4 Optimization of vitamin D and calcium intake should be considered in all patients.17 Man-agement of stress fractures is based on risk of fracture progression and sever-ity of injury at presentation (Table 3). Patients with high-risk stress fractures should bear no weight on their injured leg and use crutches. They should also be referred to an orthopedic surgeon. These fractures are notoriously slow to heal, and surgical intervention may be advantageous for the athlete who requires rapid return to their sport.18,19

For all other patients, the treatment consists of adequate rest and exercise

TABLE 1.

Key Screening Questions in the Evaluation of an

Adolescent with Shin Pain• How long have you had shin pain?

• Rate your worst pain during activity

(1-10)

• When do you have shin pain?

• Do you limp at any time?

• Have you had any changes in training

recently?

• How many hours per week do you spend

participating in sports?

• How many servings of dairy do you get

in a day?

• Do you have a prior history of stress

fracture?

TABLE 2.

Physical Examination Maneuvers to Determine Shin PainFulcrum test

Using the palm, apply force perpendicular to leg while grasping ankle and moving opposite

to applied force. Positive test produces pain

Tap test

Using two fingers, percuss the entire length of the tibia. Positive test increases bony pain

Single leg hop test

Patient is asked to hop on one leg 10 times. Note any difficulty completing the task, increased

landing time, or decreased jump height when compared to unaffected side

PEDIATRIC ANNALS • Vol. 46, No. 1, 2017 e31

FEATURE ARTICLE

modification. Patients with mild-to-moderate symptoms may do non- impact aerobic exercise (eg, aqua jog-ging, cycling, rowing). Core strength-ening should be encouraged as well. Patients with mild symptoms may con-tinue to compete as long as their symp-toms do not worsen. If pain is severe, crutches should be provided and the patient should bear no weight on the injured leg. Crutches can be discon-tinued and activity can progress when pain has subsided and the patient can ambulate without an antalgic gait.

Return to sporting activities is a gradual process based on severity of pain. Premature return risks worsening the injury and delays time to recovery.

BONE HEALTHRisk factors associated with stress frac-

tures and preventive measures should be discussed with these patients. Patient edu-cation regarding proper diet, bone mineral density (BMD), and adequate levels of vitamin D should be emphasized.20,21 Ad-ditional evaluation is important in women who are athletes with menstrual irregu-larities and eating disorders due to the in-creased risk of stress fractures.22

Lower BMD delays recovery from these injuries and increases the risk of future osteoporotic fractures.22,23 Dual-energy X-ray absorptiometry (DEXA) scans should be performed on all ado-lescents with a history of more than one stress fracture.

CONCLUSION Recognition of athletes at risk for stress

fracture aids in prompt diagnosis. Early

activity modification is essential to expedite recovery. Patients with high-risk anterior mid-tibial stress fractures need to be provided with crutches and referred to an orthopedic surgeon. Pa-tients with stress fractures should have underlying risk factors addressed. Re-current stress fracture is an indication for a DEXA scan. Prevention pro-grams should focus on proper training regimens and a healthy diet.

Figure 1. Radiograph of a proximal tibia stress fracture. (A) Anteroposterior view and (B) lateral view reveal band of sclerosis and extensive periosteal reaction. Reprinted with permission of SLACK Inc.24

Figure 2. Tibia stress fracture. (A) Coronal view, (B) sagittal view, and (C) axial view. Magnetic resonance imaging reveals significant soft tissue and bone marrow edema surround-ing the stress fracture identified in the axial image (arrow). Reprinted with permission of SLACK Inc.24

A B

A B

C

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FEATURE ARTICLE

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TABLE 3.

Summary of Evaluation and Management of Shin Pain in Adolescents

Injury RiskInitial

Management ImagingFollow-Up

IntervalReturn to

SportIndications for

ReferralAdditional Work-

Up

Posterior

(medial)

Low risk (com-

pression side)

Crutches for

comfort

Nonimpact activity

AP and lateral

radiographs

2 weeks; may

compete as long

as symptoms do

not worsen

If low grade,

1-2 months

If high grade,

3-5 months

Pain with ambu-

lation

Pain lasting >3

months

Serum vitamin D

[25(OH)D]

DEXA scan if his-

tory of >1 stress

fracture

Anterior

(mid-tibial)

High risk (ten-

sion side)

Strict non–weight-

bearing with cast

or fracture boot

and crutches

AP and lateral

radiographs

3 weeks; may

return to activity

gradually when

comfortable

>5 months All

Surgery may

benefit elite

athletes

Serum vitamin D

[25(OH)D]

DEXA scan if his-

tory of >1 stress

fracture Abbreviations: 25(OH)D, 25-hydroxyvitamin D; AP, anteroposterior; DEXA, dual-energy X-ray absorptiometry.