Member Case Study: Pain in Medial Tibial Shaft of Right Leg

author : AMSSM

comments : 0

The pain is palpable after a run mid shaft, medial to bone around the interosseous border. Resistive movement does not effect it. Most pain is with load bearing during a run.

Question from dexter

I have pain mid way up my medial tibial shaft of my right leg. The pain is very pronounced when I run. It may linger a little after the run. Once in a while I feel it though the day at no particular time or activity. I started training a year ago. Started running 6 month ago. I am over weight at 5'9" and 190 pounds.

The pain started a month or two after my first tri. I usually don't do more then 5K at a time, 2-3x week. Video analysis of my run shows some pronation on the right side. I fought ant. tib shin splits but have eliminated them. The pain is palpable after a run mid shaft, medial to bone around the interosseous border. Resistive movement does not effect it. Most pain is with load bearing during a run. The pain is almost immediate when I start to run. It may get a little worse during the run. Its about a 4-5/10. I have rested is some, during the off season but want to start run training soon. Thanks Dex

Answer

I believe that until proven otherwise, you have a stress fracture in the symptomatic leg. There are several risk factors that you list, including an above-average body mass index and recent institution of a training program. Signs that are concerning include no change in the pain with resistive movement and immediate onset of pain with running. Physical exam for the diagnosis of stress fracture is largely unreliable.

In your case, I would consider an x-ray to rule out other causes of localized bone pain such as a bone cyst that could be a fracture risk (fairly uncommon, but important to identify). X-ray for the diagnosis of stress fracture itself is unreliable, and at best will detect stress fractures about 50% of the time. If there is x-ray verification of a stress fracture though, that is considered diagnostic, and no further testing is necessary, so that’s usually the best place to start. If x-ray studies are negative, further imaging should be done to rule this problem out definitively. Choices would include an MRI or radioisotope bone scan. Both are considered sensitive enough to definitively rule out the problem if negative.

Other possible causes of one-sided leg pain with exercise include chronic exertional compartment syndrome, radiating nerve pain from the back, muscle growths (very rare) or vascular problems in the leg (primarily a condition known as popliteal artery entrapment syndrome). The description you have provided would seem to lead away from each of these.

Treatment for a tibial stress fracture is multifaceted. First, the location of the injury determines the amount of weight bearing restriction. Anterior tibial stress fractures are much slower to heal, and need lots of supervision. Otherwise, weight bearing can usually be maintained, with activity allowed as long as it is pain-free.

There is some evidence that a long-leg air splint can shorten the healing time by two-thirds. I always get my patients cross-training with aerobic exercise that doesn’t overly impact the injury, whether that is in the pool, or on closed-chain cardio equipment (like an elliptical cycle). This prevents weight gain, and also smoothes the path back to road training when it is safe. Nutritional intake should remain optimized.

Finally, when my patients have been pain-free completely for two weeks, I start them on a walk-run progression (in addition to the cross-training) whereby the running component increases week-to-week. This should be done under the guidance of a sports physician.

I hope that you are back to running soon, and congratulate you on your fitness goals.

Chad Carlson, M.D.
Stadia Sports Medicine
Des Moines, IA
Member, AMSSM

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date: March 5, 2006