An insidious onset of shin pain in a young athlete after a sudden increase in activity. There is focal tenderness and some surrounding edema. What is the most likely diagnosis and the next step in management?

• A. Shin splints; rest and NSAIDs
• B. Tibial stress fracture; order a plain film
• C. Compartment syndrome; urgent fasciotomy
• D. Osteomyelitis; MRI

Answer: (B)

When a young athlete develops shin pain that starts insidiously after a sudden jump in activity and there is focal tenderness with some surrounding edema, think tibial stress fracture from overuse. The most appropriate next step is to obtain a plain radiograph of the tibia to look for a fracture line or periosteal reaction. While early stress injuries can be radiographically occult, X-rays are the first imaging test to establish the diagnosis; if the film is negative but clinical suspicion remains high, more sensitive imaging such as MRI or bone scan can detect a stress reaction or fracture that isn’t yet visible on X-ray. Shin splints tend to cause diffuse, not focal, tibial pain; compartment syndrome presents with severe pain out of proportion to exam, tense swelling, and pain on passive stretch; and osteomyelitis would typically involve systemic signs or risk factors and is not the most likely diagnosis in this presentation.