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Lower Leg Pain In An Elite Level Triathlete: A Case Study

Posted on April 28, 2010 in ,

Chad R. Barylski, DC, DACBSP, CSCS a , Reiko Takahashi, MS, ATC, CSCS a, John Crawley, MS b, Bill Moreau, DC, DACBSP c a Sports Medicine Fellow, Performance Services, United States Olympic Committee, Chula Vista, CA b Exercise Physiologist, High Performance Director, United States Olympic Committee, Chula Vista, CA c Director of Sports Medicine Clinics, United States Olympic Committee, Colorado Springs, CO

HISTORY: A 23-year old female elite triathlete presents with insidious right medial lower leg pain. Pain was increased with running and climbing out of the saddle. Pain is sharp and tender over a focal area on proximal medial tibia. Pain is rated 8/10 during activity and 2/10 at rest. The athlete’s medical history includes 8 stress fractures, osteopenia, anemia, amenorrhea, and anorexia.

PHYSICAL EXAM: Localized edema, +2 TTP along the proximal medial aspect of the right tibia, +2 hypertonicity of the soleus, flexor digitorum and posterior tibialis. AROM was decreased in inversion and dorsiflexion with 4/5 strength with resisted inversion. Video analysis of running gait revealed varus hindfoot, prolonged forefoot pronation, & genu valgum. Orthopedic & neurological evaluation was unremarkable.


  • Posterior Tibial Stress Syndrome
  • Exertional Compartment Syndrome
  • Periostitis of the Tibia
  • Posterior Tibialis/Flexor Digitorum/Soleus strain/tendonitis
  • Tibial Stress Fracture

TESTS AND RESULTS: X-Rays were unremarkable. Diagnostic Ultrasound revealed mild inflammation along the Posterior Tibialis and Flexor Digitorum. MRI revealed findings consistent with a stress fracture at the proximal tibia. DEXA T-Scores were 0.0 for left hip and -1.3 for lumbar spine. Lab studies were “In Range”.

FINAL/WORKING DIAGNOSIS: Proximal Tibial Stress Fracture.


  • Manual therapies, physiotherapeutic modalities, rehabilitation, & chiropractic manipulation.
  • Running orthotics, shoe and bike pedal modifications.
  • Alteration of training program, utilization of an anti-gravity treadmill.
  • Nutritional evaluation
  • Sports Psychology Counseling.