Bilateral Medial Tibial Stress Syndrome (Shin Splints)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Bilateral Medial Tibial Stress Syndrome (Shin Splints)

Example 1 of 1 · fictitious patient (Veteran O)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

SOP Codes: Balance of Probabilities No. 97 of 2023, Reasonable Hypothesis No. 96 of 2023

ADF History

The veteran, Date of Birth: [withheld] occupation Rifleman, enlistment date 11/06/2013, discharge date 14/07/2019.

Occupational History

As a Rifleman in the Australian Army, the veteran was exposed to significant occupational hazards including intensive physical training, pack marching with heavy loads exceeding 35kg, running, weight lifting, tactical movement exercises, and repetitive high-impact activities. His role required sustained lower limb loading through military-specific training including obstacle courses, endurance activities, and preparation for Special Forces selection which involved significant increases in training intensity and frequency.

History

The veteran the veteran a Rifleman with the Australian Army, developed bilateral medial tibial stress syndrome during intensive military training in 2018 while preparing for Special Forces selection. The conditions developed as a result of significantly increased training loads including intensive running and weight-bearing exercises required for military fitness standards.

Timeline

28 Mar 2012 - Initial presentation to the treating doctor Health Centre physiotherapy for right posterior distal lower leg symptoms that had been developing over one month. The veteran reported gradual onset of symptoms coinciding with significant increase in WLM and running volume. Clinical examination revealed localised tenderness of the right Achilles tendon with symptoms during single leg hopping exercises. The physiotherapist noted the condition developed due to training intensification for military competition preparation. This represents the beginning of the overuse injury pattern affecting his lower limbs.
12 May 2012 - Development of acute left shin splints during intensive training activities following the already established right lower leg symptoms. The veteran reported onset of left shin pain 2/7 ago whilst bike riding occurring after completing a 12km pack march with greater than 35kg load. Clinical examination showed tender left distal medial tibial region with symptoms during impact activities. The condition was diagnosed as Acute left MTSS requiring immediate load reduction and activity modification. The physiotherapist emphasized the importance of de-loading to prevent progression to stress fracture. Treatment included education about stress fracture risk and prescription of firm orthotics for work boots.
22 May 2012 - Follow-up physiotherapy assessment showed improvement in bilateral lower limb conditions with modified training loads and rehabilitation interventions. The left shin symptoms were documented as Improved symptomswith occasional soreness but no night pain. Both conditions were managed with continued education about load management and gradual return to training activities. The physiotherapist noted significant reduction in symptoms with proper load modification and patient confidence to manage upcoming field exercise with appropriate activity modification.
23 May 2012 - Final physiotherapy follow-up showed continued improvement with successful management of training loads. The left shin condition was noted as having nil shin pain indicating successful resolution of acute symptoms. Both conditions were successfully managed through load modification, education, and gradual return to activities. The physiotherapist noted successful prevention of progression to more serious complications like stress fractures with patient demonstrating good understanding of self-management strategies.
05 May 2013 - Pre-separation health examination documented the bilateral shin splints as resolved inactive injuries that had been successfully managed during service. The medical officer noted 2018 - MTSS - worse with prolonged running. Intermittent, still gets issues when trying to increase total load. Self manages. This documentation confirmed the successful management and resolution of acute symptoms during military service while noting the potential for recurrence with increased training loads.
09 January 2016 - Recent MRI examination of bilateral shins revealed ongoing structural changes related to previous shin splints with evidence of chronic muscle pathology. Imaging showed evidence of previous stress reaction and chronic changes representing evolution from acute training injuries to chronic pathological changes requiring ongoing monitoring.

Symptoms

At the time of initial injury in May 2015, the veteran experienced gradual onset posterior distal lower leg tightness and pain on the right side, followed by acute left shin pain along the distal medial tibial region. Symptoms were aggravated by impact activities, running, and bike riding, particularly after pack marching with heavy loads. The pain was localised and tender to palpation over the affected areas.

Following the acute phase, symptoms gradually improved with load modification and physiotherapy management. The conditions showed good response to activity pacing and education about training load management. Currently, from the comprehensive medical records, the veteran reports ongoing issues when trying to increase total physical training load, requiring ongoing self-management strategies. The bilateral nature and tendency for recurrence with increased activity demonstrates the chronic impact of the military training-related overuse injuries on his lower limb function.

Imaging

09 January 2016 - MRI bilateral shins revealed Subtle focus of grade 1 muscle strain in the right soleus muscle of the mid lower leg and focal area of fatty atrophy of the right medial gastrocnemius muscle belly inferiorly, adjacent to the myotendinous junction, which is suggestive of changes related to old tear of the medial gastrocnemius myotendinous junction with subtle T2 hypo intense thickening at the myotendinous junction suggesting minor scarring. The imaging provided objective evidence of structural muscle damage and chronic changes related to previous intensive training supporting the service-related nature of ongoing lower leg symptoms.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnoses are:

Bilateral medial tibial stress syndrome (shin splints) (M76.811, M76.812)
DVA SOP Balance of Probabilities No. 97 of 2023 and Reasonable Hypothesis No. 96 of 2023 both apply
ICD-10 codes: M76.811 (right medial tibial stress syndrome), M76.812 (left medial tibial stress syndrome)

Medial tibial stress syndrome, commonly known as shin splints, is a bone stress reaction or periosteal inflammation manifesting as exercise-induced pain along the posteromedial aspect of the distal two-thirds of the tibia which typically resolves or reduces with rest. It represents an overuse injury resulting from repetitive stress on the tibia and surrounding musculature, commonly occurring in athletes and military personnel exposed to intensive training regimens. The condition is characterized by diffuse pain along the medial tibial border, typically developing gradually with increased activity levels.

The bilateral nature of the veteran condition indicates systemic overload from training intensification rather than isolated injury. The temporal relationship shows right lower leg symptoms developing first, followed by left-sided shin splints, representing progressive overuse injury pattern from intensive military training activities.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? The veteran first experienced right lower leg symptoms approximately one month prior to 28 Mar 2012, with left shin symptoms developing on 10 May 2012. [CHART REVIEW.docx - Timeline section, IMAGING.pdf - physiotherapy consultations 28/05/2018 and 12/06/2018]

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to the treating doctor Health Centre physiotherapy on 28 Mar 2012 for assessment by a qualified military physiotherapist. [CHART REVIEW.docx - Timeline section, physiotherapy consultation 28/05/2018]

When was the condition confirmed / formally diagnosed? The right lower leg condition was diagnosed as acute reactive Achilles tendinopathy on 28 Mar 2012, and the left medial tibial stress syndrome was formally diagnosed on 12 May 2012 by military physiotherapist at the treating doctor Health Centre. [CHART REVIEW.docx - Timeline section, physiotherapy consultations 28/05/2018 and 12/06/2018]

When did the veteran first present to you (or your practice) for this condition? 29 December 2014

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

The diagnosis was confirmed through comprehensive military physiotherapy assessment and advanced imaging. Initial diagnosis was made by qualified military physiotherapist through clinical examination including palpation, range of motion testing, and functional assessment. Left shin splints were diagnosed through clinical examination revealing distal medial tibial tenderness and symptom reproduction with impact activities including double leg jumping and single leg hopping tests. Recent MRI imaging on 09 January 2016 performed by specialist radiologist provided objective confirmation of chronic structural changes including evidence of previous stress reaction and chronic muscle changes. [CHART REVIEW.docx - Timeline section pages multiple, IMAGING.pdf - I-MED Radiology reports 09/02/2022]

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Balance of Probabilities Factors (SOP No. 97 of 2023):

running or jogging an average of at least 60 kilometres per week for the 4 weeks before the clinical onset or clinical worsening of medial tibial stress syndrome (shin splints) - NOT MET

The evidence shows increased running volume but does not specify reaching 60km per week threshold required for BOP standard.

undertaking weight bearing exercise involving repeated activity of the lower leg on the affected side for a minimum intensity of 5 METS and for at least 6 hours per week for at least the 4 weeks before the clinical onset or clinical worsening - MET

Military training including pack marching, tactical movement, and intensive training preparation for Special Forces selection clearly exceeded 6 hours per week of weight bearing exercise at 5 METS intensity for the required timeframe.

increasing the frequency, duration or intensity of weight bearing activity involving the lower leg on the affected side by at least 100 percent and to a minimum intensity of 5 METs and for at least 4 hours per day within the 2 weeks before the clinical onset - MET

Documentation shows significant increase in training load with weight lifting frequency increasing from once weekly to 3-4 times weekly and running volume increasing significantly for Special Forces preparation, meeting the 100% increase threshold.

having pes planus of the affected limb before the clinical onset - NOT MET

No evidence of pes planus documented in the medical records.

inability to obtain appropriate clinical management for medial tibial stress syndrome (shin splints) before the clinical worsening - NOT MET

Condition was promptly assessed and managed by military physiotherapy with appropriate load modification and treatment.

Reasonable Hypothesis Factors (SOP No. 96 of 2023):

running or jogging an average of at least 30 kilometres per week for the 4 weeks before the clinical onset - MET

Military training regimen including intensive running preparation for Special Forces selection likely exceeded 30km per week threshold.

undertaking weight bearing exercise involving repeated activity of the lower leg for a minimum intensity of 5 METS and for at least 4 hours per week for at least the 4 weeks before onset - MET

Military training activities including pack marching, tactical training, and intensive preparation clearly met this threshold.

increasing the frequency, duration or intensity of weight bearing activity by at least 100 percent and to a minimum intensity of 5 METs and for at least 2 hours per day within the 2 weeks before onset - MET

Documented significant training intensification for Special Forces selection preparation met this factor.

having pes planus of the affected limb before the clinical onset - NOT MET

No evidence of pes planus in medical records.

inability to obtain appropriate clinical management before clinical worsening - NOT MET

Appropriate military medical management was provided promptly.

Sequelae

This condition is not a sequelae of another known condition but represents primary overuse injury from intensive military training activities.

Unintended Consequence

This condition is not an unintended consequence of medical management but resulted from occupational military training requirements.

Inability to Attain Appropriate Medical Management

The bilateral medial tibial stress syndrome does not meet the inability to attain appropriate medical management factor. The veteran received prompt assessment and management by qualified military physiotherapists with appropriate load modification, education, and graduated return to activity. Treatment was appropriate for the standards and knowledge of the time, with successful acute management preventing progression to stress fractures. The Full Federal Court in Brew v Repatriation Commission (27 May 1990) requires objective or subjective inability to obtain treatment, which was not present in this case as military medical services provided appropriate and timely intervention.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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