evaluating shin pain - university orthopaedic associates, llc · shin edema test firm finger...
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Evaluating Shin Pain
EricNussbaum,MEd,ATC,LATClinicalInstructor,
DepartmentofOrthopaedicsRutgers,RobertWoodJohnson
MedicalSchool
• Ihavenodisclosures.
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ValidationoftheShinPainScoringSystem
Questions:
• Whatistheoptimalclinicalapproachforevaluatingthelowerlegforsignsofinjury?
• Howsensitiveandspecificarecurrentclinicaltestsforpredictinginjury?
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Traumatic vs Non-TraumaticTraumatic• Singleincident
TypeContusion,Fracture,Traumaticmusculotendinousinjury,TraumaticCompartmentsyndrome
Signs• Ecchymosis• Swelling• Deformity• Increasedtemperature• Increasingnumbness/weakness
Non-Traumatic• NoMOI• Overuse• RepetitivemotionTypeStressFx,Compartmentsyndrome,“itis”,NerveEntrapment
Signs• Pain• Changeingait• Performancedecline• Nightpain• Swelling???
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Non-Traumatic Injury
Intrinsic• BMI• MenstrualHx• LegLength• FamilyHistory• BMD• Hormones
Extrinsic• ChangesinTraining• Equipment• Trainingsurface• Faultymechanics• Sleep/rest• Stress• Diet
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Shin Pain: Differential Diagnosis• V• I• T• A• M• I• N
• C
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Shin Pain: Differential Diagnosis• VASCULAR-- Exertional CompartmentSyndrome,Poplitealarteryentrapmentsyndrome
• INFECTIOUS-- Osteomyelitis• TRAUMA– Contusion,Fracture,Strain
• Medialtibial stresssyndrome• AUTOIMMUNE/ALLERGIC• METABOLIC– STRESSFRACTURE• IDIOPATHIC• NEUROLOGIC-- Radiculopathy• CANCER– Boneyorsofttissuetumor
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Shin Pain = HUGE problem
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Non-Traumatic Shin Pain Evaluation
• Frequencyofshinpaincanbeoverwhelming• Goodpublishedstudiesonclinicaltestsarelimited
• Thoroughevaluationcanbetimeconsuming• Bestimagingcanbecostly
• Netresult– SHINSPLINTS!!!
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What are Shin Splints Anyway?• NoFORMALDiagnosis• Garbagetermforchronicshinpain
– Theoretical“Pullingaway”ofmuscles• PosteriorTib,Soleus,FlexorHallucis Longus,FlexorDigitorum Longus
• Literaturedoesnotsupport“Pullingaway”Theoryorwhichtendoncausesit.
• Can’tidentifyitonMRI• OhnishiJ,SportsOrthop Trauma2015
• Useofthetermis“highlyinappropriate.”• BeckB,SportsMed1998
ShinSplintsPleasedon’tperpetuatetheignorance!!!
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Interesting Finding • 64Subjectsevaluatedw/hx of1wk shinpain.– Xray +BilateralMRI
• 58/64showevidenceofbonystressinjuryonMRI• 45/64(70%)(showbilateralbonystressinjury• 37/45(82%)– >GrII=Significantbonyinjury– (21GrII,9GrIII,7comboII/III)
– ValidationofShinPainScoringSystemInitialfindings.» OngoingStudy
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Early detection is key!• Tibial stressinjuriescanbedisruptivetoregularfitnessroutinesandcanendcareersofcompetitiveathletes.
• Establishdiagnosistoavoidprogressionontotruefx.• Each1unitincreaseinMRIgradeincreasesRTSrecoveryby48days.
Nattiv A,AJSM2013• Significantdifferenceinrecoverybasedondiagnosiswinfirst3weeksofsymptomsvslater
Ohta-Fukushimaetal,
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Take an interest to make an impactStartaDialogue
• MenstrualDysfunction• Eatingdisorders• Absorptionissues
– Crohn’sorCeliacDisease– Lactoseintolerence
• LowBMD– LowVit DorCa+
• Compartmentsyndrome• Tumors• HighStress/Anxietydisorders• Sleepdisorders
• Identifyproblems,educateyourpatients• Eliminaterepeatoffenders• Keeppeopleactive
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History:
• MOI• Howlonghaveyouhadthepain?• Howbadisthepainonascaleof0-10?
- >6consideredsignificant- NationalStressFx Registry
• Numbnessortingling?• Treatment?• Impactperformance?*NSFR
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0
50
100
150
1 2 3 4 5 6 7 8 9 10
Table17:SubjectivePainScore
Observation
• Swelling• Skincolor• Bumps,Bruises• Obviousdeformities• Increasedtemperature• Abnormalrashes
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Clinical Tests• PalpationTest• FulcrumTest• TapTest• ShinEdemaTest• HopTest• WeightBearingLungeTest(WBLT)• TuningFork• TherapeuticUS• StandingHeelRiseTest• ManualRepeatedDF/PFx1min• ManualMuscletesting– Lowerlegandhipmusculature
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Clinical Exam: Palpation• Palpation• FirmSqueeze
– Medialedgeoftibia– Anteriorspine– Fibula– Marker– Compartments
• Lookforfocaltenderness
• Palpationfoundtobesignificantpredictor– -NewmanP,BrJSportsMed
2012;46:861–864
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Fulcrum Test
• Provideperpendicularforcetolowerlegwhilemovingdistallowlegtowardtheforceapplied
• UsefulcrumatDistal1/3,andalsoatmidtibia– Positivetestifpatientexpressespain– Ifpainfulsuspectbonyinjury
• Intertesterreliabilitylow• Sensitivity/Specificitylowtomoderate– Currentresearch
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Tap or Percussion test
• Utilize2-3fingerstofirmlytapupanddowntibia– Hitsuspiciousareas3-4times– Notationofpainispositivetest• Lookforwince,remarkofincreasedpain
– Suspectbonyinjury
• Inter-testerreliabilitylow• SpecificityandSensitivitymoderate– unpublishedresearch
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Shin Edema Test
FirmfingerpressureoversurfaceofMedialTibiafor5-10secondsandlookforpittingedema– PositiveTestleavesindentation
• FoundtobesignificantpredictorforlateronsetofMTSS.- AustralianDefenseForceAcademyStudy– Shinoedema testOR76.195%CI9.6to602.7,Positive– LikelihoodRatio7.26,NegativeLikelihoodRatio0.095
• NewmanP,BrJSportsMed2012;46:861–864
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Tuning Fork - Vibration
• Utilizevibratingtuningfork– OnBone– Overmostpainfulsite– Increasedpainispositive
sign
• Stethoscope– Proximal– Tuningforkdistal
• Changeintone/volume
• Limitedpublishedevidence• 128Hz
– Sensitivity– 75%– Specificity– 67%
• 256Hz– Sensitivity– 92.3%– Specificity– 19%
• Doesnotsupportusingasstandalonediagnostictest
Schneiders AG,JOSPT2012
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Single Leg Hop Test• Instructathletetodo10singleleghopsashighastheycaninrepetitivefashion.– Noteflatfootedhoping– Increasedlanding(increasedkneeflexion)– Decreasedhopheight– Drifting– Increasedpain– Videoforillustration/education– *NonPublishedtestforshinpain,andfindingsnotvalidated
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Weight Bearing Lunge Test (WBLT)• Determinetightness/ROM• Facingwall,extendruler
fromwall,positionfootwithtoefacingforward,bendkneeoverfixedfoottotouchthewall.Movefootbacktillcannolongertouchwallwithoutlettingtheheelcomeupoffthefloor.– Measuredistancefromtoe
towallcm– Comparewithotherside
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Weight Bearing Lunge Test (WBLT)• WBLThasahighcorrelationwiththereferencestandardforassessingdorsiflexionrangeofmotion.– HallEA,JSci MedSport. 2016Nov23.pii:S1440-2440(16)30236-5(Epub aheadofprint)
• TheWBLTresultsweresignificantlycorrelatedwith ankle dorsiflexionin alldirectionsontheYBT-LQ(P<.05).AstrongcorrelationwasfoundbetweentheinclinometermeasurementoftheWBLTand ankle dorsiflexion (r=.74,r2=.55)– KangMH,JSportRehabil. 2015Feb;24(1):62-7
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Therapeutic Ultrasound• TherapeuticUS–
– 1-3cmhead– .5-2.0w/cm2– 30secapplication– 1cm/secapplication
– Findingofincreasedpain/ache
• Goodnumberofstudies• Variablequality,lacks
consistencyofmeasure• 9StudiesinMetaanalysis• PooledSensitivity– 64%• PooledSpecificity– 63%
– 95%CI• Pooled+LR2.09• Pooled- LR.35
– LowtomoderateSchneiders AG,JOSPT2012
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Standing Heel Rise Test• ID:Weakness,Lackofendurance• Standstraight,singlelegheelrisetopoint,onefingerforsupport,metronome30-40,raisewitheachbeat.– Testterminatedifkneeflexed,ht decreasedby½orleaned/pressuredonsupport
– 25SHRconsideredNORMAL– Validated
• Mean27(SD=11.1,Range6-70,)• Upper/lower99%confidenceintervals29.8,25.8• Male/Femaleequal
– LunsfordB,PhysTher 1995;75(8):694-698
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Manual Dorsi/Plantar Flexion Test
• MRE• Sittingontable• RepeatedDF/PFx1minute– Numbness/tinglingintofoot+Test
– PreferredoverrepetitiveheelriseascomponentofDFactivityforAntcompartmentalwork
- NonPublishedstudy,findingsnotvalidated
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Radiographic Work-up
• Plainradiographs– RuleoutFrankFx– Oftennegative
• Initial-only5-25%positive• Lessthan50%everpositiveovertime
– Sometimescanseeperiostealreaction,corticalthickening,“dreadedblackline”
– Oftenusedasbasisofdiagnosis– FalseNegative
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Bone Tumors – they do happen!
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Manual Muscle Testing
• ManualmuscletestingtoR/Omusculotendinousinjury
• Identifymuscularweakness– Gastroc Soleus– Peroneals– Anterior/PosteriorTibialis– FlexorHallucis
– Hip• Hipweaknesscontributingfactortolowerlegpain.
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Summary
• Shinpainiscommon,taketimetoevaluate• Shinpainmaybethetipoftheiceberg• Utilizeclinicalteststoidentifysourceofpain• Clinicaltestsnothighlypublicizedorvalidated• Radiologyisrecommendedinitially,butavoidfalsenegativediagnosis
• Earlierdiagnosisleadstoquickerresolution
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Take home points
• Bonystressinjuryisacommoncauseofshinpain• Initialx-rayimportant• Pain>6consideredsignificant• PositivePalpationandhoptestsignificant• Earlieridentificationleadstobetteroutcomes• Taketimetoevaluateandopenthedialogue
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