Tibial Stress Fractures/Shin Splints

Diagnosis/Definition

• Inflammation due to repetitive stress of the broad proximal portion of any of the musculotendinous units originating from the tibia. 
• Symptoms of overuse injury are precipitated by initiation of training, an increase in training intensity or a change in surface or equipment.  The mechanism for overuse injury is overload of forces on the muscle, tendon, or bone, which leads to an inflammatory reaction.

Initial Diagnosis and Management

• History and physical examination.
• Rest of the affected muscle-tendon bone unit.
• Use of crutches, bracing or casts as needed.
• NSAIDs may be beneficial
  • Adults - 200 to 400 milligrams (mg) every four to six hours as needed for up to 2 weeks.  Example: Ibuprofen
  • Take tablet or capsule forms of these medicines with a full glass (8 ounces) of water.
  • Do not lie down for about 15 to 30 minutes after taking the medicine. This helps to prevent irritation that may lead to trouble in swallowing.
  • To lessen stomach upset, these medicines should be taken with food or an antacid.
• Encourage active range of motion.
• Appropriate restrictions of activity.

Ongoing Management and Objectives

• Rest is individualized depending upon severity.
• Immobilization should be utilized if simple weight bearing (walking) is painful.
• Obtain X-rays of both legs if pain occurs with simple weight bearing.
• Obtain bone scan for chronic shin splint pain.
• The duration of rest varies from 1-2 days for mild shin splints to several months for severe stress fractures. 
• Ice for 10 to 15 mins with hourly reapplication.
• Elevate leg frequently with compressive wraps.
• Slow and sustained active stretches when no pain is present.

Indication a profile is needed

• Any limitations that affect strength, range of movement, and efficiency of feet, legs, lower back and pelvic girdle.
• Slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects that may prevent moderate marching, climbing, timed walking, or prolonged effect.
• Defects or impairments that require significant restriction of use.

Specifications for the profile

• Weeks 1-8
  • No running and jumping
  • No rucking
  • Walking to tolerance
  • Swimming recommended
• Weeks 8-12  progress profile to bike/run at own pace and distance.

Patient/Soldier Education or Self care Information

• See attached sheet.
• Demonstrate deficits that exist
  • Describe/show soldier his/her limitations.
• Explain injury and treatment methods.
  • Use diagram attached to describe injury, location and treatment.
• Instruct and demonstrate rehab techniques.
  • Demonstrate rehab exercises as shown in attached guide.
  • Warm up before any sports activity.
  • Participate in a conditioning program to build muscle strength.
  • Do stretching exercises daily.
• Ask the patient to demonstrate newly learned techniques and repeat any other instructions.
• Fine tune patient technique.
• Correct any incorrect ROM/stretching demonstrations or instructions by repeating and demonstrating information or exercise correctly.
• Encourage questions.
  • Ask soldier if he or she has any questions.
• Give supplements such as handouts.
• Schedule follow up visit with primary care.
  • If pain persists or worsens.
  • The pain does not improve as expected.
  • Patient is having difficulty after three days of injury.
  • Increased pain or swelling after the first three days.
  • Patient has any questions regarding care.

Indications for referral to Specialty Care

• To Physical Therapy: Routine referral for rehabilitation.
• In the rare instance when there is a visible fracture line on plain radiographs – orthopedic consultation is appropriate.

Referral criteria for Return to Primary Care

• Completed specialty care.
• For MEB if symptoms persists for > 6 months despite above treatment.
• MEB to be initiated by primary care and referred to Tripler Army Medical Center orthopedics MEB and peblo for completion.