Tricky One - "Shin pain"

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Hello-ha.........

I'll try to keep this brief-ish but if you want any extra info, please ask (I'm sure you will).

23 y/o female. Type 1 DM. Being tested for Chronic fatigue/Fibromyalgia. Good general health. Fairly active. Quit smoking 6 months ago.

Present with pain in shins. Present for several years but "getting much worse last 2-3 years". Pt points to distal 1/3 both tibias and crossing TCJ to dorsum of both feet near insertion of tib ant. (not painful today).

Pain gets to 7-8/10 at worst. Occurs when running/walking briskly. Time of onset varies - walk around block or can do long exercise and pain occurs just before reaching home. Pain causes patient to rest and it "burns and aches and then settles down".

In short, pt has tried better (and appropriate) Asics footwear, varying terrain, varying exercise activities, icing, thorough warm-up, stretches before and after etc etc
Muscles strength testing = WNL.
Thicker thigh muscles = increased external rotation at hip bilaterally and reduced internally. HIp flexion WNL.

ASRT = hard
Jack's test = delayed - faster and improved when foot in neutral. Tip toe test (single leg and both feet together) revealed no weakness of tib post.

Patella out facing
Gen Valgum
Slightly hyperextended 1st interphalangeal joints.
Moderate medial longitudinal arch formation on WB
Heel vertical. Heel inverted at HS - slight subtalar joint 'hesitation' during gait?
Slight pronation during gait L>R (not enough pronation through MS?).
Slight medial roll off hyperkeratosis at B/1st interphalangeal joints. Sl hyperkeratosis L/5 metatarsophalangeal joint and styloid. B/heels also have sliight hk.

So, I thought
DDX = chronic anterior compartment syndrome; Muscle strain; periostitis, Stress fractures?.

I trialled inverted J strapping to both feet and also suggested Magnesium supplements as she mentioned the pain can feel like a 'cramp".
Encouraged to keep altering training surfaces and duration of activity yet patient has tried these things. Discussed possible need for orthosis.

On review - biomx and casting? X-ray or bone scan to rule out or confirm tibial stress fracture or periostitis?

SECOND VISIT
Pain bit better this week. Patient came in after a walk to try to re-create symptoms. She reorts strapping didn't help "I actually felt more pain in my foot [pt point's to lateral L/ankle]. I've been for a quick walk today but it's not excuciating. It's not as bad as last week - it's probably about a 5-6/10 but at it's worst it 8-/10

Lower legs didn't appear swollen and no colour changes noted.

Pain and tenderness on palpation today along medial tibia's (along border where posterior compartment muscles attach). Palpation of either side of tibia (ie soft tissue regions) did not elicit same tenderness. Muscle strength still WNL. Tuning fork applied along b/tibial borders - no pain elicited. No pain upon palption of peroneal tendons when muscle strength tested against resistance.

Today I thought = medial tibial stress syndrome?; chronic exertional compartment syndrome; tibial stress fractures? patient reports that General Practitioner has mentioned he thinks Stella has "fibromyalgia...but this has been occurring a long time before I've been experiencing chronic fatigue (I've been tested for chornic fatigue".

So, basically, I have spoken with the Imaging crew re: further dx tests to try and confirm/rule out my dx.

The GP will arrange X-rays, MRI if he deems necessary. I was hoping they might do a bone scan too but.... will the GP listen to a pod? Who knows, in his hand now.

I have written a letter to the GP requesting thorough further investigations as I fear he will just put it down to fibromyalgia. I then requested he keep in mind referral to Specialist Sports Centre for ICP testing, ulstrasound tx etc; Pain Clinic and possible surgery review (naturally thicker fascial bands?)


Anyway, your thoughts O Great and More Experienced Ones?!?!?!?

 

How embarrassing... that wasn't brief at all.......... sigh. It's a girl thing.