Bone Scan Noting Tibial Injury

Leg Pain in a Runner: Tibial Stress Fracture (Part 2)

Recently a long distance runner presented with leg pain of 4-5 months. The pain came on suddenly during a long training run. The patient attempted to run through the pain, because it was not too bad, for 2 months. Then, common sense dictated stopping running for the last 2 months. The pain is not only not better (can I throw a few more nots around) but now hurts walking around which it never did before. He tried changing shoes and icing occasionally. These measures did not help. 

In a runner with leg pain developed with long distance training, the diagnosis is a stress fracture until proven otherwise. The following 3 X-rays just taken show a healing tibial stress fracture with marked amount of new bone formation. Try to look along the normal border of the bone. As the normal border gets obscure, this is the new bone forming. Unlike this X-ray, you normally do not see a fracture line with a stress fracture only the subtle new bone formation. 

On this oblique view, one can really see the fracture line. Fractures look bad for a long time for 2 reasons. The fracture line looks worse then it really is since there is more water content near the fracture itself in the bone. More water makes the fracture look worse. Fractures heal inside out, so total healing may have occurred internally, but the X-ray still shows signs of the fracture still present.

Due to the compression forces and the muscle contractions of the leg muscles, most running stress fractures on the tibia occur on the back surface of the bone. This makes it hard to locate and hard to see any swelling.

Leg Pain in a Runner: Tibial Stress Fracture

Over the next week, I am going to talk a lot about stress fractures. This is a common one in the lower inside of the shin (tibia) seen in a runner increasing his mileage. 

This AP Tib/Fib Xray documented the new bone formation seen next to the marker in a long distance runner. This bone reaction is called periosteal reaction and signifies that the bone is trying to heal. The new bone formation should be the thickest nearest to the fracture.

Shin Splints: They Could Be Stress Fractures

     This time of the year (September and October) is made for Shin Splints. Cross Country season is starting and all high school and some college coaches are drowning in Shin Pain. Most of the time the athlete's pain is related to the bone and muscles not being used to the activity and overuse occurs. A shin splint technically is when the muscle pulls so hard on the bone that the lining of the bone (called the periostium) is pulled away from the bone causing bleeding between the bone and bone covering. This normally is improved with time, icing, some stretching, and activity modifications.

      However, when the bone is weaker (poor base of running, low Vit D or Calcium, low estrogen, abnormal bone structure) than the muscle, the bone may actually be the weakest link in the chain and break. This break in the bone normally remains a stress hairline fracture not detectable by normal xrays. Only in rare cases does the bone break all the way through into a complete fracture. The complete fractures are easy to diagnosis, due to the intense pain. A hairline stress fracture, also called a fatigue fracture of the bone, can at times be run on for weeks and even months. Top athletes, with apparently high pain thresholds, have presented to our office with 3 to 5 stress fractures and still running with so-called "shin splint pain".

     So, when shin splints are not improving with the simple measures of relative rest, ice, shin sleeves, cross training, shoe changes, etc, I advocate the use of a bone scan. It is positive within several days of a stress fracture, and is less expensive than an MRI. In our hospital, for the same price you get both legs for comparison, where MRIs are now being charged for only one side at a time and small areas at a time. 

    Christina, a freshman X-Country runner in high school presented with significant pain right greater than the left tibias. Definitely she could not run through this pain. Bone Scans below documented a stress fracture only on the left side. The right tibia had generalized increase uptake of the dye which we call pre-tibial stress fracture or tibial stress reaction. Stress reaction can hurt just as much as a stress fracture, although heal quicker.

On this front view of the tibias, see the intense dye uptake in the middle of the left tibia. Since Christina is fourteen, she is still growing so her growth plates near the knees and ankles are still very active.

Here is a side view of both tibias with the left again showing the spot where the tibia broke.

     This is also a good example of why MRIs probably would have mislead us in Christina's case. Christina had more pain on her right side. Due to the expense of MRIs, and the fact that each side has a separate cost, I probably would have only done the right side. I would not have found the fracture, and probably allowed her to run sooner. We never will know. So consider getting a limited bone scan instead of an MRI when shin splints are not improving. Thank you Christina for being a good model, but sorry your shins hurt.

Calf Cramps: Common Causes and Diagnosis Not To Miss

     Calf cramps are a very common problem seen in my practice. I have experienced severe nocturnal cramps after too much basketball, or too many miles, as have many of my patients. I eat a daily banana with my morning coffee as a preventative measure. I need to drink more as the articles below discuss since dehydration is a big factor. I am always slightly dehydrated and have a mental block about drinking more (one of my many mental blocks). I have always found good stretching right after your workout of any muscle that cramps, and then one more time before bed, can greatly diminish or eliminate these cramps. If you have disc disease in your low back, the associated nerve root can cause severe leg cramps (after you lie down) in the muscle groups involved. Finding the right position of your spine in bed, and sometimes getting a new bed or mattress, can be important. So, dehydration, low potassium or sodium, low carbohydrates, tight muscles, strenuous exercise with a buildup of lactic acid or other waste products, low back irritation, and poor circulation are truly the main causes of cramps, mild to severe. Before I present my story about Doug, please glance through these links below so you can see what is out there for the consumer and why I want to tell (and slightly brag) Doug's story.
http://www.sportsinjuryclinic.net/cybertherapist/back/backlowerleg/calfcramp.htm

http://www.dummies.com/how-to/content/nocturnal-leg-cramps-nighttime-calf-muscle-pain.html

http://www.associatedcontent.com/article/218563/calf_cramps_causes_and_solutions.html

http://www.associatedcontent.com/article/218563/calf_cramps_causes_and_solutions.html

http://www.associatedcontent.com/article/218563/calf_cramps_causes_and_solutions.html

http://www.crampshelp.com/nighttime.html

     Doug presented to my office for a 2 week followup appointment after fracturing his right 5th metatarsal and being placed in a removable cast. This is a routine procedure. After about 10 days in the cast, he no longer had any foot pain in the fracture area, but began to get calf cramping on the side of the fracture. The calf cramping steadily got worse over the 3 days before his normal followup visit. The night before his visit he could not sleep because of the pain caused by the cramping. Removing the cast did not help his symptoms, and stretching the muscles did not help. It is easily explained by some dehydration, some electrolyte imbalance (have another banana), some tightness developing in the cast in an already tight calf, and some restriction of the circulation from the velcro straps holding the cast on his leg. These are all common causes by themselves of cramping, and they are exaggerated when several co-exist together. I also thought Doug may have tweaked his low back with the cast, even though he had an Even-Up, which could have been a 5th factor. It could have been easy to have dismissed it, simply giving the typical advice of stretching, drinking, massage, but something was different that is hard to put into words.There is definitely a sixth sense that plays out here (and I believe in guardian angles also). Doug knew his body, and something was not making sense. Red Flags went up. Doug was concerned. I listened. We decided to rule out the one in ten thousand chance he had a blood clot in his leg. This is never mentioned in the articles above, because it is rare. He had none of the predisposing factors for blood clots, except the slight foot fracture.

http://www.stoptheclot.org/learn_more/blood_clot_symptoms__dvt.html

Doug went that day to get an ultrasound to rule out a one in ten thousand chance that he had a blood clot, AKA Deep Vein Thrombosis. He called me 8 and 1/2 hours later, first availbability of getting that test, that the test was positive and he was on his way to the ER to be started on blood thinners. What a day!! Boy, did I feel good after that call that we had not missed it. But, Doug and his family probably felt better, much, much better, especially when you read the stats.

To all the articles on leg cramps, I say add an asterick for this possibility (call it Doug's Law). To Doug, I am glad you listened to your body, and I am glad this blog/this story can hopefully help someone else. Golden Rule of Foot: Increasing Leg Cramps over several days should be worked up for DVT.

Shin Splints Part II: An Anatomy Lesson

As I discussed in Part I of Shin Splints, the pain is from below the knee to above the ankle. It is a large area with many possible structures involved. In most cases the pain is self-limiting, but with some use of the 10 basic treatments (see Part I)  you are guaranteed that the rehab will be quicker than with just REST.



Let us review the anatomy of Shin Splints. The 4 basic types of shin splints are Medial (most common), Anterior (2nd), Lateral (3rd), and Posterior (4th). The medial group of muscles (function) are the posterior tibial (controls over pronation), flexor hallucis longus (stabilizes the big toe), and the flexor digitorum longus (stabilizes toes 2 to 5). Photo below shows where medial shin splints occur. Since over pronation, bunions (unstable big toes), and hammertoes (unstable lesser toes) are all common problems, this type of shin splint is the most common. More specific treatments of these problems include various methods in controlling pronation (there will be a series of posts on this topic), stablizing the big toe area or stablizing the lesser toes.These include toe separators/spreaders, shoe inserts with Morton’s extensions, and big toe spica taping to stabilize the big toe area, and toe crests, toe taping, reverse Morton’s extensions all to stabilize the lesser 4 toes.

Many patients purchase shoes too wide in the toe box leading to marked instability, especially when they have bunions. Too much room with resultant sliding around is just as bad on bunions and hammertoes as having too little room with resultant crowding.

The 2nd most common form of shin splints is anterior shin splints (see photo above). The muscles (functions) involved all help to control foot slap after heel strike, and then to help lift the foot off of the ground at toe off. Overuse situations can easily occur with hill running and increases in the speed of workouts. The muscle/tendons involved are the anterior tibial (controls over pronation and stabilizes the first metatarsal), extensor hallucis longus (stabilizes big toe and lifts toe up at toe off), extensor digitorum longus (stabilizes lesser toes and lifts these toes up at toe off), and the peroneus tertius (stabilizes the outside of the foot including the cuboid , 4th metatarsal and 5th metatarsal).



This muscle group is normally the weakest of the 4 groups and has to constantly pull against the more powerful Achilles tendon. As the calf/Achilles gets too tight/too strong with vigorous exercise, it is hard for the anterior group to keep up. These muscles will strain under the added stress of working against the tight Achilles. Hopefully, you can see, when someone has anterior tibial shin splints, treatment should be directed towards:
• Stretching of the calf

• Decreasing hills/speed for awhile

• Stabilizing pronation (medial support) or stabilizing supination (lateral/cuboid area support)

• Stabilizing any digit appearing unstable (with toe separators, taping, toe crests, etc.)

The 3rd most common form of shin splints is lateral shin splints (see photo). The muscle/tendons (functions) involved are the peroneus longus (stabilizes the lateral ankle against excessive supination and stabilizes the cuboid and the first metatarsal), and the peroneus brevis (stabilizes the lateral ankle against supination and stabilizes the cuboid and fifth metatarsal). So they stabilize the lateral ankle, and both sides of the midfoot area. Ankle braces, ankle proprioceptive exercises (see post on flat footed balancing), power lacing, and stable shoes if you pronate or supinate too much can all be part of the treatment.

The 4th common form of shin splints is posterior shin splints (see photo). The upper 2/3 of the calf is considered a shin splint if the pain is deep. This is normally a stress fracture on the posterior aspect of the tibia (very common in runners) and often misdiagnosed as calf muscle strain. It may also be a strain of the soleus muscle (deep part of the calf) where it originates on the tibia. The gastrocnemius (or gastroc) is the bigger, more superficial, muscle of the calf. The soleus muscle starts deep to the gastroc and becomes the other ½ of the Achilles tendon below. Therefore, the soleus functions to lift the heel. It also attempts to slow down pronation at heel contact, so over pronators may strain the muscle. It is harder to strengthen the soleus then the gastroc, so weaknesses may develop and muscle strains can occur with relatively minor overuse situations.



A further post will discuss various ways to strengthen the gastroc versus the soleus. In general, soleus strengthening is done with the knee bent 45 to 90 degrees and the ankle is then plantarflexed with resistance (pointed downward like a ballerina on her pointe shoes). Treatment of this type of shin splints must initially rule out tibial stress fracture which requires more modifications. Once tibial stress fractures are ruled out, functional changes include decreasing ankle plantarflexion (extension) and stabilizing pronation. Also, avoiding activities that produce a negative heel effect (see separate post), like getting off your seat in cycling. A slight biomechanical change in activities to minimize heel lift (ie. walking more flatfooted even when going up hills, or lowering the seat on your bike) can greatly speed up treatment.

Shin Splints Part I

Shin Splints (Part I): What are they? What is the basic treatment?

More Inspirations from Italy: this time Monterrosso al Mare (see photo above)

Shin Splints literally means pain somewhere between below the knee joint and above the ankle joint. There are a lot of structures that can produce pain in that area, so the treatments range from simple to complex. Mostly, shin splints is an overuse of one group of muscles/tendons that start (originate) in the leg, and end up (insert) into part of the foot. Each one of these muscle/tendon has various functions around various joints. It can be one of these muscle functions that has been forced to work in an overuse fashion that produces pain. Podiatrists, physical therapists, orthopedists, and physiatrists (rehab specialists) tend to be the most qualified to recognize the exact muscle/tendon involved when treatment is stalling.

Shin splints is so common, and normally responds so well to basic treatment, that most clinicians do not get too involved in its complexities. The basic treatment of shin splints involves:

1. Reduce activity to pain free levels for at least one week.
2. Ice the involved area for 30 minutes 3x/day.
3. Change your athletic shoes if they may be worn down.
4. Minimize your speed workouts and hill workouts.
5. Consider if levels of Calcium and Vitamin D may be low.
6. Attempt 3 to 4 days/week alternative exercises as long as it is pain free (i.e. cycling, elliptical, walking, swimming, court sports, etc.)
7. Stretch the achilles tendon 2 positional (knee straight and knee bent) for 1 minute each 3x/day.
8. Experiment with an ankle brace or ankle taping if it is painful to walk.
9. Wear tie-on supportive athletic shoes full time while the shin is healing (although you may experiment with clogs as an alternative).
10. Attempt pain free muscle strengthening of the muscle group involved. More on this in a later post.

As your symptoms get better, gradually increase your activity back to normal levels (normally 20% increase per week if you were still able to exercise, and 10% per week if you had to shut it all down). A walk/run program may be appropriate (see separate post).

The next part of this topic in the next blog post will talk about the various muscle groups in the leg, and the various functions they perform in these amazing bodies of ours. Talk to you soon.