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Tibial
Shin Splint Treated With
A Single Acupuncture Session: Case Report
And Review Of The Literature
Robert A. Schulman, MD
ABSTRACT
Background Sometimes acupuncture is effective, yet often
defies simple biomedical explanation. Such a situation occurred in a
case of medial tibial stress syndrome (shin splint).
Objectives To report a case of medial tibial stress syndrome
and its treatment, and to review the literature on aspects of this condition.
Design, Setting, and Patient A single case report and
a review of MEDLINE for articles on medial tibial stress syndrome and
acupuncture.
Intervention The patient was treated at ST 45, SI 18,
and GB 44, and was prescribed Traumeel, a homeopathic anti-inflammatory
preparation.
Main Outcome Measure resolution of shin and calf pain.
Results The patient reported complete resolution of pain
within 2 days. The literature search yielded a single related article.
The definition, etiology, diagnosis, and treatment of medial tibial
stress syndrome and stress fractures are discussed.
Conclusion The case reported herein illustrates the use
of acupuncture as a simple and effective treatment for medial tibial
stress syndrome.
KEY WORDS
Shin Splint, Medial Tibial Stress Syndrome, Stress Fracture, Acupuncture
INTRODUCTION
Medical acupuncturists are occasionally gratified by nearly total resolution
of the presenting symptoms after a single treatment. In some instances,
the extraordinary results can be explained by the use of a neuroanatomical
construct, by citing myofascial restrictions, or by high-tech imaging
studies correlating increased neural activity in the brain with stimulation
of distal points. However, it is those settings in which acupuncture
proves efficacious, and yet does not allow easy biomedical explanation,
that are the most fascinating. Discussion of 1 such case follows.
SHIN SPLINT
Etiology
Biomechanical abnormalities are likely significant factors in predisposing
certain persons to such injury. Training errors are also major etiologic
factors.1
Imaging Studies and Diagnosis
On physical examination, the most obvious feature is localized bony
tenderness. Occasionally, redness, swelling, or periosteal thickening
may be present at the site of the stress fracture. The diagnosis of
stress fracture is primarily a clinical one.2 However, if the diagnosis
is uncertain, various imaging techniques can be used to confirm the
diagnosis, including monitoring of intracompartmental pressure during
exercise and technetium bone scans.3 In the majority of stress fractures,
there is no obvious abnormality on plain radiography. Initial conventional
radiographs may reveal an early sign of stress fracture, the "gray
cortex."4
Although the triple-phase bone radiograph is extremely sensitive, the
fracture itself is usually not visualized and it may be difficult to
precisely locate the site, especially in the foot. The radionuclide
scan may detect evolving stress fractures at the stage of accelerated
remodeling; the findings must be closely correlated with the clinical
picture. The characteristic bone scan appearance of a stress fracture
is of a sharply marginated area of increased uptake, usually involving
1 cortex of the bone. Computed tomography is a helpful modality if the
fracture needs to be visualized or to distinguish between a stress reaction
and stress fracture. Magnetic resonance imaging (MRI) is increasingly
being used as the technique of choice to visualize stress fractures.
The typical findings on MRI are of periosteal and marrow edema, as well
as fracture line.1
MRI may be used rather than 3-phase bone scan and radiographs for evaluating
acute tibial pain in athletes where avoidance of radiation exposure
is desirable. Similar sensitivity and specificity may be expected from
both investigations.5
MRI may help identify a progression of injury, starting with periosteal
edema, then progressive marrow involvement, and ultimately, frank cortical
stress fracture. MRI findings correlate with an established technetium
bone scan grading system, and may more precisely define the anatomic
location and extent of injury. Some authors recommend MRI over bone
scan for grading tibial stress lesions in runners. MRI is more accurate
in correlating the degree of bone involvement with clinical symptoms,
allowing for more accurate recommendations for rehabilitation and return
to impact activity. Additional advantages of MRI include lack of exposure
to ionizing radiation and significantly less imaging time than 3-phase
bone scintigraphy.6 MRI has been shown to be excellent for demonstration
of fracture lines, callus, and marrow and soft tissue abnormalities
seen in association with longitudinal stress fractures.7
One study found that MRI identification of a "fracture," "fatigue"
line, or a cortical signal intensity abnormality was predictive of a
longer symptomatic period, whereas muscle edema was predictive of a
shorter symptomatic period. A published grading system could be used
in only 24 patients; the MRI grade of injury did not show correlation
with clinical outcome. The MRI finding of either a medullary line or
a cortical abnormality appeared to indicate a more severe stress injury
of bone. A previously published MRI grading system for stress injuries
of the tibia was not prognostic in this more heterogeneous patient group.8
Treatment
Treatment of a stress fracture involves rest from the aggravating activity.
Most stress fractures will heal in a straightforward manner, and return
to activity can occur within 6-8 weeks. Symptoms and physical findings
should influence the rate of resumption of activity. When free of pain,
patients may resume the aggravating activity and slowly increase participation.
An essential component of the management of stress fractures, as with
any overuse injury, involves identification of the factors that contributed
to the injury and, where possible, correction or modification of some
of these factors to reduce the risk of recurrence.1
Surgery is performed in certain acute and chronic cases.9 Compartment
pressures are used as an indicator, including fasciotomy with or without
periosteal cauterization, and surgery is performed using local anesthesia
on an outpatient basis.3,10-16 Some studies have reported that the surgical
or conservative treatment of medial tibial stress syndrome is not successful.3
A number of specific stress fractures require additional treatment because
of a tendency to develop delayed union or nonunion. These include stress
fractures of the neck of the femur, anterior cortex of the tibia, and
navicular and 2nd and 5th metatarsals.1
CASE REPORT
A 38-year-old man presented with acute-onset pain and swelling in the
left shin and calf that began 3-4 days earlier. The pain was made worse
by descending stairs. The previous week, the patient reported that he
walked several hours each day in heavy boots on concrete slab construction
sites. He had no significant past medical history.
On examination, the tibialis anterior and posterior areas of the left
calf were swollen without pitting. Tenderness was noted on palpation.
No ecchymosis was appreciated, and the dorsal pedis and posterior tibialis
pulses were intact. Ankle range of motion was within normal limits.
No swelling or pain was noted at the ankle. Sensation was preserved
to light touch.
ACUPUNCTURE TREATMENT
The patient was treated with a single acupuncture session using the
tendinomuscular meridians; ST 45, SI 18, and GB 44 were needled. The
swollen, tender area was surrounded with 4 other needles. The needles
remained for 20 minutes. On removal of the needles, the swelling appeared
unchanged. Therefore, MRI was performed on the calf. The patient was
advised to take Traumeel (a homeopathic anti-inflammatory agent).
Outcome
MRI of the left lower extremity was interpreted as revealing moderate
tibial edema, with vague increased signal intensity in the underlying
cortex, for which the differential considerations included medial tibial
stress syndrome (grade 1-2 injury).
Various options were discussed during a telephone follow-up, including
a cast boot to limit swelling and a patellar-tendon-bearing orthosis
to decrease the weight bearing on the tibia.
The patient reported an unrelated ailment 6 weeks later. When asked
about the calf pain and swelling, he replied that it had totally resolved
2 days after the acupuncture treatment. Thus, he did not deem it necessary
to pursue further treatment.
DISCUSSION
A review of MEDLINE from 1966 to the present using the search terms
acupuncture, medial tibial stress syndrome, shin splint, compartment
syndrome, chronic compartmental syndrome, stress fracture, and calf
pain produced 1 article describing an acupuncture needle-induced compartment
syndrome.17 Presumably, this may be the first reported case of treating
tibial shin splint with acupuncture.
Currently, the term tibial shin splint is used widely, variably, and
with little consensus of definition. Broadly, it denotes the occurrence
of exertional lower leg pain; more specifically, it refers to an anatomical
site of periostitis. A multiplicity of descriptions and definitions
of shin splints result from the complex etiologies and differing perceptions
of these conditions. It is proposed that the term shin splint be recognized
as generic, rather than diagnostic, and that specific conditions under
this term be differentiated.18
The evidence seems clear that shin splint pain has many different causes,
reflected in the variation in the anatomy. It would be preferable to
describe shin splint pain by location and etiology; for example, lower
medial tibial pain due to periostitis or upper lateral tibial pain due
to elevated compartment pressure.19
Medial tibial stress syndrome has been reported to be tibial stress
fracture or microfracture, tibial periostitis, or distal deep posterior
chronic compartment syndrome.10 The medial tibial syndrome is frequently
cited as the most common overuse injury,11 which occurs at the inner
border of the shin, mostly in the lowest and middle thirds.12 Three
chronic types exist and may coexist: type I (tibial microfracture, bone
stress reaction, or cortical fracture); type II (periostalgia from
chronic avulsion of the periosteum at the periosteal-fascial junction);
and type III (chronic compartment syndrome). Type I disease is treated
non-operatively.10
Compartment syndromes and superficial peroneal nerve compression are
noted as associated complications.9 The anatomy of the origin of the
tibialis posterior muscle and the crossing point of tibialis posterior
and flexor digitorum longus may correlate with the location of medial
tibial stress syndrome, and provide insight into anatomic reasons behind
biomechanical factors responsible for medial tibial
stress syndrome.20
Some authors recognize medial tibial syndrome as a distinct clinical
entity from deep posterior chronic exertional compartment syndrome.
Measurement of muscle compartment pressures helps confirm the diagnosis.21
CONCLUSION
The tendinomuscular meridians allow access to the Wei Qi, or defensive
energy. This type of Qi is thought to flow just beneath the skin, at
the fascial-muscle interface. Helms recommends using a tendon-muscular
input for injuries during the initial 10-14 days.22 It has been suggested
that laminar flow of extracellular fluid is responsible for the transmission
of electrochemical information.22 Matrix theory23 may provide insight
into the flow of microcurrents transmitting electrical information via
the extracellular matrix.
The case report herein presents the use of a simple and effective treatment
for a medial tibial stress syndrome. Since the natural history of the
condition is variable, it is speculative to ascribe cause and effect
entirely to the acupuncture intervention. However, this case does suggest
that acupuncture should be considered early in the presentation of this
condition.
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3. Allen MJ, Barnes MR. Exercise pain in the lower leg: chronic compartment
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V. Surgical treatment of medial tibial stress syndrome (shin splint)
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19. Bates P. Shin splints: a literature review. Br J Sports Med. 1985;19:
132-137.
20. Saxena A, O'Brien T, Bunce D. Anatomic dissection of the tibialis
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stress syndrome. J Foot Surg. 1990;29:105-108.
21. Abramowitz AJ, Schepsis AA. Chronic exertional compartment syndrome
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22. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians.
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AUTHOR
INFORMATION
Dr Robert A. Schulman is a Fellow, American Academy of Physical Medicine
and Rehabilitation; Member, Board
of Directors, American Academy of Medical Acupuncture (AAMA); Diplomat,
American Board of Pain Management; Clinical Associate Professor of Rehabilitation
Medicine and Surgery, Weill Medical College of Cornell University; Clinical
Affiliate, New York-Presbyterian Hospital; and Clini-
cal Instructor, UCLA School of Medicine Medical Acupuncture for Physicians
Program.
Robert A. Schulman, MD, FAAPM&R
104 East 40th Street, Suite 702
New York, NY 10016
Phone: 212-983-1166 o Fax: 212-983-1161
E-mail: rschulmd@banet.net
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