Exertional Leg Pain and Shin Splints – PediaCast 523

Show Notes


  • Dr Drew Duerson and Anthony Bartko visit the studio as we consider exertional leg pain and shin splints, which are common conditions in student athletes who run and dance. Discover the cause, symptoms, diagnosis and treatment on our podcast for parents. We hope you can join us!


  • Exertional Leg Pain
  • Shin Splints




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.


It's Episode 523 for August 30th, 2022. We're calling this one "Exertional Leg Pain and Shin Splints". I want to welcome everyone to the program.


So, school is back in session for most students in the United States, which also means the fall sports season is getting underway. And one of those sports, cross-country running, often results in exertional leg pain and shin splints, especially as one begins running after a summer of relative inactivity or as physical activity revs up with the start of a new season.




Of course, cross-country runners are not the only ones impacted by these conditions. Anyone who runs or dances could develop exertional leg pain and shin splints.


Today, we will describe what causes the problem, typical symptoms, diagnosis, treatment, and prevention of leg pain associated with running. And that includes, of course, shin splints. It's one of those terms you probably heard of, but unless you or family member have suffered from shin splints, you might be a little fuzzy on exactly what we mean when we use that term.


To help us explore the topic and in our usual PediaCast fashion, we have a couple of terrific studio guests joining us today.  Dr. Drew Duerson. He is a sports medicine physician at Nationwide Children's Hospital. And Anthony Bartko is a certified athletic trainer also here at Nationwide Children's.




And, of course, they spend a lot of time with student athletes in terms of prevention and treating problems when they arise. And they tell me that shin splints and exertional leg pain, especially between the knee and the ankle, is very very common in student athletes. So, this is really going to impact a lot of patients and families today because it will be some great information, especially if you or a loved one is a runner.


Before we get to our guests, I do want to put a quick plugin for COVID vaccines, which are now approved for ages six months and older. And in case you were wondering, I highly recommend them. You may have noticed we skipped a couple of weeks of PediaCast episodes and that is because I am now just recovering from COVID.


It took 30 months for the onus to catch up with me. And despite of fully vaccinated, plus two booster doses of COVID vaccines, so I've had four shots altogether, I caught COVID and actually had a moderately difficult time with it.




Now, you may be wondering why bother with the vaccines? You probably know a lot of people, including me, who had all their vaccines and still manage to get sick with COVID. Well, here's the important thing to remember, I did not end up in the hospital and I did not end up dead.


So, chances are most of the other people you know who are fully vaccinated but developed COVID anyway, I would suspect that most of them also did not end up in the hospital or dead as a result of COVID. And that really is the point of the vaccine, to prevent hospitalizations and deaths, rather than preventing all COVID infections.


So, in my case, the vaccine did its job and the vaccines have done their job for millions of other Americans. They're likely do the same job for you and your children, so be sure to ask your doctor and your child's doctor about COVID vaccine if you have not already done so. It's an important and potentially life-saving thing to do.




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So, let's take a quick break. We'll get back to Dr. Drew Duerson and Anthony Bartko settled into the studio and then we will be back to talk about exertional leg pain and shin splint. It's coming up right after this.




Dr. Mike Patrick: Dr. Drew Duerson is a sports medicine physician at Nationwide Children's Hospital and an assistant professor of pediatrics at the Ohio State University College of Medicine. Anthony Bartko is a certified athletic trainer at Nationwide Children's. They both have a passion for helping student athletes when injury or pain strikes and that includes exertional leg pain and shin splints.




They're here to talk about the who, what, when, where why and how of these conditions. But first, let's extend a warm PediaCast welcome to our guests. Thank you both so much for being here today.


Dr. Drew Duerson: Thanks for having us.


Anthony Bartko:  Yeah, thank you.


Dr. Mike Patrick: Yeah, really appreciate you taking the time out of your busy schedules to join us.


I wanted to start, Drew, with just some definitions. When we say exertional leg pain and shin splints, what exactly are we talking about?


Dr. Drew Duerson: So, exertional leg pain in its simplest form is pain that's below the knee and above the ankle with exercise. And specifically, we see that with running most often. But it's not exclusive, you can see that with jumping, squatting, other activities as well.


And then, shin splints is a common term that our patients will come in describing their pain. So, it's pain in the shins with exertion. In medicine, we prefer the term medial tibial stress syndrome.




Dr. Mike Patrick: Great. Medial tibial stress syndrome. And so tibial is that big bone in the lower leg. Medial means toward the inside and then the stress syndrome is just muscles and ligaments and tendons being stress?


Dr. Drew Duerson:  Correct. Yeah, I'm sure we'll talk about that a little bit more later.


Dr. Mike Patrick: So, this is really an isolated area between the knee and the ankle that we're talking about?


Dr. Drew Duerson:  Correct.


Dr. Mike Patrick:  And how common are shin splints and who's affected?


Anthony Bartko: It's extremely common. You see a lot with the runners like we already said but you can see in another sports, soccer. I've had some football players come up to me and they've expressed that they've had lower leg pain. I've also found that individuals of flat feet and on the other side of that, high arches, can go ahead and also have symptoms of shin splints too. And we can kind of get into why that is a little bit later.


Dr. Mike Patrick: Yeah. I would imagine a lot of it comes down to mechanics, right, in terms of the stress that's put on the muscles and the bone and tendons and ligaments. What exactly is happening, Drew, when this occurs?




Dr. Drew Duerson: So, when we think about shin splints, there's several theories that have been postulated. But essentially, what happens is that the tibia is not able to withstand an excessive load. And again, that's typically with running.


Some of the early theories that came out where it's a muscle problem. And it's a muscle pulling on the bone where it attaches to the tibia. And with that, that causes excess stress to the outer shell of the bone and possibly actually inflammation.


And then, on the flipside of that, others have postulated that it's muscles that are too weak and can't withstand the load of running. It puts too much stress on the actual bone. More recently, we've, I think, found that there's a correlation between low bone mineral density in the tibia and shin splints.


Hard to say which comes first. Is it the low bone mineral density that causes the excessive load in the pain? Or is it the excessive load that causes the low bone mineral density and then the shin splints? The good thing is usually after the syndrome is complete and the pain is gone, that bone mineral density comes back to normal.




Dr. Mike Patrick: Yeah, that's encouraging. That's good. When we talk about how common this is and you say you see it a lot, some of the numbers that I had come across as I was preparing for today's episode, that 10% to 15% of all running injuries can be attributed to this kind of exertional leg pain. And that when you do have leg pain in athletes of the lower leg like shin splints themselves end up being like 60% of all folks who are experiencing leg pain. So really really very common.


Dr. Drew Duerson: Yeah, very common. I think there's several risk factors too that we'll see when it comes to shin splints. And there's a list of them that people have looked at. And I think that allows a lot of people to fall in this category.




So, we see it more often in females. We see it more often in obese athletes. We'll see it in those that don't have as much growth to their lower leg. Like Anthony said, we'll see it in those kids that have flat feet or a pronate when they run, or their feet fall in.


And then, there are several other risk factors that you can't really modify outside the patient. So, their running surface, the amount of running they're doing, the intensity of running they're doing. Sometimes, it comes down to the shoes they're wearing or the cushions that they have inside their shoes. So, all risk factors for it.


Dr. Mike Patrick: Yeah. And so that makes it really important to see someone if you're experiencing these problems, to see someone who knows what those risk factors are and can try to figure out which one or ones might be modifiable in your particular situation.


And how important is it that you choose a good running shoe? You'd mention that and I would think that that may be able to help mitigate mechanics and the running surface like to help with that. Is it important to choose a good running shoe?




Anthony Bartko: Yeah. Speaking to that, I used to work track at Ashland. And it seems like when I was with the distance kids all the time, it seems to be, "Oh, I have this Nike running shoes." And I'm not trying to harsh on Nike, but if you can fold them in half, that's not a good supportive running shoe. These need be built to last.


And different running company shoes typically have ones that are meant for pronators or people with flat feet or people with high arches that don't really move as much or more rigid. So, shoes are in critical role.


Dr. Drew Duerson: Yeah. Unfortunately, very expensive, too. And I think numbers that I see, usually around six months and the runner has to start talking about switching shoes, especially in our young runners that are outgrowing their shoes pretty quickly, too. So, they're going through a lot of pairs each season.


Dr. Mike Patrick: And the shell itself might look like it still a really good shoe, right? But it's just not giving you the support that you need anymore. So, it may look like the shoe is fine but after six months to a year, especially if you're experiencing exertional leg pain or shin splints, that may be something to look into, getting a new pair of shoes.




Dr. Drew Duerson: Yeah. And I think looking at the sole of the shoe too, looking at the wear pattern is very important. Then you can tell a little bit of information about how the athlete's running.


Dr. Mike Patrick: I'm going to put a link in the show notes to a blog post that we have at the 700 Children's blog called How to Choose Running Shoes. And so, that maybe of interest to folks who want to learn more about what makes up a good quality running shoe for you.


Anthony, what kind of signs and symptoms do we see in kids with exertional leg pain or shin splints? What kind of raises a red flag that that's what's going on?


Anthony Bartko: So obviously you're going to have pain going down through your lower leg during exercise. But sometimes, if it's bad enough, patients going to experience pain, like a throbbing sensation that they say that they experience even after exercise is complete.


It can be localized, or it can be the entire shin bone, that whole tibia. And you can also just get some kind of just pain that's very localized to the touch. And even when you're walking, you're just going to feel that pain.


So that's when it's a little more advance, you're going to feel that pain to the touch, pain with. But just at first, it just presents as pain during exercise or you're running.




Dr. Mike Patrick: Got you. I'd come across that this can be graded like grade one to four. In student athletes, do you typically grade them or is that more in the adult world?


Dr. Drew Duerson: Yeah. So, we look at that. A lot of times, that comes down to an MRI classification when we're most of the time trying to rule out a bone stress injury or stress fracture, which we'll probably get to later in this discussion. But yeah, you can typically grade this on a severely scale of one to four, with one being the best and four being the worst.


Dr. Mike Patrick: And some of that grading, as you mentioned, is what the appearance looks like on the MRI and also what clinical symptoms that they're having, whether it's just with exercise or it's there all the time. It's going to be, as you get down on those grades from one to four, four is going to be it hurt so much, you can't really participate, right?


Dr. Drew Duerson: Right. Yeah, like Anthony was saying, so those early stages, you're going to have pain maybe just toward the end of the run. And then, it subsides shortly after and then all the way to more severe injury where you're going to have pain with that first step and then pain even afterwards with the rest of the times.




Dr. Mike Patrick: You had mentioned that there are other things that could cause pain in that area with exercise. What are some of those things?


Dr. Drew Duerson: So, when I think of exertional leg pain, I tend to break it down to three categories. So, is it musculoskeletal? Is it neurologic or is it vascular?


So, what we mostly been talking about today is shin splint or medial tibial stress syndrome. So that would fall clearly under the musculoskeletal category.  But once we've identified that's not the problem and we see a patient that comes in saying they just have bad shin splints, a lot of times, my mind goes straight to a tibial stress injury. So, a bone stress injury or what most people refer to as stress fracture.


So that a lot of times is the next step in the diagnostic workup, trying to figure out if it's an actual stress fracture. And then from there, we move to other categories. So, I start to think more vascular, which is going to be less common and a little bit more complicated of a diagnosis, but we can see something called popliteal artery entrapment syndrome.




So that's the main artery behind our knee and that can get kinked for several different reasons. A lot of times, it's a muscle anomaly. Sometimes, you have normal anatomy and it's just the large muscle or stiff muscles that occurs when you run. That kinks the artery. And that can cause lower leg pain, as well as other symptoms.


And then, the last thing that I think about most of the time is something called chronic exertional compartment syndrome. And that probably could fall under both the muscular skeletal and the neurologic category. That's a complicated diagnosis as well, but it can look very much like popliteal artery entrapment syndrome.


But essentially, what happens with that is the volume and one or more of the four lower leg compartments increases when we exercise. And with that increase in volume, we see increased pressure. And with that, we get pain along with other symptoms, such as nerve injuries, with numbness and tingling, or even to the point where we feel weakness in the leg.




And then, also under that neurologic category, again, maybe not as common enough where we're thinking about, first off, when we see a patient with leg pain but it's a nerve entrapment. So, there's different nerves that can get entrapped around our knee, down into our lower leg, and even to our ankle that can cause more neurologic symptoms.


Dr. Mike Patrick: In terms of differentiating between all of these things and sort of settling is it shin splints, is it one of these other things that's happening, how do you differentiate between those?


Dr. Drew Duerson: The first step is a good physical exam and a history. And that's usually all that's needed for shin splints. If they come in with the classic presentation, that's a lot of times where we'll stop. But if it's the patient that again comes in with more localized pain, pain that's in one spot of the shin bone, pain that's more severe where it's even maybe at rest and it doesn't go away when the running stops, that's when I move straight to a radiograph or an X-ray. So that's when we're going to try to rule out stress fracture.




Unfortunately, our X-rays aren’t always perfect. And we'll catch an injury early on in its stages and we won't be able to see it on an X-ray. So, then we have to move towards other more advanced images, such as an ultrasound. Maybe we do in clinic or, again, an MRI is going to be the gold standard.


And then, once we've looked at those two most common causes of exertional leg pain of shin splints and stress fracture, then we move on to these other possibilities that we discussed just a second ago. And those become a little bit more complicated. You still rely on your exam.


So, for the popliteal artery entrapment syndrome, we're going to focus mostly on palpation of pulses. And we'll get the patient in certain positions and try to see if we can see if those pulses diminish. And a lot of times, that's not a good enough, we have to move towards another type of image.


Ultrasound becomes another tool that you can use to look at that artery and put patients in these different positions. You can also look at blood pressure, something called an ABI. And that's another test that you can do in clinic. And you can see if that ABI diminishes when you put these patients in certain positions.


And then lastly, you end up, most of the time, having to do an image called an MRI, where you look at blood vessels and the anatomy around that blood vessel.




And then, the compartment syndrome, that can very much look like popliteal artery entrapment syndrome. So, a lot of times, you're ruling that out concurrently. So, you're moving towards something called intercompartmental pressure testing.


And this is probably the least fun thing that I do in sports medicine, and I tend not to do it that much anymore. But this is where we use this special manometry to where we stick a fairly large needle into these compartments before and after exercise to see what the pressure is.


And there's no clear protocol. But we usually get folks on a treadmill, get them to run to their maximum exertion where they can tolerate symptoms. And then, we'll check the pressure in those compartments and compare them to normal and compare them to rest. And then that's how we'll make that diagnosis.


Dr. Mike Patrick: We're going to talk about treatment in particular of shin splints and exertional leg pain. With these other things that you're talking about with the popliteal artery and the compartment syndrome, are those treatable things or is that like a sports participation ending moment when you find out that you have one of those things?




Dr. Drew Duerson: It could be either. So, the simple answer to some of these is you just stop running and the pain goes away, and the symptoms go away. So, that is a hard sell for a lot of our young runners because they want to, obviously, continue to run because that's their passion.


Fortunately, there are some treatments. Conservative treatments aren't always successful with those two ideologies, especially that we'll give it a try. So, it maybe something as simple as a gait analysis and gait retraining, trying to change the way they run.


Maybe it's something as simple are an orthotic and a shoe or some exercises that work on lower leg, flexibility, and strength. But a lot of times, it's becoming an anatomic issue, so something that needs fixed. And that's when we rely on our surgical colleagues and vascular surgeon and orthopedics to help us treat this.




Dr. Mike Patrick: And then, Anthony, as we think about exertional leg pain and shin splints, how is that particular treated?


Anthony Bartko: So, in the athletic training room, there's a lot of different avenues that you can go down. The ones that I like to go to try to get away from the mobilization avenue because if you stick a kid in a boot, their world is over. Just that's how they react to that type of treatment but sometimes it is necessary.


While I'm on the top… boot, me personally as athletic trainer, I like to go you have to have two out of three strikes for me to have to boot you. You to have a history of it, strike one. Strike two is you have to have pain with blocking. And strike three, you have to have pain to the touch.


You have two of three, you usually get in the boot for at least five to seven days, just to kind of get the area to calm down, take some pressure off of that shin bone and try to promote an area of healing.




But, in order to avoid that, we try to mobilize the calf muscle. There's a lot of literature out there that supports that if you have increased dorsiflexion or bringing your foot up towards your face, you can go ahead and decrease some of that pain that you're having because you have more mobility in that ankle.


So, with that being said, we'll use like a grass and type of scraping instrument assisted soft tissue mobilization. I've done capping on the ankle before, and it seems to really help when you prepare with stretching of that calf and the gastric soleus complex.


And then, also tibialis anterior strengthening, so the muscle that's next to the shin bone, it's nice and squishy for touching your lower leg, trying to strengthen that up. Same with the literature there, if you have strong tibialis anterior, it typically helps to take some of the pressure off of that shin bone.


And as Drew mentioned earlier, orthotic are great tool, especially for those individuals with flat feet. There's a lot of people I talked to, they'll go out and they'll get the Dr. Scholl's brand.




Again, not to harp on a particular brand or anything, but the Dr. Scholl's brands are typically just cushioned and gelled. And those are better for people who just have a high arch because if you look at the medial arch, if you have too much of an arch and you're not really distributing any force anywhere, that's going to have to go somewhere. It's going to go up your shin.


So, if you can provide some kind of cushion for that person that has that high arch and some shock-absorption power, then you're going to decrease the amount of force going through that shin bone. Where we like to hand some semi-original orthotics out for those people with more flatter feet, people that need the ground brought to them, that will help, again, for the same reasons.


If the force isn't going through your arch, it's going through your tibial bone. So, you need to have some type of shock-absorption there or some kind of support there. So arch supports are great form of treatment.


And then, of course, rest in cross-training. We can get into this a little bit more later. You'll never be able to tell a runner not to do anything. It's not good for their psyche.




So, if you get them on an exercise bike or an elliptical, something that doesn't have as much force, if at all. I know some high schools have Assault bikes, the fan bikes. Those are great workouts.


I worked with three patients in the college setting that absolutely despise when I told them they have to go on an Assault bike because they would just come back dripping sweat and they will get a similar workout to running.


Dr. Mike Patrick: Yeah, absolutely. So, in the beginning, as you're first seeing these patients, it's the old RICE, rest, ice, elevation, compression, to try to get the swelling down and get it to calm down. And then, you're going to be working on mobility, strength training, that kind of thing?


Anthony Bartko:  Yeah, absolutely.


Dr. Mike Patrick: More on support.


Anthony Bartko: Yeah, you can kind of work hand in hand with those two methods as well. You can kind of stack method as we look at it.


Dr. Mike Patrick: And then, you were mentioning, especially for runners, and folks who may want to still maintain their cardiovascular fitness. And so, using different body muscles that maybe they're used to it running can be helpful.


Swimming, is swimming are good options for these folks?




Anthony Bartko: Swimming and threading water is amazing for people. I always like to tell swimmers, get a land workout. And land workout people, get a swimming workout, because it's amazing.


Dr. Mike Patrick: And still cardiovascular help by using a different set of muscles which can be helpful.


Drew, what can happen if runners ignore the pain and just try to run through it? And they're not going to see anyone. They're just thinking, "Oh, it's going to go away as I continue to run more." So, what are the complications that are possible if they delay treatment?


Dr. Drew Duerson: When we think of shin splints, I think of it as a spectrum. And if the shin splints are ignored over time, that may lead to potential bone stress injury in the tibia. And like we mentioned before, there's different stages of that injury. So, I think most often, we see a runner present after several weeks or months of pain that was ignored and they end up having a later stage for more severe case of a tibial injury.




And then, we can look at different parts of that tibial bone. Most of the time, we think of that posterior medial part, so the back part of the bone. But if we see a stress fracture in the front part of that bone, so the anterior cortex, that's a high-risk stress fracture.


And those can be issues. They're hard to treat. They're often led to non-union, or the bone just doesn't heal. And that's going to have a poor outcome.


When we think of those other causes of lower leg pain, compartment syndrome, not often, but this could lead to acute compartment syndrome which is surgical emergency. So, it's going to be a limb issue. So that's something you want to recognize right away.


Sometimes, we will see small muscle fascial herniation. So little breaks in the fascia that hold the muscles together and those little holes can allow muscles to protrude, bulge through.


With popliteal artery entrapment syndrome, this isn't often, but if this is a long-standing issue, that popliteal artery could become narrow or stenotic. And that could lead to symptoms with just normal daily activities, such as just walking. You can have pain.




And then, if it's a severe case, sometimes, you could even run into issues with permanent nerve issues or muscle damage. So those luckily are not often but can be a consequence if we ignore the symptoms.


Dr. Mike Patrick: So, really important, if you're a runner and you're having pain, make sure you see someone to get to the bottom of what's causing that pain so that we can get you fixed before things get worse.


Dr. Drew Duerson: For sure.


Dr. Mike Patrick: And then, Anthony, what about people who are running, maybe they don't have shin splints, which is great? Are there ways to prevent this from happening in the first place?


Anthony Bartko: It sounds like with the exertional leg pain, it is kind of just congenital or just kind of develops over time. But with shin splints in particular, we have many athletes that, "I had shin splints last season that really knocked me out of my whole season. But then I came back this year and I'm running in full force. Oh, I have leg pain again." You got to kind of ease back into this, especially if you have a history of that.




So, to answer your question, is it preventable? Yes, but you have to be smart about it. You have to have strategic plan that you develop with your coaches and the parents. And it's kind of part of running at times but you really have to just be diligent about managing it.


Dr. Mike Patrick: I would imagine that strength training could be important in the prevention of this. I think a lot of runners want to go out and run but there is some value to doing strength training like in the weight room.


Anthony Bartko: Absolutely. And our strength and conditioning coaches here at Children's Hospital are fantastic. We have a lot of them at our high schools. They know the difference between a football athlete and a cross-country athlete or track athlete.


We're not going to train them the same but yes, strength training would place in the load on those bones, increasing the bone density, as Drew said. There's some research potentially showing the difference between bone density and correlation between shin splints and exertional leg pain.


Dr. Mike Patrick: Do you see this more in men versus women or women more than men? Is there a sex difference with this?




Dr. Drew Duerson: Yes. I think we see it more in females. And I was going to add to that, prevention is always most important when it comes to our world. In our female runners, we always want to ask the right questions if we are seeing them in clinic and we try to get to the bottom of something called RED-S or relative energy deficiency syndrome.


So being able to identify if that female athlete is fueling her body the way it needs to be fueled to meet the demands of her sports. So, I think that's one of those things that you might be able to catch early. But yeah, most definitely if I have a female athlete in my clinic, I'd definitely have a high suspicion for one these injuries.


Dr. Mike Patrick: And as you think about bone mineralization and calcium and making sure that their diet's good, got enough calcium and vitamin D and all that to make strong bones because it's still important.


Dr. Drew Duerson: Right. And some have postulated that if you have a low vitamin D level, if we can get that above 40 or even around 50, the risk of shin splints actually could go down. So, that's another good thing to ask about.




Dr. Mike Patrick: And then, of course, choosing the right running shoe is going to be an important thing. And again, we'll have that link in the show notes so you can read how to do that.


In terms of athletic trainers, I would imagine you really, especially the ones that are in the schools on the front line, been here in clinic. So, folks have to come to you, get plugged in to Sports Medicine and then see you and have the strengthening and conditioning program. But when you're in the school, you're really able to see kids as the symptoms are developing. I'm sure that that's an important thing.


Anthony Bartko: Oh yeah, absolutely. And just being able to be known and let us know that we are there for them, come to us. I mean, we want to see you. We don't want to see you, but we do, especially if something is hurting you. And yeah, just use us as a resource for sure.


And even if you are to that advanced stage, you're trying to push it off or just kind of run through it, we have access to be able to help you and get you to see our amazing Sports Medicine doctors here at Children's Hospital.




Dr. Mike Patrick: I would imagine that coaches also play a role in identifying kids who are having shin splints and exertional leg pain and helping to get them plugged in to Sports Medicine too, right?


Anthony Bartko: Yeah, absolutely. Our coaches work well with us. They know that we don't want them to be just sat out and in a boot for months at a time. We want them out there running, too. So, they trust us, and they look for our opinion and our help.


Dr. Mike Patrick: And then what about parents? We send our kids off to play sports and they do their practices

and they come home. What are the questions the parent should be asking to see if their child is having a problem?


Anthony Bartko: Just inquire, if their child is saying, "Hey, my legs hurt," just be like, "Where's the pain?" especially after they listened to this podcast, they'll know. "I might know what's going on here. Maybe we should see a sports medicine physician." Or if the athletic trainer thinks we caught it early, we can kind of manage it and treat it well, then go ahead and save your doc's visit, too.




Dr. Mike Patrick: Drew, what's the role of the primary care physician? What sort of questions should we be asking during sports physicals and well checkups to identify these kids?


Dr. Drew Duerson: So, going back to prevention, I think if you do have, again, a female athlete in front of you, you want to ask all those important questions when it comes to caloric intake, vitamin D intake, menstrual history, all those things that we know to ask.


And then, if it's a patient that's a runner that's high risk for one of these causes of pain, we want to get to the bottom of how much are they are running, what's the mileage, the intensity, what surface are they running on? Do they cross-train?


Have they had a history of pain? Like Anthony was mentioning, one of the big risk factors for shin splints is a history of shin splints. So, I want to make sure that they haven't had this in the past.


Maybe even getting a specific look at their shoe wear and looking at their feet. And do they need any type of special cushion in their shoe or special orthotic?




And then, obviously, if they have pain, then you ask all the normal questions. Where's the pain localized to? What other associated symptoms are you having? Are you having any numbness, tingling down on your foot, weakness in your foot?


Do you notice any swelling? Sometimes, it's a real pressure feeling, or you can even see it, the muscles, the compartments in your lower leg look very taught and hot pressure.


So, yeah, I think there's a list of questions that you can ask but those will be what we got to focus on.


Dr. Mike Patrick: I would imagine that when kids come in for a pre-sports physical, we focus a lot on, "Hey, are you having any symptoms now? What is your physical exam like at this moment?" But I think it would be an important thing to ask about that previous sports season, as you said, since having had shin splints in the past is a risk factor for having them again.


So maybe those kids, they may not have any symptoms now, but maybe if they had trouble last season, would that be a reason to have them go ahead and see Sports Medicine?




Dr. Drew Duerson: It could be or better yet check in with someone like Anthony at the school. And they can give them some exercises to do, to work on mobility of the ankle and flexibility and even all the way up to chain. There are some studies that show that hip range motion that can cause some shin splints.


So, Anthony and our athletic trainer do a great job of being able to look at that athlete and being able to find where their weaknesses are and, for sure, give them some preseason exercises to do, to work on those and then let them know the symptoms to be looking out for. So, if they recognize those early, we can get this treated I think successfully and get them back out there quickly running.


Anthony Bartko: Yeah, kind of going off that, we have just a stack of papers, just the shin splint rehab, go ahead and… Pre-hab rather, go ahead and do these hip strengthening exercises, these hip stretches, work above and below the chain of where it's going to hurt, strengthen your quad, strengthen your hamstrings, all the other good stuffs that you need. And they come in, they run through it, they're in and out 10, 15 minutes and they're good to go.




Dr. Mike Patrick: Yeah, and that can go a long way to preventing problems in that particular season.


Anthony Bartko: I'm one of the huge prehab athletic trainers. I'd rather do all the work now than do it when it hurt.


Dr. Mike Patrick: And plus, then, it's going to be a much better experience for the student athlete.


Anthony Bartko: Absolutely.


Dr. Mike Patrick: And the family not to have that injury. We focus on the physical aspects of these injuries but there's really also mental health aspect. You guys have mentioned several times like it's the end of the world when these kids can't run anymore. Or even just to say we're going to wear a boot for a week, that can bring tears.


And, of course, anxiety can go along with that. And then the decrease in performance because of the pain really can be a mental health issue with these things, too.


Anthony Bartko: Absolutely.


Dr. Mike Patrick: But the Sports Medicine Program here at Nationwide Children's, we are ready for not only physical issues but also mental health issues. Drew, tell us a little bit more about the team. It's really multidisciplinary, right?




Dr. Drew Duerson: Yeah, so it definitely is a team. So, we have a large group of us. So, we have sports medicine physicians. We have athletic trainers. We have dietitian. We have strength and conditioning professionals. We have administrative and clinical staff that are behind the scenes a lot of times but very important to our teams.


So, we have I think nine fellowship trained sports medicine physicians with eight clinics spread across Columbus. And we're open five days a week and we typically have the same day appointments. We're pretty much every day of the year.


And we have athletic trainers like Anthony that are out in our contracted schools, on those frontlines, helping cover athletic events and see athletes in the training room. Then we have athletic trainers that work in our Functional Rehabilitation Department. So those are our athletic trainers that help treat our injuries after we see them in clinic.


So, we're here to really treat any type of musculoskeletal issue but we definitely have specialists when it comes to exertional leg pain like we've been talking about today.




Dr. Mike Patrick: And we're going to put a lot of links in the show notes for folks. One, to Sports Medicine at Nationwide Children's Hospital so you can learn more about what they do and who all is involved in the team. And then we have a couple of information articles on shin splints themselves from our website in the 700 Children's blog.


And then I've mentioned How to Choose Running Shoes. We'll put that link in there, too. So please check out the show notes for this week's episode, 523, over at pediacast.org.


So once again, Dr. Drew Duerson, sports medicine physician at Nationwide Children's Hospital and Anthony Bartko, certified athletic trainer with Nationwide Children's, thanks again to both of you for stopping by today.


Anthony Bartko: Thank you.


Dr. Drew Duerson: Thank you as well.






Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks to our guests this week, Dr. Drew Duerson, sports medicine physician and Anthony Bartko, certified athletic trainer, both with National Children's Hospital.


Don't forget, you can find us wherever podcasts are found. We're in the Apple and Google podcast apps, also iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


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Don't forget about PediaCast CME. That stands for Continuing Medical Education. It's our sibling podcast. It's similar to this program. We turn the science up a couple notches and offer free Continuing Medical Education credit for those who listen. And that includes not only doctors, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.


And since Nationwide Children's is jointly accredited by many professional organizations, all of the ones I mentioned, it's likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements. Of course, you want to be sure the content of the episode matches your scope of practice.


Shows and details on the free Category I Continuing Medical Education credit is available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.


Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.






Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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