[Case Studies] Managing bilateral shin pain in a runner with Beau Walker Tyrrell

In this episode with Beau Walker Tyrrell, we explore an interesting case study on a real patient of his – a Hyrox athlete, preparing for a marathon with bilateral shin pain. We cover:

• Differential diagnosis within the shin region
• Objective testing related to bilateral shin pain
• Role of acute:chronic work load ratios
• Role of imaging with this patient
• Interdisciplinary management plan of this patient
• Beau’s reflective reasoning

This episode is closely tied to Beau’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

 👉🏻 Watch Beau’s case study here with our 7-day free trial:
https://physio.network/casestudy-tyrrell

Beau Walker Tyrrell, commonly known as the Stress Fracture Physio, is an Australian physiotherapist who specialises in treating runners with bone stress injuries at The Running Room, where he is Head of Professional Development. Known for his evidence-based approach and extensive experience managing stress fractures, Beau provides consulting for both patients and physios, and regularly presents internationally on bone stress injuries.

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Our host is @Sarah_Yule from Physio Network

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Transcript

SPEAKER_02 0:02

Today's case explores the assessment and management of a bilateral bone stress injury in a runner. On today's episode with Bo Tyrell, we explore the case of a runner presenting with progressive bilateral shin pain and how careful clinical reasoning helped guide the diagnosis and management of a bilateral bone stress injury. Bo is a senior physiotherapist at the Running Room and is known for his dedication to understanding and applying research in runners. With experience in private practice, amateur and semi-professional sport, Bo brings a unique perspective to his role. The Running Room is at the forefront of bringing high-performance athlete management to recreational and sub-elite runners. And Bo has been leading the revolution in assessing, rehabilitating and coaching runners. He has extensive experience managing stress fractures and also offers expert consulting for physiotherapists managing these injuries in clinics across Australia and globally. Having personally experienced a rare high-risk stress fracture himself, Bo understands the challenges runners face with these potentially devastating injuries. Bo has also done a case study with Physio Network on this topic, where you can dive much deeper into this area than we'll be able to cover in today's episode. You can click the link in the show notes to watch his case study with a free seven-day trial. You're going to love this episode because it gives you a glimpse into how his teachings can have a profound impact on your clinical reasoning. I'm Sarah Yule, and this is Case Studies. Well, Bo, thank you so much for joining us on Case Studies. We're going to launch straight in. So to start us off, can you walk us through the subjective history of the runner and the case?

SPEAKER_01 1:40

Yeah, uh, so Mr. S is a 20-year-old runner who presented with bilateral shin pain. He had basically started trying to build up for a marathon, his very first marathon. And he was trying to, at the very same time, actually build up for Hyrox. And everyone kind of knows what a marathon is. It's 42Ks. But Hyrox is kind of a newer event that I think people are, you know, not everyone's going to be as familiar with. It's basically like doing exercise stations, pushing a sled, doing the rower, doing the skiog, and then in between each of these eight stations, doing a kilometer sprint, right? They're trying to do high-intensity running amidst endurance or or resistance-based exercises. That's kind of different to a marathon. So this patient was essentially ramping up their intensity to do this speed-based Hyrox event and their volume to do a marathon event. So they picked up some right-sided shin pain first that was pretty mild, a three out of 10. They were able to keep training through it. And then as they kind of got towards this HIROX session and they were doing a lot more speed work, the event was just around the corner and they actually picked up really bad left-sided shin pain that kind of came on, was getting worse quite quickly, and progressed to a point where they were limping after finishing a session. They went home, had night pain, pain at rest for a couple of days. And it took about a week for that to start to subside, which is when they they presented to me. Just to put in perspective, kind of the ramp and change here. I won't go into details about how much the speed changed, but this patient over the course of about three months went from running 30 kilometers a week to 70 kilometers a week, which is basically doubling their load and increasing that case per week really rapidly and aggressively.

SPEAKER_02 3:27

Yeah, that's a that's a huge increase. So we've got 20-year-old runner, bilateral shin pain, first marathon plus high rocks. So large increase in load, and then right sided shin pain followed by left-sided shin pain with some night pain. So based on your subjective history, what were your key differential diagnoses that you were considering at that stage?

SPEAKER_01 3:47

Yeah, so I think a lot of people will see the fact that it's on both sides and immediately start to think that it's more likely to be something like shin splints as a colloquial term, or medial tibial stress syndrome. Because of the high severity of the left-sided shin pain, the big progression in load leading up to the injury, particularly with intensity, uh, and really just the fact that it got to the point where the patient's limping, they're having pain at rest and pain at night. My biggest concern was straight away for a bone stress injury. And we haven't really gotten to, you know, where the pain was, but we'd want to make sure this wasn't a high-risk bone stress injury on either side. That's kind of the biggest concern in terms of a differential diagnosis. It could very well just be a really severe case of medial tubial stress syndrome that's occurring on both sides because that that is more common. Other things, you know, we haven't spoken about the sensations, you know, if they've had loss or paresthesia, loss of sensation, loss of power, things that might make us think it's uh neurological. And we also haven't spoken to, you know, whether they they felt any kind of like pull or tear as they were going through that might suggest that it's more like a gastrox strain or anything like that. If we were to go through it, the differentials would be a bone-related or bone stress injury, MTSS, which is a stress around the inside of the bone, that would appear quite similar, a calf strain or muscle injury, and then some kind of neurological or vascular condition. Already off the presentation, it does fall more in line with with a bone stress injury right off the bat.

SPEAKER_02 5:15

And it's sounding like, as with many of these things, that subjective the cues and clues we get with a subjective exam are really important. Like you've mentioned, that 24-hour pattern was obviously what drove you towards this diagnosis.

SPEAKER_01 5:31

Yeah. And if if we had had a kind of a different presentation where it was warming up, not really giving resting pain or pain with ADLs, that could be something where, you know, if it was presenting just with impact activity, it could be medial tibial stress syndrome. On the flip side, if it was something that was just building during training, as they ran, they're having this big increase in pain and discomfort and tightness in their shin or calf as they're running. But then as soon as they stop, there's no pain, right? Or subsides very quickly and they don't have any other issues. Almost the opposite of it warming up and going away, it building, but then still resolving very well. That could be something that would fall into more of an exertional compartment syndrome, kind of vascular or neurovascular presentation. And if there were things like pins and needles, numbness, tingling, loss of power in concombination with like shooting or burning sensations, maybe we would be saying, oh, maybe this is more just a neurological presentation. So that that history can all sometimes be quite clear. And it's not to say we couldn't have three or four of these things going on at once or two of them going on at once, but that history really makes you go, oh, bone stress is the big thing we want to be looking for.

SPEAKER_02 6:43

Absolutely. So it's sounding like you've got a really good subjective examination with your suspicions. Tell me, what did the objective exam reveal? And were there any findings that helped clarify your thinking?

SPEAKER_01 6:55

Yeah, yeah. So on objective testing today, oh sorry, on the day that that I reviewed him, he didn't have any pain with walking, which is an awesome sign. He didn't have any pain with calf raises, resisted muscle testing, palpation through any of the muscles around the shank. But as soon as you got him to do a double leg pogo, you know, a hop on the spot on two legs, he started to feel some of the discomfort, particularly on the left side. And then when we transitioned to doing that on single leg, it became immediately reproductive of his full symptoms. And he actually just couldn't jump really well on that side. There was a there was a loss of power, this almost reluctance, which we call, you know, almost bony reluctance when it's related to a bone stress injury. That is just this huge red flag to go and investigate. In terms of palpation on his medial shin, which was where we localized the pain to with the palpation, uh, sorry, with the hop test, on palpation of his medial shins, he had this short, I think it was five centimeters of tenderness on the right side. And on the left, he had quite a marked tenderness of a few centimeters. And then he had this really broad tenderness sweeping across the shin. And, you know, conventionally we kind of think of tenderness and the length being really determinant of bone stress injuries. And that's definitely true. But I think it's the length of this the severe tenderness that we want to be looking at. And that really short length of marked tenderness on the left side was again another nail in the coffin for us to go and investigate, pretty much another red flag for us to be going and exploring more aggressively. And those two things, that positive hop test and that positive palpation, are two of the strongest predictors of a bone stress injury. So we we took that as to say almost, you know, in the contour, I said, look, I'm pretty confident you have a bone stress injury. We can go get a scan and go from there and start our management. But this is very confidently what we're going to be looking at.

SPEAKER_02 8:48

Yeah, okay. So you've got that focal tenderness as well. And I'm curious just on that. When you're palpating someone with medial tibial stress syndrome versus this bone injury, how does that palpitary assessment differ on that medial border of the tibia?

SPEAKER_01 9:04

Yeah, so there there often won't be that that marked tenderness on in patients that have medial tibial stress syndrome. They may still have this quite broad length of tenderness, but it comes down more to the history that you know the pain either warms up, is not very severe, is is not progressive, and is much more tolerable and doesn't take away power, that subjective element is probably the bigger indicator as to whether it's going to be something like MTSS, more than just the length of tenderness. If there is, you know, a long length of tenderness and no loss of power, no night pain, no resting pain, it's not progressive, and there is no marked tenderness within it. I think that's generally the the time when I'm pretty happy to say, cool, this is going to be much uh lower risk of an injury. But they still do take a long time if it's MTSS. So I wouldn't I wouldn't say it's a complete get out of jail free if if we narrowed it down and said, Oh, this is actually MTSS.

SPEAKER_00 10:02

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SPEAKER_02 10:27

So, based on your subjective and objective findings, your provisional diagnosis at that stage was presumably a bone stress injury. When did you decide that imaging was required and what helped you confirm that diagnosis?

SPEAKER_01 10:39

Yeah, so in in speaking uh with this patient, they're about six weeks out from completing their first marathon, CNI marathon, and they were pretty keen to explore if there was even a small chance for them to be able to do it. And they were also keen to know how long they would be off running because they really enjoyed running. They they picked it up and just found it to be the kind of relief and release that in an activity that they really got a lot of value out of. So with that in mind, the patient was very keen. They had a race coming around the corner and we had pretty quick and easy access. There, there was no financial restraints to go and get a scan. So we actually referred for an MRI and he got it done two days uh later, which then confirmed the diagnosis of bone stress, actually on both sides. Conventionally, I think MRI is obviously the gold standard for imaging of these injuries, but it's not always necessitated to manage this case. If there was financial constraints, if there was lack of access, this case in particular is clear enough to manage according to symptoms, because even if it was MTSS, the patient wasn't going to be able to tolerate load. And on the flip side, if you know you still needed to chase diagnoses in these settings, I think X-rays are quite undervalued in the imaging of bone stress injuries, particularly at ruling out large bone stress injuries. And if we're thinking about stress fractures when there's a cortical breach and healing that needs to occur, that's when an X-ray can be really quite accurate and quite easily accessible, as well as repeatable to check that it is healing properly and well. That's something that, you know, I think a lot of people should consider. This was a unique circumstance in that the patient had a race coming up and they were pretty keen to get a scan. But that's not always what we have to do to get these kind of cases sorted out.

SPEAKER_02 12:25

So once you've reached your diagnosis, what did your management plan look like for this chap?

SPEAKER_01 12:31

The initial plan was basically just to keep him off running for a while. The diagnosis was confirmed to be a bilateral bone stress injury, a grade one on the right and a grade three on the left. With that greater severity, there's going to be a little bit more healing that needs to occur. So we decided to offload him from running and impact and jumping, which he had already essentially done. And then we looked at what's the next most likely activity that he is prone or is more likely to increase that could, you know, delay his recovery here. And that would be one, you know, increasing his step count excessively. There's quite a lot of bone load that comes through. And two, just is walking actually going to be safe? And given this was a posterior medial bone stress injury, which is low risk, he was not symptomatic with walking and he had overall good health, which we hadn't really gone through. But he wasn't the type of patient that was going to have massive setbacks if you allowed him to be weight bearing. This is not the type of bone stress injury that will not tolerate weight bearing if symptom-free. So we managed him according to a symptom-free approach with weight bearing. And that meant he was allowed to walk around. What often happens with that though, if you take running away from a runner, but you can still walk, they'll go out and do a bunch of long walks. They'll go out and do a bunch of, you know, intensive walks up hills and things to try and maintain fitness. So you really had, I really had to be clear with him. You're allowed to walk, but here's the step count. I think I gave him 7,000 steps as a limit for a week, and then we just started building that up. There was a lot of education and discussion about why this happened. And we got him to get some blood tests and he had a dietitian already. So we got him to review with his dietitian again just to make sure it was nice and safe, an environment for the bone to heal and safe to progress. And then we basically went through and said, look, these are the errors that you made in your training. This is a huge spike. This is a huge change in load. And going forwards, this is things that you need to be aware of and manage. And that actually ended up with him deciding to take on a running coach later on. That was kind of the initial management plan, just in terms of education and assessment. From there, we basically just got him into the gym as soon as he was tolerating 7,000 steps with no pain. We built up his calf strength, his foot strength, his ankle strength, and kept him doing all of his lower body resistance training at a high level. And we started some cross-training at a fixed level just because he hadn't seen the dietitian yet. And once the dietitian cleared in, we allowed him to ramp up his training load. Once completing the strength training, we got him to start a progressive impact loading program that essentially took him from really easy, fast-moving calf razors all the way up to single-leg pogos to make sure it was ready to transition into a return to rent face.

SPEAKER_02 15:11

Yeah, great. And I'm curious, did the Hyrux component make it into your strength and conditioning planning? Or was it run the focus?

SPEAKER_01 15:20

No, he said he didn't care that much about Hyrux. I think it made it easy for him to access it and go in and do, you know, standing skierg. He was happy to do some rowing, he was happy to do some cycling, those things that it was just more accessible because he was already interested in doing those things. But he actually ended up going into triathlon after that. So he much preferred the stationary bike and the cycling element and got into swimming as well off the back of this injury. I mean, I kind of enjoy and I prefer when runners are open to kind of shifting and pivoting and enjoying other tasks because he kind of just got a whole new different world of enjoyment and hobbies out of this injury. And that was kind of that was kind of a nice unknown benefit or unexpected benefit rather.

SPEAKER_02 16:01

Yeah, absolutely. So it sounds like there was a few, a few things or many things that went well with it. Is there anything else that you found went really well? And conversely, what would you do differently next time?

SPEAKER_01 16:12

Yeah, I think the education piece went quite well with him because as I mentioned, he he ended up going and reviewing with his dietitian again. He ended up getting a coach that helped him manage his load, and he started picking up like other habits and other hobbies to spread out his his training and his effort and keep him balanced rather than just going extremely hard. And he also had a really smooth progression through the strength and the plyometrics and the running because he was quite diligent. Probably the element that didn't go as well from my perspective is, and I don't know how much of this is, you know, it not going well versus one, a bit of bad luck, and two, just being a bit more cautious. The patient saw my colleague in the interim when I was sick, I was off sick one day, and my colleague uh saw the report for the scan and it said it was an anterior medial bone stress injury, which would be considered high risk. So my colleague offloaded him on crutches to protect the site because that's a high-risk injury that won't go well. But the reality was the the it was a grade three, so there was no fracture, and the swelling from the posterior medial tuberal bone stress had just moved around to the anterior medial shin. So he didn't actually have an anterior medial bone stress injury, his symptoms weren't there, the bone stress wasn't there, just the swelling had moved. So he got offloaded for a week because of that. It delayed him a little bit. And then just because he didn't actually want to do the marathon anymore, and he was happy for us to go slower, we then even made it go slower afterwards. I don't know if that's a bad thing. You know, we can have a discussion here at how much is too much offloading for too long or how much is holding someone out of sport, then detrimental. I think, you know, in a high performance setting, which is kind of the background I I come from, I would have got him back loading a lot sooner and not not held him back at as many steps. But in the setting of a 20-year-old that's just had two bone stress injuries and has a long running career, I was pretty happy just to hold him back a bit more.

SPEAKER_02 18:05

Yeah, definitely. Just out of curiosity, how did you and your colleague work out the location differential there?

SPEAKER_01 18:12

I assessed him clinically, hops were painful in the posterior medial border. So symptom-wise, that's where his the reproduction of the the loading-based symptoms was coming on. The palpation was tender there, it wasn't tender anterior medially. And then looking at the the scans, you can just see like the the place where he saw is swollen and then it comes around to the front, but it also goes down. So he points to one spot, but they're swelling five centimeters down, about 10 centimeters down from that. That's obviously not going to be strongly indicative that the bone stress is 10 centimeters down because it just moves around. He also saw a sports doctor that confirmed, that reinforced my opinion that it was a low-risk bone stress, too, just to make sure that he was confident in the plan too.

SPEAKER_02 18:55

Yeah, great. Well, Bo, thank you so much for walking us through that case and for sharing your clinical reasoning. I think these cases can be challenging injuries for both runners and clinicians. And so hearing how experienced practitioners approach these clay cases is always incredibly valuable. And for all those listening, if you'd like to dive deeper into this topic, make sure you check out Bo's full case study with Physio Network, which you can access through the link in the show notes. Thank you again for joining us, Bo.

SPEAKER_01 19:23

No worries, thank you for having me, Sarah. That was awesome.