Anterior Shin Injury with Pop, Hematoma, and Pain on Dorsiflexion
This clinical presentation is most consistent with a tibialis anterior muscle or tendon injury (strain or partial tear), and you should initiate immediate PRICE protocol (Protection, Rest, Ice, Compression, Elevation) with functional support using a removable boot or lace-up ankle support, NSAIDs for pain control, and arrange follow-up imaging if symptoms persist beyond 1-2 weeks.
Initial Clinical Assessment
The key diagnostic features to evaluate immediately include:
- Mechanism of injury: A "pop" sensation in the anterior shin during dorsiflexion suggests acute muscle-tendon unit disruption 1
- Functional testing: Assess active dorsiflexion strength against resistance—weakness or inability to dorsiflex suggests significant tibialis anterior involvement 2
- Palpation: Localize tenderness along the anterior tibial border and tibialis anterior muscle belly; a palpable defect suggests complete rupture 1
- Hematoma location: Distal third anterior shin hematoma with pain on dorsiflexion is highly specific for tibialis anterior injury 2
- Neurovascular status: Ensure no compartment syndrome signs (severe pain out of proportion, pain with passive stretch, tense compartment) 1
Critical pitfall: Do not dismiss this as simple "shin splints"—the acute "pop" with immediate hematoma distinguishes this from chronic medial tibial stress syndrome 3, 1.
Immediate Management (First 72 Hours)
PRICE Protocol
- Protection: Use a removable boot or lace-up ankle support to limit dorsiflexion stress while maintaining some mobility 4
- Rest: Avoid activities requiring active dorsiflexion for 48-72 hours 4
- Ice: Apply cryotherapy to reduce swelling and pain 4
- Compression: Use compressive wrapping to control hematoma expansion 4
- Elevation: Elevate the leg to minimize swelling 4
Pharmacologic Management
- NSAIDs: Initiate nonsteroidal anti-inflammatory drugs to reduce swelling and pain, which may accelerate return to activities 4
Weight-Bearing Status
- Immediate weight-bearing as tolerated with assistive devices (crutches) for comfort if needed 5
- The patient can bear full weight if tolerable, but should use the removable boot for protection 5
Imaging Strategy
Initial Imaging Decision
Radiographs are NOT immediately indicated unless you suspect:
- Avulsion fracture at the tibialis anterior insertion
- Associated tibial stress fracture
- Inability to bear weight (meeting Ottawa Ankle Rules criteria) 4
If radiographs are obtained and negative, but symptoms persist beyond 1-2 weeks:
Advanced Imaging for Persistent Symptoms
- MRI without contrast is the gold standard for evaluating muscle-tendon injuries, determining extent of tear (partial vs. complete), and guiding treatment decisions 4
- MRI will show muscle edema, hematoma size, tendon integrity, and any associated bone stress injury 4
- Ultrasound can be used as an alternative for focused evaluation of the tibialis anterior tendon, with the advantage of dynamic assessment 4
Follow-Up and Rehabilitation
Re-evaluation Timeline
- Reassess at 3-5 days: Determine if symptoms are improving with conservative management 4
- Reassess at 2-3 weeks: If no improvement or worsening symptoms, obtain MRI to evaluate for complete tear or other pathology 4
Rehabilitation Protocol
Once acute pain subsides (typically 5-7 days):
- Graded exercise regimen with progressive strengthening of ankle dorsiflexors 4
- Proprioceptive training using ankle disk exercises to prevent recurrent injury 4
- Gradual return to activity based on pain-free dorsiflexion strength
Red Flags Requiring Urgent Referral
- Inability to actively dorsiflex the foot suggests complete tibialis anterior rupture requiring surgical evaluation 2
- Palpable tendon defect warrants orthopedic or sports medicine referral 2
- Compartment syndrome signs (severe pain, tense compartment, pain with passive plantar flexion) require emergency surgical consultation 1
- No improvement after 2-3 weeks of conservative management 4
Special Considerations
Diabetic patients with neuropathy: Consider more protective immobilization with a non-removable boot and partial weight-bearing until healing is confirmed, as pain may not be a reliable indicator 5.
Athletes: Early MRI may be warranted to determine exact injury grade and expedite return-to-sport planning 4.