Evaluation of Shin Pain

Differential Diagnosis

Common

1. Tibia or Fibula Stress Fractures

2. Tibia or Fibula Periosteal Contusion

3. Tibia or Fibula Fracture

4. Tibial Periostitis

5. Chronic Compartment Syndrome (Deep Posterior or Anterior)

Note: There are several features for Differentiating Shin Pain

Less Common

1. Referred pain from the Lumbar Spine, Neural Structures, Superior Tibiofibular Joint or Ankle

2. Pes Anserine Tendinitis or Bursitis

3. Osgood-Schlatter Disease

4. Chronic Peroneal Compartment Syndrome

5. Entrapment Syndrome of Popliteal Artery, Anterior Tibial Artery, or Superficial Peroneal Nerve

Not to be Missed

1. Tumors (Osteosarcoma or Osteoid Osteoma)

2. Vascular Insufficiency

3. Erythema Nodosum

4. Hyperparathyroidism

5. Ricket's

6. Paget's Disease

7. Sarcoidosis

8. Syphilis

9. Acute Anterior Compartment Syndrome

History

• Relationship of pain to exercise (aggravated or alleviated)

• Pain with jumping

• Numbness, tingling, or 'dead foot'

Physical Examination

Remember that a complete examination should include the joint above and below. Always examine the knee to rule out knee injury or ligamentous disruption. Also examine the ankle

Inspection

1. Assess for swelling

2. View ankle from behind: loss of definition of acchilles tendon indicates significant swelling

3. Check condition of skin

Palpation

1. Tibia

2. Fibula

3. Soleus Muscle Body

4. Soleus Aponeurosis

5. Deep Posterior Compartment

6. Anterior Compartment

Motion

Muscular Strength

Muscular strength is graded on the MRC Scale

1. Plantarflexion; Gastrocnemius and Soleus,

2. Dorsiflexion; Tibialis anterior, extensor digitorum longus, extensor hallicis longus, peroneus tertius

3. Inversion; Tibialis anterior,

4. Eversion; peroneus longus, peroneus brevis

Neurovascular

1. Check the Heel Jerk Reflex (S1 S2) and grade

2. Check Distal Sensation

Special Tests

1. Stress Fracture Test

Investigations

1. Plain Films: May be positive in stress fracture of greater than 2-3 weeks duration.

2. Bone Scan: Reveals increased uptake if stress fractures are present. Periositis may be seen as increased uptake along the medial border of the tibia. Compartment syndrome usually yields a normal bone scan, however, but may show some increased uptake.

3. MRI: Excellent for stress fractures.

4. Compartment Pressure Measurement.

Appendix

Muscular Movers of the Ankle

Index

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