May Journal Club

[Sarah Bosserman]

Pt case details:
Subjective: Pt is a 15 yo female with a diagnosis of MTSS that first began in December with the start of indoor track. New coach had them going for indoor/outdoor runs over various surfaces (gravel, grass, dirt, track, etc.) Before coming to PT, was working with AT at school (mostly calf strengthening – heel raises, 4-way ankle with theraband, has orthotics/new shoes) without improvement in symptoms. H/O “shin splints” a few years ago. She runs year-round: cross country, indoor (500m, 1000m), and outdoor (400m, 800m). Imaging negative for stress fracture. Had a Right ankle sprain in November, not treated with PT (with history of B ankle sprains). Denies current LBP, N/T or burning sensation. Started break from running a week before start of therapy per MD orders.
LEFS: 55/80
Pain NPRS: 0/10 current, 8/10 at worst
Location: B anterior medial lower legs, R>L
Aggs: Running >50m, arch taping, jumping (after running)
Eases: Rest after 10min, though can last longer
Goals: Return to running track events without pain.
Posture: B calcaneal eversion, Tibial IR, mild pes planus (R>L). R rib hump.
Functional Tests:
DL squat: weight shift to left, posterior LOB near 90 deg, unable to get great toe to the ground
SL Stance: mild trunk sway left, moderate on right, LOB after ~10sc
SL squat: dynamic valgus, Trendelenburg L/R
SL stepdown: dynamic valgus bilat, loss of balance.
Hip Swing test: limited hip extension on R.

(-) neuro screen, (-) knee special tests/ROM, (+) Thomas test, limited hip extension R
Joint mobility: Talocrural: Hypomobile A-P glides (limited DF R>L). Normal hip joint mobility. Mild hypomobility w/ tibial ER.
Palp: TTP over medial gutter >5cm
MMT: Hip abduction 4+/5 right, 5-/5 left. Glute max 4/5 bilat. Hip external rotation 4/5 right, 4+/5 left. Hamstrings 5-/5 bilat. Quad 5-/5 bilat. Gastroc ~8 reps to fatigue (can perform 15 reps but decr height/deviations noted). No pain with resisted DF/PF/INV/EV of the ankles.
**There were a lot of distal factors to address with her concerning foot/ankle stability/proprioception, intrinsic foot, graded loading program. With her, there were also some significant proximal factors including core/hip strength.

PICO question: In a patient with recurrent medial tibial pain, would the addition of proximal strengthening exercises when compared to addressing distal factors alone, result in decreased risk of re-injury in the future for a female athlete?

Discussion Questions:
1.What would be high on your differential diagnosis list for this patient? What are some s/s you would be on the look out for both subjectively and objectively?
2.Concerning her PMH, what stood out to you that may be affecting either her prognosis or risk of future injury?
3.What further information or tests would you have wanted concerning this case?
4.What exercises would you have initiated first with this patient? What patient education?
5.In your experience, what has been successful/difficult in treating lower extremity overuse injuries?

[Sarah Bosserman]

Verrelst R, De Clercq D, Willems TM, et al. Contribution of a muscle fatigue protocol to a dynamic stability screening test for exertional medial tibial pain. Am J Sports Med. 2014;42(5):1219–25.

Attachments:

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[Tyler France]

Hey Sarah,

1) Before looking at objective findings, my differential diagnosis list would include some form of bone stress injury, compartment syndrome, and tibialis posterior tendinopathy. I’d want to get a pretty good idea on when symptoms come on during activity and how long symptoms remain following activity to help grade severity of bone stress injury. Symptoms such as numbness/tingling, pressure, and burning could take you more towards compartment syndrome.

2) The two main things that stood out to me regarding her PMH were her history of prior “shin splints” and history of bilateral ankle sprains. A history of bone stress injury could indicate some underlying biomechanical factor or training error that may predispose her to these types of problems. History of ankle sprains could lead to deficits in ankle mobility, stability, and strength that could also play a role in the way she loads her tibia.

3) I’m sure we will discuss it during journal club, but I would like to get an idea on when during activity her symptoms are present. You could also do some hop testing to get an idea of tissue irritability in the area.

4) Based on the article that you attached and the objective findings, I would probably go with some single leg activities (squats, lunges) to try to address hip strength and motor coordination. You could also incorporate foot intrinsic work (toe yoga, short foot) in these single limb positions to incorporate more distal factors as well.

5) Activity modification is what I have found to be most successful in my patients with overuse injuries of the lower extremity. Based on her symptom severity, it may be appropriate to shut her down for a few weeks and have her cross train until you find it appropriate to gradually increase her running back to pre-injury levels. If it seems to be less severe, it may be appropriate to decrease distance and attempt to regulate her running surface to reduce loads. Unfortunately, what I have found most difficult with these patients is deciding what level of activity modification is most appropriate for which patients.

[Katie Long]

Hey Sarah

1) Similarly to what Tyler said regarding differentials, I would agree that I would be concerned about a BSI or posterior tib dysfunction. I also had a similar patient (young athlete) who had “bilateral compartment syndrome” who ended up having some neurogenic components due to a spondy, but it sounds like she is not experiencing any numbness like my patient did.

2) I also think the PMH of her ankle sprains are significant, as her sx seem to be worse on her R vs L, and her R ankle was her most recently sprained. Her talar hypomobility may also be significant in regards to CAI. I am wondering if potential proprioceptive ankle impairments are a contributing factor to her sx during running.

3) I am curious to see what her neurodynamics look like, specifically when tested with a tibial or perineal nerve bias. I am also curious to see what she looks like when running. I am willing to bet she has some motor control impairments and I would like to see if I could provoke her sx when running, as they seem to come on relatively quickly, to see what you can do to change her sx.

4) It sounds like posterior tib endurance strengthening could be beneficial for her, especially if this is a motor control problem. It also sounds like she may be a good candidate for some of the exercises from the running course (toe dissociation/Toga, rearfoot on forefoot stability, SL stance with arch, etc.). Exercises incorporating motor control and stability of proximal and distal components in SL stance are likely going to be very beneficial for her.

5) Unfortunately, I don’t have a ton of experience with these patients, so I don’t know that I have much advice for you from personal experience.

[Justin Pretlow]

Hi Sarah, Thanks for posting.
What’s the medial gutter? Is that posterior to medial malleolus?
Agree with above- diff. dx BSI or posterior tibialis injury.
As for additional information – Have you already had the conversation about female triad components?
Were the SL Heel raises painful or just easily fatigueable? 8 reps seems odd if she has been doing some calf strengthening with her athletic trainer.

[Eric Magrum]

Here are some of my thoughts/questions:
– What about training history/errors prior to injury/beginning of season
– Specifics of her orthotics – do they accomplish what you would think they should
– what does imaging (-) mean – what imaging, and what results – can guide treatment decision making or mean nothing
– Please discuss search strategy/results, and how came to choose this specific article
– MTSS is a continuum from soft tissue to bone pathology – where do you feel she is on this spectrum?
– ? walking, and running gait mechanics
– what is the medial gutter in this case (knee joint assesed arthroscopically)

Looking forward to the discussion

[Myra Pumphrey]

Hi all –

– In regards to clearing the differential list, besides neuro screening, any thoughts on quick clearing tests for the lumbar spine that would relate to her agg factors (hint, agg in upright activities which increase vertical load).

– Also, you discovered many important findings in your examination which may be associated factors to her pain, but it would be helpful if you can reproduce her pain to gain a better understanding of the structures involved and for better reassess for improvement with treatment. Based on her aggravating factors, what will likely be the ultimate functional tests to observe? Also, I am wondering if previous negative tests may be positive if tested after she has been running/jumping.

– In what ways do the subjects in this study differ from your patient?

[Jennifer Boyle]

Hey Sarah! Thanks for posting.

Along with what Tyler said I would look at activity modification first. Maybe reducing the amount she is running or the surface she is running on and unloading the effected areas for a short period of time would be beneficial in the long term, although I typically do not like to take an athletes sport away. Do you think she would be receptive to this?

I would also love to see her running mechanics and think that a gait analysis would be huge to see any other deficits occurring up the chain. If you can possibly tease out any potential compensatory strategies she has been using it may make exercise prescription more meaningful to her.

Looking forward to discussion!

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