What would you be thinking in this case study?
Here’s another case that I came across at the clinic.
I’ll break it down into the hard facts, share the things that I’ve performed, lay out the outcomes, give possible diagnoses, and offer insight as to what my thought process was through it.
HISTORY - Here’s the facts:
Sport: Obstacle Racer
Right side dominant 27 YO female with left leg pain
Complained of tight calves and sharp anterior leg pain after running 16 miles
Achiness continued 4 days after initial onset
General deep ache
The athlete had increased her intensity and frequency of training the past month in preparation for her upcoming race
It felt better with wearing shoes (versus flats), support with an ankle brace, and taking medications
It felt worse with hiking, sprints, walking, not wearing the brace
Rated it a 8+ out of 10 (numerical rating scale)
FINDINGS - Here are the outcomes:
Neurovascular assessment
WNL
Inspection
Patient walking with an antalgic gait favoring ipsilateral side
No edema, redness noted
Palpatory findings
Tenderness to palpation along the anterolateral leg (particularly the anterior tibialis muscle belly > insertion) and posteromedial leg (particularly the posterior tibialis muscle belly > insertion)
Tonicity along the anterior/posterior tibialis, flexor/extensor digitorum, flexor/extensor hallicus longus gastrocnemius-soleus complex, peroneals, hamstrings, quadriceps, adductors, gracilis, popliteus
No noticeable temperature changes note
Range of motion
Ankle - dorsiflexion > plantar flexion limited compared to contralateral side
Knee - WNL
Hip - WNL
Lumbar spine - WNL
Movement assessment
Multi-segmental flexion - WNL
Multi-segmental extension limited - WNL
Multi-segmental rotation limited - WNL
Orthopedic evaluation
(-) - Hip impingement tests
(-) - Ankle ligamentous tests
(-) - Knee ligamentous tests
(-) - Bow test
(+) - Diffused tenderness along the anterior tibialis muscle belly
(+) - Hop test; recreation of chief complaint within the anterolateral leg
DIFFERENTIAL DIAGNOSES - Here’s what I was thinking it could be:
Anterior tibialis tendinitis “Shin splints”
Posterior tibialis tendinitis “Medial tibial stress syndrome”
Periostitis
DEDUCTIVE REASONING - Here’s how I narrowed it down:
Anterior Tibialis Pathology -
Palpated the anterior tibialis
(+) finding - tenderness along the length of the belly
Assessed end range of motion
(+) finding - pain and/or recreation of symptoms in PLANTAR FLEXION + INVERSION
Manual muscle test
+4/5 anterior tibias/ED/EHL complex
VERDICT - LIKELY
Posterior Tibialis Pathology -
Palpated the postior tibialis
(+) finding - tenderness along the length of the belly
Assessed end range of motion
(+) finding - pain and/or recreation of symptoms in DORSIFLEXION + EVERSION
Manual muscle test
+4/5 posterior tibias
VERDICT - LIKELY
Osseous Pathology (Periostitis) -
Palpated the tibial shaft
(+) finding - some tenderness; however not at significant as along the soft tissues
Orthopedic test
(+) Diffuse tenderness
(-) Bow test
VERDICT - POSSIBLE
Since assessment of the soft tissue showed up with some definite findings, I knew that those tissues needed to be treated. Both the anterior and posterior regions of the leg were inflamed and involved. The one thing that I was not 100% confident in ruling out just yet was osseous involvement. The fact that she was inflamed impeded definitive results to rule that out.
TREATMENT (DAY 1) -
Here’s some of the things we did:
Soft tissue work via Active Release Technique (ART) and Functional Soft Tissue Transformation (FSTT) along the whole leg
Extraspinal Chiropractic Manipulative Treatment (ECMT) along the foot and ankle
Rocktape to provide sensory input along the anterior and posterior leg
Suggestions:
Anti-inflammatory methods
Maintain ROM and strength
Decreased training activities altogether
Return in 3 days
TREATMENT (DAY 2) -
Here’s the follow up:
35-40% improvement in symptoms
Antalgic gait less, but still present
Able to do some activities without pain (cycling/rowing)
Left infra-patellar knee with some discomfort a day or so ago, but better now
Here’s the reassessment:
Palpaltion:
Continued TTP along the anterior tibialis muscle insertion/belly
-5/5 MMT Anterior and posterior tibialis
Orthopedic test:
(-) - Bow test
(-) - Local tenderness test
(+) - Diffused tenderness along the anterior tibialis muscle insertion/belly
(+) - Hop test; some discomfort within the anterolateral leg
Here’s some of the things we did that day:
Continued soft tissue work via Active Release Technique (ART) and Functional Soft Tissue Transformation (FSTT) along the whole leg
Extraspinal Chiropractic Manipulative Treatment (ECMT) along the talocrural and subtalar joints
Rocktape to provide sensory input along the anterior leg
Suggestions:
Continue anti-inflammatory methods
Maintain/improve ROM and strength
Still decrease/modify training activities altogether
Return in 1 week or so
So guess what happened after treatment?
FOLLOW UP -
Patient contacted and noted these findings:
Symptoms have become worse without increased activities
Increased difficulty to walk and bear weight
The pain is now localized at the anterior and posterior tibial shaft
No radiating pain down the shin/leg
Anti-inflammatory measures are not providing relief
Due to these findings, we agreed that imaging was necessary
I advised to stabilize the area and minimize weight-bearing until she could be imaged
X-Ray Results
Radiographs were unremarkable
Soft cast and crutches administered
Medications recommended
Advanced imaging if symptoms persist (which it did)
MRI Results
Impression: “Abnormal signal that mainly shows decreased signal intensity but adjacent to it are areas of increased signal intensity. It is felt that this most likely represents a fracture (possibly a stress fracture) with adjacent bony contusion”
Images actually illustrated a “black line” transversing the proximal tibia shaft approximately 1 cm wide.
NWB activities 2-4 weeks in a boot (since the fracture site was too proximal to cast)
Repeat X-Ray Results
Performed 3 weeks afterwards
Increased bone density along the fracture site illustrated, indicative of the bone healing
Here’s the take home message:
I think education and communication are the take home messages. As a clinician, you want to be able to keep the individual at ease and give them that confidence in you knowing that you have their best interest at heart. Those things can be established if you are thorough in your explanation of their condition, and can be able to communicate it in words they understand. Explain what condition the patient is currently experiencing, then provide the prognosis, or the direction of what the condition could turn into if not taken care of properly or adequately.
Unfortunately, in this case the symptoms progressed, which makes it that much more important to be able to communicate and educate. People do not know their bodies and what it will go through so they are in a very venerable state. We as clinicians must be willing to provide that extra time to enlighten and guide them through. That is our responsibility, and also a component of the healing process…
Thanks for being curious and taking the time to read this! Hope it added value to your life and equips you to become better than you were yesterday!
Dr. Joe Jaime, DC, DACBSP®, ATC, CSCS®, FRC®ms, CES
BONUS: I try to reflect on the cases that come through, to see how I can improve my evaluation and treatment game, so here’s some of my afterthoughts …
Here’s what I think:
The transverse stress fracture wasn’t initially present until a couple weeks after initial assessment; therefore, taking EVEN MORE conservative measures may have been helpful
If someone presents with BOTH anterior shins splints and medial tibial stress syndrome, then be highly suspicious that stress fracture may follow
More questions about Relative Energy Deficiency in Sport (RED-s) may have been beneficial
Assess navicular drop for >6mm, which indicates increased risk of MTSS (Beckett et al. 1992)
Credit:
Anatomy Pictures extracted from Visual Body App