Stress Fracture or Shin Splint?

author : AMSSM

comments : 0

I have a sharp pain in my leg. I feel this throughout daily activities and while sitting at my desk as well. It has been ongoing, progressively worse, and much much more intense the past few weeks.

Member Question

I have a sharp pain in my leg. I feel this throughout daily activities and while sitting at my desk as well. I can feel a slight jolt when walking (just less intense than when running). 

The pain is: Left leg only, two inches up from ball on ankle, front of shin towards the inside of leg. The pain is concentrated but the "trigger area" is about the size of a baseball. It does not feel like there is any meat or muscle between the area of pain and where I touch it.  Sharp pain in area, tender and unpleasant.  I have no pain whatsoever when cycling 

I've had this pain but much less intense before, I usually give it a week and then it becomes tiny and insignificant.  It has been ongoing, progressively worse, and much much more intense the past few weeks.

What shall I do?  I have a marathon in a month. 

Answer from Aaron D. Campbell, MD, MHS
Member AMSSM

A stress fracture is the most concerning cause of your leg pain, although you could also have shin splints. A stress fracture presents as an isolated painful spot, in the lower 1/3 of the medial border of the tibia (shin bone). It is typically only 1-2 cm in length, may be associated with redness, swelling, or warmth, and will hurt with load bearing activities such as jumping or running, and possibly walking. They often hurt at rest, where some have pain waking them from sleep. Shin splints, may hurt in that same area, but the distribution is much longer, more like several centimeters. Shin splints typically hurt during the activity, but calm down when you stop. In more severe cases, they can be red, swollen, or warm to the touch.

A stress fracture is best diagnosed with an MRI. X-rays, however, are a valuable component of the work up, may show the fracture in some cases, and can rule out other causes of bone pain that would be unexpected, such as a malignancy. The treatments of both, while similar, do have some differences, and the return to your activity, both when and how, will depend on the true diagnosis. A stress fracture is a broken bone, which can take several weeks to heal. Knowledge of the injury will best get you back to your sport sooner and help guide you to prevention.

There are two theories for how stress fractures occur. 1) Weight bearing exercises strengthen bones by remodeling. Cells actually break down the bone, then other cells rebuild it. The bone-building phase can lag behind the breakdown phase, leaving the bone susceptible to fracture as you are too quickly increasing the mileage and intensity of your workout. 2) Strong, repetitive forces on the bone at insertion points of muscles lead to micro fractures that can exceed the bone’s ability to tolerate the focal bending stresses, leading to a fracture.

Treatment of a stress fracture is non-weight bearing until one is able to walk without pain, then avoidance of jumping/running for a 2-3 week period until you can perform this activity without pain, or a “hop test” becomes negative. An air splint or walking foot/ankle immobilization boot can decrease duration of pain and recovery time. Both stress fractures and shin splints are symptomatically treated with relative rest from the painful activities, gentle focal massage, and over the counter pain medication as needed.

Risk factors of both injuries in jumping or running sports are poor pre participation conditioning, core instability, increasing mileage and intensity too quickly, rapid changes in running surfaces, hyperpronation or other foot anatomy issues, obesity, female gender, hormonal imbalances, and nutritional deficiencies such as Vitamin D or Calcium deficiency.

Prevention includes gradual increases in mileage and intensity, no more than 10% per week, adequate warm ups and cool downs, stretching, core muscle training, adequate hydration, rest and nutrition, as well as modifications in footwear if needed based on your anatomy, and retiring shoes after 200-250 miles.

Aaron D. Campbell, MD, MHS
Family and Sports Medicine
University of Utah, Salt Lake City, UT

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date: March 17, 2014