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He beat everybody on one leg.

Kenny Perry, US professional golfer, referring to Tiger Woods playing with two stress fractures in the left tibia in the 2008 US Open


The leg, defined as the anatomic region below the knee but above the ankle, is a common site of complaints among sportspeople, particularly in distance runners. The term “shin splints” is commonly used by runners as a nondescript reference of their leg pain; the term was also used by health professionals to describe the pain along the medial border of the tibia commonly experienced by runners or to describe shin pain in general. Neither use of the term is pathologically precise. There are multiple unique causes with defined pathophysiologies that should lead the clinician to a more specific diagnosis of leg pain in sportspeople. A more accurate and specific diagnosis allows for targeted treatment. Therefore the term “shin splints” should be abandoned in favor of a more specific, anatomical, and diagnostic terminology.


This chapter focuses on four major pathologies that cause leg pain:


  • medial tibial stress fracture

  • anterior tibial cortical stress fracture

  • medial tibial stress syndrome

  • chronic compartment syndromes.


Clinical perspective


Leg pain in sportspeople generally involves one or more of several pathological, anatomically specific processes:


  • Bone stress. A continuum of increased bone damage exists from bone strain to stress reaction and stress fracture.

  • Vascular insufficiency. This includes a reduction in arterial inflow (such as popliteal artery entrapment) or vascular outflow (due to venous insufficiency), thrombotic disease, or vascular collapse (due to elevated intracompartmental pressures).

  • Inflammation. Inflammation develops at the insertion of muscles, or along the tendons. Periosteal changes at the tibialis posterior and soleus, and fascial changes at the medial border of the tibia may be due to traction or a variation of the stress injury to bone.

  • Elevated intracompartment pressure. The lower leg has a number of muscle compartments, each enveloped by a thick, inelastic fascia. The muscle compartments of the lower leg are shown in Figure 35.1). As a result of overuse/inflammation, these muscle compartments may become swollen and painful, particularly if there is excessive fibrosis of the fascia.

  • Nerve entrapment.

Figure 35.1

Cross-section of lower leg

(a) The various muscle compartments

Graphic Jump Location

(b) The individual muscles, nerves, and vessels

Graphic Jump Location

The differentiation between these processes and the narrowing of the differential diagnosis begin with historical clues, are narrowed by clinical examination findings, and confirmed with specific targeted imaging or clinical tests (Table 35.1). Two or three of these conditions may exist simultaneously. For instance, it is not uncommon to have a stress fracture develop in a patient with chronic periostitis; periostitis ...

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