What is the next best step for a 21-year-old male with bilateral medial tibial stress syndrome (shin splints) who has persistent pain despite 6-8 weeks of rest and no relief with naproxen (nonsteroidal anti-inflammatory drug, NSAID)?

From the Guidelines

The next best step for a 21-year-old male with bilateral medial tibial stress syndrome (shin splints) who has persistent pain despite 6-8 weeks of rest and no relief with naproxen is to obtain imaging studies, specifically an MRI, to rule out stress fractures or other underlying conditions that may be contributing to the persistent symptoms. According to the study by 1, imaging studies such as MRI can be useful in detecting degenerative changes, chronic tendinopathy, and partial tears, which may be relevant in this case.

The patient's persistent pain despite rest and NSAID treatment suggests that the condition may be more complex than simple shin splints. Some key points to consider in the management of this patient include:

• The use of relative rest, avoiding high-impact activities, to prevent further injury and allow the tissues to heal
• The potential benefits of physical therapy, focusing on proper biomechanics, strengthening exercises for the lower leg muscles, and gradual return to activity
• The importance of cross-training with low-impact activities like swimming or cycling to maintain cardiovascular fitness without exacerbating symptoms
• The need for further investigation, including imaging studies, to rule out underlying conditions such as compartment syndrome or stress fractures, which may require different management approaches, including possible surgical intervention in severe cases.

It is also important to note that the study by 1 suggests that eccentric exercise has proved beneficial in Achilles tendinosus and patellar tendinosus, and may be helpful in other tendinopathies, including medial tibial stress syndrome. However, the patient should be referred to a sports medicine specialist or orthopedist for further evaluation and management, as they can provide more specific guidance on the best course of treatment.

From the Research

Next Steps for Bilateral Medial Tibial Stress Syndrome (Shin Splints)

Given the persistent pain despite 6-8 weeks of rest and no relief with naproxen, a nonsteroidal anti-inflammatory drug (NSAID), the next best steps should consider the complexities of chronic pain and the potential effects of NSAIDs.

• Reevaluation of Pain Management: The patient's condition may require a more integrated approach to pain management, considering the biopsychosocial aspects of pain, as suggested by 2. This includes assessing the patient's overall well-being, psychological factors, and social environment, in addition to the physical symptoms.
• Alternative Pharmacologic Options: Since naproxen has not provided relief, other pharmacologic options might be considered. However, it's crucial to weigh the benefits against potential risks, especially considering the association between NSAID use and increased risk of stress fractures or delayed healing, as indicated by 3.
• Non-Pharmacological Interventions: Education, exercise, and cognitive behavioral therapy are effective non-pharmacological approaches for managing chronic pain, as noted by 2 and 4. These methods can be used alone or in combination with pharmacotherapy.
• Consideration of NSAID Side Effects: The patient's lack of response to naproxen and the potential for NSAIDs to cause central nervous system effects, as discussed in 5, should be taken into account. This might involve exploring alternative treatments that have fewer side effects or considering the patient's overall health profile to minimize risks.
• Multidisciplinary Approach: Given the complexity of chronic pain conditions, a multidisciplinary approach involving healthcare professionals from various specialties could provide a more comprehensive treatment plan, addressing both the physical and psychological aspects of the patient's condition, as suggested by 2 and 4.