A 22 year old patient complains of left leg pain. It is on the medial aspect of her leg, mainly at the junction of the upper third and the lower two thirds of her leg. It has first occurred 2 years ago. This pain is recurrent. It occurs after walking long distances or running. It doesn't occur immediately, but several hours later (when she wakes up the next day). A stress fracture was suspected and an X-Ray was done. There were no findings. Pain is still present, its intensity varies. What could possibly cause this pain.
Dear Alia Al Khozondar,
A possibility for the pain is shin splints/medial tibial stress syndrome. What do you think about? Is really common In runners. I think that this paper can help to understand more about the medial tibial stress syndrome. I hope I've helped.
http://www.ncbi.nlm.nih.gov/pubmed/25379543
Best regards,
Dear Alia Al Khozondar,
I am in agreement with Bruno Luiz de Souza Bedo with medial tibial stress syndrome as the most likely diagnosis. The location and timing best suit this possibility.
A strong contender would be anserine bursitis with mild knee valgus. The clinical profile can be identical.
The other condition (slightly less likely) is Patellofemoral pain syndrome (PFPS). Though the clinical profile you described in not classical for this condition, but the prevalence of PFPS is much higher than the first 2 conditions mentioned. It is the commonest cause of knee pains in a young individual. So epidemiologically it remains in contention.
regards
The so-called "Shin splints" is possible. It may last for months even years, and may follow a course of chronification and exacerbation. This strange syndrome should be proved by US or MRI in the acute phase. It also could be medial but also anterior tibial stress syndrome. Where is the pain - anterior or medial ?
Thank you Dr. Panayot Tanchev.
It is mainly medially.
But may I ask what are the US findings to look for in this case?
Thanks again.
Vascular examination, incl. Doppler ultrasound, is done to exclude vascular pathology, i.e.popliteal artery entrapment syndrome. Otherwise, in MTSS or LTSS the US findings are normal. But it is important to differentiate between different lower leg pain conditions. because the signs are overlapping and diagnosis making is difficult. Sometimes bone scintigraphy is considered.
if you suspect a stress fracture you may have to look at more than just an X-ray. Further diagnostics such as a bone scan may be appropriate. You also need to ask nutritional questions and frequency of menses. Due to the age of the patient there may be contributing factors leading to the possible 'stress fracture'. That is, if this is the end diagnosis.
You should also consider 'biomechanical breakdown'. If she does not have good core strength or glut med strength to stabilize during a long run then this would, over time, show as pain in the medial aspect of the leg. Poor control of IR of the femur and continuous poor 'landing'/impact will show over time (2 years) and cause pain. Step back and look at the whole picture and see how this athlete functions throughout the entire kinetic chain. Other items are tight hip flexors not allowing a full stride with running or poor hindfoot position. Fatigue is a huge factor that will precipitate this breakdown and that may be why this person does not have pain until the following day or after the workout.
i hope this helps.
Dear Alia
The 11 most common walking pains are:
Chronic exertional compartment syndrome ,plantar fasciitis, ingrown toenail, bunion, achilles tendinits, lumbar strain, neuroma, shin splints, bursitis, runner,s knee, stress fracture
I guess we are talking about causes of pain in the leg and not about pain in rest of the lower limb,as I see answers related to pain in knee,ankle,foot,toes,etc..! I agree these may have some percussion on leg symptoms.
I Think that the pain could have origin by a compartimental sindrome or periostytis inserzionale of the tibial muscles
agree with previous post. have patient run for about 15min and then can check compartment pressures in the office to the affected area. this will be diagnostic and guide treatment.
less invasive suggestions can be to use orthotics to lessen the strain of the anterior muscle groups. PT to address any equinus contracture may be needed concurrently.
hope this helps.
Look for shin splints into the literature. No compartment pressure measurement. Deal with shortened muscles (Tib. ant, achilles) provide strengthening for foot muscles and for insoles with medial arch support.
This could be medial tibial stress syndrome, a condition with a multifactorial etiology. Potential impairments include weakness of the posterior tibialis muscle, soleus muscle, anterior tibialis muscle as well as tightness of the gastrocsoleus muscle group. Training errors or faulty biomechanics during running may be involved. Check the patient's unilateral heel rise to assess the strength of the posterior tibialis muscle (watch for inability to maintain rearfoot in neutral/varus), check the foot type and arch height, and muscle length of lower extremity muscles. Consider a treadmill running evaluation to assess her biomechanics. And talk with her about her training regimen and surface. Referral to a good orthopaedic physical therapist, particularly one specializing in sports and running, would be helpful.
I think, we should see all the exams you performed, and as teached me my teachers - everytime we should see the patient with our eyes, and palpate with our hands.
Dr. Cosciug, you are absolutely right. The discussion above is just an exercise on presumptive medicine. As Nelson stated above, leg pain is a symtom and may be a part of different nosologies.
Dr. Panayot Tanchev, благодарю за понимание и внимание.
Alia Al Khozondar, please, give other simptoms which suffer your pacient. And if you can, show examinations of lombar zone, USG of ankle region, plz.
Thank you for your helpful answers. The patient suffers from no other symptoms.
I will as soon as possible.
Thank you again.
it would be medial shin tibial syndrome. just avoid prolonged exercise ,walking. and medical treatment
I think you should do good clinical examination including muscle power of the lower limb compare it with the sound one, EMG , MEASURMENT OF THE COMPARTMENT PRESSURE. BONE SCAN(TO EXCLUDE STRESS FRACTURE OR SHIN SYNDROME) AND RADIO ACTIVE ISOTOPES AFTER EXERCISE (TO EXCLUDE CHRONIC COMPARTMENT SYNDROME) ,LAST MRI MAY HELP.
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