Dedication Simple Solutions Experience

67 year-old woman with unrelenting shin pain following a hip replacement

This case turned out to have a simple solution, although the bearer of the leg pain never would have guessed it when she first visited me. She'd had a successful replacement for a severe left hip arthritis four months prior to visiting me. But for the six weeks prior to seeing me, she'd been experiencing worsening pain in her right shin, and neither her internist, her physical therapist, her hip surgeon, or her podiatrist had an explanation. She was frustrated, because everyone she'd seen for this new pain seemed to not listen or care that it was becoming severe, and didn't attempt to figure out what it was or why it started.

This case dovetails nicely with the previous case of the businessman with the ankle pain. That's because it also has to do with leg length differences. One of the most frequent "side effects" I see in patients who've had hip replacement surgery is a difference in the length of their legs. I imagine it must be extremely difficult for a surgeon to assure that leg length will be symmetrical after hip replacement, considering variations in bone density, seating of the prosthesis in the bone, muscle contraction, preexisting leg length differences, etc.

In this patient's case, there was focal extreme tenderness to palpate her mid-right tibia or shinbone. The tenderness only occupied an area about a half-inch wide. Classically this usually represents a stress reaction or stress fracture, rather than shin splints, which usually are tender about a much greater area of the shinbone. Stress reactions in the tibia are caused by too much impact, and are common in dancers who switch from soft floors to hard floors, or in runners who begin running outdoors after having been used to cushy treadmills.

So why should she have what looked like a stress reaction in her right tibia if the obvious reason for stress transferred to that leg—namely a painful arthritis in the opposite hip—had been successfully taken care of? If you refer to the final paragraphs of the case of the 35-year-old businessman with unrelenting ankle pain, you'll see how we cover leg length and its effect on calf tightness or looseness. In the case of this current patient with the worsening shin pain, I found her operated hip side had a ¾-inch shorter leg. I also found, as in the case of the man with the ankle pain, that her shorter leg had a very tight calf, and her long leg—the leg that hurt—had a much looser calf. This newly-long leg had to do something to even out the leg length difference, so it tried to make itself as short as possible. The only way to do that was to not do the tip-toe action of push-off which normally happens at the end of each stride.

Not tip-toe-ing, or heeling-off, quickly resulted in weakness in this calf due to disuse. I was able to measure this when I tested her calf flexibility and found it to be extremely over-flexible on the side with the longer leg (and hurting shin). How did his extreme calf flexibility result in an impact injury to her shin?

Think of the calf as a parachute which brings the heel in for a landing. If a calf is weak or hyperflexible, it will not be an efficient parachute, and the heel will begin to impact the ground too forcibly. In an older patient, who likely has decreased bone density (resistance to impact) and who'd likely already been stressing the leg opposite her bad hip for years, a stress injury to this leg is just waiting in the wings.

Her treatment? Begin calf-strengthening exercises (tip-toe repetitions), and begin Pilates exercises to strengthen the muscles about the pelvis (whose strength will also slow down heel impact), but mainly begin using a ¼" heel lift on the short side to enable the long side to begin heeling-off properly in stride and regain its strength.

It was a delight to receive a call from her. She was amazed. One month after seeing me, her pain was gone. I advised her to only gradually increase her activities, and keep in touch.

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