"I told the doctor I broke my leg in two places. He told me to quit going to those places.” ​
-Henny Youngman

Over the next few weeks, your patient schedule will fill with young runners dealing with shin pain, trying to save their cross-country season before it starts.

"Shin pain" can mean many things, with drastically different recommendations and treatments depending on the pain generator

Today, let's focus on differentiating between "shin splints" (i.e., MTSS/LIMP) and a tibial BSI.

What's their health history?

An accurate health and athletic history should help you understand an individual patient's BSI risk.

A history of a BSI is the greatest risk factor for a future BSI. If a runner has a history of bony injuries, regardless of location, I worry they have another one. If they have a history of disordered eating or an eating disorder, my worry skyrockets.

Asking about their sport history, specifically whether they played multidirectional sports during their growing years, is helpful, as that's been shown to decrease (not eliminate) the risk of a BSI.

If they're an athlete who only ran (or only participated in non-gravitational sports like cycling and swimming), think potential BSI. If they have a compromised relationship with food, a history of iron deficiency, or poor hormone function, get more concerned.

How do they describe their symptom behavior and trajectory?

Bony versus soft-tissue injuries have typical histories.

Shin splints typically

• Warm-up
• Present bilaterally
• Have variability during running (feel better/worse with specific pace, duration, or environment)
• Allow athletes to continue to train

Tibial BSIs normally

• Don't warm up
• Present unilaterally
• Aren't better with adjusting pace, duration, or environment
• Have a steep decline in an athlete's tolerance to training

What is their clinical exam?

Palpation isn't a great test for ruling in or out a BSI, but can be useful in differentiating bone versus soft tissue pain in the medial tibia.

Broader pain with palpation (>5 cm) is more likely a soft tissue complaint, while focal symptoms suggest a potential BSI, with the most common location being the posteromedial tibia a few centimeters superior to the medial malleolus.

Here are a few other locations I've seen tibial BSIs in clinical practice (I bolded the ones I see the most).

• Posteromedial tibia
• Posterior tibia
• Anterior tibial cortex (high-risk location)
• Medial tibial condyle
• Lateral tibial condyle.

Single-leg hop testing is also an important differentiator.

If a runner has a reproduction of shin pain with hopping, or is unable to hop due to compensation or apprehension, it's more likely a BSI.

What's your gut tell you?

I've treated patients who break every rule I just mentioned.

• BSIs that warm up.
• Bilateral shin pain that's really bilateral tibial BSIs
• Tibial BSIs with pain across the entire medial tibia
• Tendons with significant pain and apprehension.
• Athletes that can run on a stress fracture for months.

That is why the most important question is "what does your gut tell you?"

If you think it's a BSI, or symptoms aren't improving in a relatively short period, get an image to know what your patient is dealing with.

If they're seeing you, running may need to be shelved.

If you spend much time running in circles, you learn shin pain is relatively common.

Typically, runners figure out how to keep training despite discomfort and eventually get on the other side.

Once symptoms reach the point where a runner has to change training, it's often a BSI, not a soft-tissue complaint.

Keep that in mind for every patient that enters your clinic.

If their shin pain is affecting how they train, they're likely not dealing with "shin splints."