Validation of the Shin Pain Scoring System: A Novel Approach for Determining Tibial Bone Stress Injuries

Eric D Nussbaum; Charles J Gatt Jr; Robert Epstein; Jeffrey R Bechler; Kenneth G Swan; David Tyler; Jaynie Bjornaraa

doi:10.1177/2325967119877803

Validation of the Shin Pain Scoring System: A Novel Approach for Determining Tibial Bone Stress Injuries

Orthop J Sports Med. 2019 Oct 30;7(10):2325967119877803. doi: 10.1177/2325967119877803. eCollection 2019 Oct.

Authors

Eric D Nussbaum^{1

2}, Charles J Gatt Jr¹, Robert Epstein^{3

4}, Jeffrey R Bechler^{1

2}, Kenneth G Swan^{1

2}, David Tyler⁵, Jaynie Bjornaraa⁶

Affiliations

¹ Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.
² University Orthopaedic Associates, Somerset, New Jersey, USA.
³ Department of Radiology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.
⁴ University Radiology, New Brunswick, New Jersey, USA.
⁵ Department of Statistics and Biostatistics, Rutgers University, New Brunswick, New Jersey, USA.
⁶ St Catherine University, Minneapolis, Minnesota, USA.

Abstract

Background: The incidence of adolescent overuse injuries, including bone stress injuries (BSIs), is on the rise. The identification of a BSI in the early stages is key to successful treatment. The Shin Pain Scoring System (SPSS) was developed to aid clinicians in identifying patients with a BSI.

Hypothesis: The SPSS will correlate with magnetic resonance imaging (MRI) grading of a BSI in an adolescent population.

Study design: Cohort study (diagnosis); Level of evidence, 2.

Methods: Enrolled in this study were 80 adolescent high school athletes between the ages of 13 and 18 years participating in a variety of sports with more than 1 week of atraumatic shin pain. The SPSS questionnaire was completed for each participant, and physical examination findings were recorded. Each question and physical examination item was allotted a point value, which totaled 29 points. Radiographs and MRI scans of both lower legs were obtained for each participant. The SPSS score was statistically analyzed using logistic regression, a classification matrix, and a 2 × 2 contingency table to evaluate validity and predictability.

Results: Logistic regression analysis of our data determined that 3 categories of SPSS scores provided the highest diagnostic value when compared with MRI grading based on the Fredericson classification (0-4). The SPSS correctly identified 43.5% of injuries for category 1 (MRI grades 0-1), 62.5% for category 2 (MRI grade 2), and 50.0% for category 3 (MRI grades 3-4). Overall, the SPSS correctly identified the degree of BSI in 54.4% of all tibias studied. Binary analysis for validity demonstrated a sensitivity of 96%, specificity of 26%, positive predictive value of 76%, and negative predictive value of 71% for the SPSS relative to the "gold standard" MRI results.

Conclusion: The SPSS is a potentially valid method to identify tibial BSIs, given the sensitivity and negative and positive predictive values. It also provides helpful categorization to alert clinicians to the presence of a BSI and direct further diagnostics and/or interventions. The SPSS should be considered as an additional tool to use when evaluating adolescents with atraumatic tibial BSIs.

Keywords: adolescent; scoring system; shin pain; stress fracture.