Tag: Differential diagnosis

Introduction

Welcome to the second part of the three series of my blog on shin splints. Lest I forget, I wish to thank you for reading my first blog; hopefully, I have been able to respond to your questions. If you have not had the chance to read my first blog, click here. I will suggest that you do that to have a good grasp of the topic. This section will be a continuation of the first part.

There are several medical conditions that mimic shin splints and it is important that they are differentiated from shin splints which include using certain diagnostic tests and procedure.

The content of this present blog will be around differential diagnosis and clinical tests of shin splints. First, I will define differential diagnosis, and then the blog will cover the conditions that have similar clinical features like shin splints, followed by the diagnostic procedure for shin splints before concluding.  You are more than welcome to drop your comments.

Differential diagnosis

Differential diagnosis is the process of comparing of signs and symptoms to identify the underlying problem so that treatment can be planned as specifically as possible (Goodman et al, 2017). This is important for condition that can present with similar clinical features such as chronic lower leg pain (Edwards et al, 2005).

Chronic lower leg pain can result from various conditions, most commonly are shin splints, stress fracture, chronic exertional compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome (Edwards et al, 2005).  Because of the ambiguous nature of the symptoms, it is difficult to differentiate shin splints from the other chronic lower leg pain (Couture and Karlson, 2002). Nevertheless, shin splints is still considered as a distinct clinical entity that is different from other chronic lower limb pain (Edwards et. al, 2005). Table 1 below shows the presenting clinical features of shin splints and other similar conditions.

 

Conditions	Characteristics	Origin
Shin splints	Pain that starts after exercise but gradually improve with rest. Pain can affect both shins. Pain can be felt over a large part of the shin (an area over 5cm across). Occasional swelling.	Bone/periosteum
Stress fracture	Pain with activity and decreases during rest. Occasional swelling around painful area. Slight pain and/or weakness at fracture point “Pinpoint pain” (tenderness at the site of the fracture when it is touched).	Bone/periosteum
chronic exertional compartment syndrome	Lower limb cramping pain with exercise. Swelling/visibly distended muscle. Tingling sensation. Affected area turning pale and cold.	Muscle/tendon
popliteal artery entrapment syndrome	Aching pain, numbness, and tiredness in the calf with exercise. Symptoms disappear shortly after stopping activity/exercise. Occasional leg swelling.	Vascular

Table 1: Conditions presenting with chronic lower limb pain.

Despite the overlapping nature of the symptoms of shin splint with other conditions, there is a consensus within the literature in using a simple logical approach in establishing a definitive diagnosis (Edwards et al, 2005). This approach requires a detailed history taking and physical examination as well as a good knowledge of anatomy and biomechanics (Brewer and Gregory, 2012).  Additionally, interpretation of appropriate diagnostic tools is also essential (Nelson et al, 2015).

Diagnostic Procedure of shin splints

History

Detailed information about the onset and location of the pain is usually the initial line of inquiry. This information includes:

• Any pain induced by activity alongside the medial two-third of the distal border of the leg.
• History of factors that aggravate or relieve the pain. If pain is aggravated with exercise and relieved with rest (see table 1 above) a shin splint should be suspected.
• Additionally, it is also important to eliminate other possible causes of the pain as shown in table 1 above.

Physical examination

Newman et al (2012) reported two categories of clinical test that can be used to establish the diagnosis of shin splint:

• Shin palpation test

This involves the examiner palpating the posteromedial tibial border and asking the patient for the presence of any recognizable pain as shown in figure 1 below.

Figure 1: shin palpation test (Newman et al, 2012).

If there is pain upon palpation and the pain is felt in an area over 5 cm then shin splints should be suspected however, if this is not the case, then other conditions such as stress fracture (if the pain is palpated over an area less than 5 cm) should be suspected and the individual is termed as not having shin splints (Nelson et al, 2015).

If other symptoms not typical of shin splints is present (see table 1 above): other leg injury should be considered.

If recognizable pain is present on palpation over 5 cm or more and no atypical symptoms are present, the diagnosis of shin splints is confirmed.

• Shin oedema test

Here, the examiner is required to apply a sustained (hold for 5 seconds) palpation of the distal two third of medial surface of the tibia. A positive shin splint requires the presence of pitting oedema.

Figure 2: Shin oedema test (Newman et al, 2012)

Imaging:

Most times, imaging is not necessary to confirm the diagnosis of shin splints. However, it is good clinical practice when in doubt, or conservative treatment failed. Imaging is considered to provide more insight.

Magnetic resonance imaging (MRI) can be used to differentiate between a tumor and a shin splints. It is usually used to depict the periosteal reaction and oedema (Nelson et al, 2015). Additionally, bone scan and x-ray can differentiate between stress fracture and shin splints (Brewer and Gregory, 2012).

Outcome measures:

An outcome measure is an instrument that is used to objectively determine whether a condition is getting better following an intervention. To use an outcome measure, a baseline measurement needs to be established then after the intervention, the same outcome measure is used to determine the efficacy of the treatment (Nelson et al, 2015).

The medial tibial stress syndrome score (MTSS) is a patient-oriented outcome measure. Winters and colleagues (2016) show the validity and responsiveness of MTSS to measure the severity of shin splints among different population that are exposed to exercise-induced lower limb pain including athletes, military personnel. This instrument can be used to guide therapy including its effectiveness (I will discuss the treatment of shin splints in more detail in my next blog).

Shin splints is a chronic debilitating lower limb condition that can be difficult to diagnose due to many conditions that can present with similar clinical features. Detailed history taking, and physical examination are generally used to establish its diagnosis.  However, where other conditions such as stress fracture cannot be eliminated from radiographic imaging, MRI are used to differentiate shin splint from other conditions.

 

References

1. Brewer, R.B. and Gregory, A.J., 2012. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health, 4(2), pp.121-127.
2. Couture, C.J. and Karlson, K.A., 2002. Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints’. The Physician and sports medicine, 30(6), pp.29-36.
3. Edwards Jr, P.H, Wright, M.L. and Hartman, J.F., 2005. A practical approach for the differential diagnosis of chronic leg pain in the athlete. The American Journal of Sports Medicine, 33(8), pp.1241-1249.
4. Goodman, C.C, Heick, J. and Lazaro, R.T., 2017. Differential Diagnosis for Physical Therapists-E-Book. Elsevier Health Sciences.
5. Nelson, E.C., Eftimovska, E., Lind, C., Hager, A., Wasson, J.H. and Lindblad, S., 2015. Patient reported outcome measures in practice. Bmj, 350, p. g7818.
6. Newman, P., Adams, R. and Waddington, G., 2012. Two simple clinical tests for predicting onset of medial tibial stress sysndrome: shin palpation test and shin oedema test. Br J Sports Med, 46(12), pp.861-864.
7. Winters, M., Moen, M.H., Zimmermann, W.O., Lindeboom, R., Weir, A., Backx, F.J. and Bakker, E.W., 2016. The medial tibial stress syndrome score: a new patient-reported outcome measure. Br J Sports Med, 50(19), pp.1192-1199