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4 
Copyright © by Indiana State University         Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188   Volume 1 – Issue 2 – October 2018 

Exercise Dependence and Shin Pain in a Division I Cross-Country 
Runner: A Case Study 
Allyssa K. Memmini, MS, ATC 
University of Michigan, Ann Arbor, MI 

ABSTRACT 

The following case investigates insidious onset of shin pain in 
a Division I female cross-country runner. Though her initial 
evaluation revealed early onset medial tibial stress 
syndrome, the sequence of events that occurred immediately 
afterwards is what makes this case unique. As the student-
athlete underwent lower extremity rehabilitation to increase 
her mileage, she reported that her pain had plateaued. The 
initial x-ray revealed a periosteal reaction of the posterior 
left tibia. After adhering to the treatment plan for four 
weeks, the student-athlete continued to report significant 
bouts of pain as demonstrated by the Visual Analog Scale. A 
follow-up x-ray revealed a transverse fracture through the 
proximal tibia. It was discovered through teammates that she 
was exercising at the university’s recreation center for up to 
three extra hours per day, despite set limitations by the 
athletic trainers, team physician, and coaches. Her roommate 
also confided in the coaching staff that there were instances 
of the student-athlete deliberately skipping meals, and even 
conducted bouts of binging and purging. The student-athlete 
was immediately removed from team activities and referred 
to the team physician, who reviewed her case and relevant 
medical history. Further, she was referred to additional 
behavioral counseling for disordered eating, obsessive 
compulsive tendencies, and her idealization of weight and 
excessive exercise. Although true exercise addiction is rare, 
the comorbidity rate in patients with disordered eating is 
clinically relevant. The Exercise Addiction Inventory is a 
simple and reliable questionnaire for healthcare providers to 
utilize during pre-participation examinations as a way of 
identifying athletes who may have a related medical history, 
and greater risk of developing comorbidities. 

Key Phrases 
Emotional wellness and mental health, comorbidities, college 
and university patient population 

Correspondence 
Allyssa K. Memmini, University of Michigan, 401 Washtenaw 
Ave. Ann Arbor, Michigan 48109 
E-mail: amemmini@umich.edu

Full Citation 
Memmini AK. Exercise dependence and shin pain in a division 
I cross country runner: a case study. Clin Pract Athl 
Train.2018;1(2):4-8. 
https://doi.org/10.31622/2018/0002.2  

Submitted: August 6, 2018  Accepted: October 4, 2018 

INTRODUCTION 

A Division I female cross-country runner with a 

previous history of depression, anorexia, and 
bulimia nervosa presented with increasing left 
proximal shin pain at the beginning of winter 
training. Initial evaluation revealed early-onset 
medial tibial stress syndrome, which was treated 
conservatively for two weeks with instrument 
assisted soft tissue mobilization, as well as 
intrinsic foot, gluteus medius and calf 
strengthening. Despite defined parameters for 
cross-training, in addition to daily rehabilitation 
and treatment, her reporting of pain remained 
relatively high compared to her baseline levels 
at the onset of medical care. As cross-country is 
often defined as an aesthetic sport, this student-
athlete experienced episodes of body 
dysmorphia, depression, disordered eating 
habits, and even unhealthy patterns of excessive 
exercise. At this time, the student-athlete was 
referred to our team physician, nutritionist, and 
behavioral psychology department for further 
evaluation. 

Patient Information 

Patient: The student-athlete is a female cross-
country runner (age=20years; height: 1.91m; 
mass: 56.9kg). She had a previous history of 
bilateral tibial and metatarsal stress fractures 
that began as a freshman in high school and 
occurred intermittently until her senior year of 
college. She was consistently meeting with a 
psychiatrist through the institution for episodes of 
anorexia nervosa and bulimia, which initially 
began upon arrival to campus. The student-
athlete’s parents were well-known 
ultramarathoners – sometimes running up to 80-

https://doi.org/10.31622/2018/0002.2


Exercise Dependence and Shin Pain in a Division I Cross-Country Runner: A Case Study 

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Copyright © Indiana State University  Clinical Practice in Athletic Training 
ISSN Online 2577-8188 Volume 1- Issue 2 - October 2018

100 miles a weekend which may have added 
additional pressure for her success. In terms of 
family dynamic, she would often report a 
distanced relationship between herself and her 
father, and a heightened desire to please her 
parents. Although she has an extensive medical 
history specifically related to the female athlete 
triad, her parents would often minimize her 
injuries, such as blaming the reoccurrence of 
injuries on inconsistent wear of compression socks 
or inadequate turnover rate in her training shoes. 

Differential Diagnosis and Evaluation 

The student-athlete presented with left shin pain 
of insidious onset. She denied night pain, 
including difficulty falling or staying asleep, and 
denied antalgic gait pain during the first few 
steps after awakening. When asked to point 
where the pain resides, she was able to locate 
the muscle belly of the tibialis anterior. She 
reported that it did not replicate the same pain 
that she experienced previously during her 
numerous stress injuries. In general, she reported 
the most discomfort while ascending and 
descending staircases when her ankle was 
positioned in full plantarflexion. She reported no 
difficulty completing activities of daily living, but 
reported that she could only run one mile before 
the symptoms became bothersome. The 
differential diagnoses list included: chronic 
exertional compartment syndrome, tibialis 
anterior contusion, tibial stress reaction or 
fracture, fibular stress reaction or fracture, and 
medial tibial stress syndrome. With continuation 
of rehabilitation and controlled training 
parameters, her reporting of pain remained 
moderately high. After an additional two weeks 
of rehabilitation, initial x-rays confirmed a left 
proximal periosteal tibial stress reaction, and she 
was again limited in weight-bearing training. 
Approximately four weeks post-imaging, a 
follow-up x-ray revealed a complete transverse 
fracture through her left proximal tibia.  

Body Structure and Function 

Upon examination, she was tender to palpation 
along the muscle belly of the tibialis anterior and 
its insertion of the muscle onto the tibia, but did 
not present with edema surrounding the muscle 
belly, or effusion within the tibiofemoral joint. 
There were no other signs of trauma. A tuning 
fork was placed at her tibial tuberosity and 
along her distal tibial shaft to determine any 
areas of stress-related injury. She denied pain at 
all of the locations that the tuning fork was 
placed. The patient reported pain was a 4/10 
measured with the Visual Analog Scale. When 
compared bilaterally, she demonstrated full 
active and passive ankle and knee ranges of 
motion and were all within normal limits. Manual 
muscle tests demonstrated weakness of the left 
tibialis anterior (4/5), gastrocnemius (4/5), 
medial hamstring (4/5) and gluteus medius 
(4/5). During functional testing, she was able to 
complete calf raises without discomfort, but 
noted localized pain with double leg hopping 
(forward/backward and side-side).  

Activity and Participation 

Due to her medical history, the mileage assigned 
for this specific student-athlete was scaled back 
to 30-35 miles/week, in comparison to the rest 
of the team, which typically completed around 
60 miles. As a high school runner, she was very 
successful at regional and state track and field 
championships. When she initially arrived at the 
university, she presented with a significantly 
smaller frame than when she was first recruited, 
thus leading the coaching staff to believe she 
was suffering from some form of disordered 
eating or possible overtraining. She was referred 
to mental health counseling the following week 
and continued to work with counselors until her 
junior year of college. 

Environmental and Personal Factors 

She had a previous mental health history that 
included depression, anorexia nervosa, bulimia 
and most recently, suicidal ideation. The student-
athlete’s parents were well-known for competing 



Exercise Dependence and Shin Pain in a Division I Cross-Country Runner: A Case Study 

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Copyright © Indiana State University  Clinical Practice in Athletic Training 
ISSN Online 2577-8188 Volume 1- Issue 2 - October 2018

in ultramarathons, and appeared unconcerned 
about the number of stress-related injuries that 
she had accumulated over time.  

INTERVENTIONS 

The physician and athletic trainers outlined a 
structured cross-training plan to maximally 
reduce the amount of force through her shins 
while maintaining her overall fitness. The student-
athlete’s adherence to the treatment plan was 
demonstrated by completing rehabilitation at 
least three times during the week. Despite 
consistent treatment sessions with the athletic 
trainers, her symptoms continued to worsen with 
specified training intervals. When the team 
physician asked her to clarify her symptom 
reporting, she reported lower pain thresholds 
compared to what she reported to her athletic 
trainers and coaching staff. She was to solely 
complete one workout per day for a maximum of 
30 minutes on the bicycle, or 60 minutes in a 
pool setting. Her training progression would 
begin with aqua jogging or supervised bike 
workouts, and then eventually to elliptical and 
anti-gravity treadmill training until she became 
asymptomatic for at least eight weeks. 

OUTCOMES 

Body Structure and Function: Prior to her follow-
up x-ray, she described having a “drop foot” 
sensation while walking to class. Subsequent 
evaluation demonstrated knee joint effusion and 
edema at the proximolateral tibia. A 
neurological screen of the lower quarter was 
completed and proved to be negative. Despite 
rehabilitation to strengthen her gastrocnemius 
and tibialis anterior, she still lacked full strength 
in comparison to the contralateral side (4/5 
manual muscle testing).  

Activity and Participation 

Based on her numerous referrals, and previous 
physical and mental health history, the athlete 
ultimately decided that it was in her best interest 
to dismiss herself from all team activities. She 

was immediately removed from activity and 
referred to our team physician, who then 
referred her to mental health counseling and 
nutrition staff. In order to ensure that she had full 
potential to return to a healthy lifestyle, she had 
access to the same medical treatment that was 
available to her while actively participating on 
the team. Although she was no longer physically 
on the team, she remained active with the 
student-athlete community through an internship 
developed by the nutritional department. She 
volunteered her time by preparing post-practice 
meals, and setting up hydration stations 
throughout various facilities. She remained 
roommates with her previous teammates until her 
graduation the following spring. 

Environmental and Personal Factors 

Over the following weeks, the healthcare team 
was notified of the student-athlete completing 
numerous additional unsupervised cross-training 
sessions lasting between two to three hours at the 
university recreational center. Furthermore, the 
student-athlete’s roommate confided in the coach 
that she observed her skipping multiple meals 
throughout the week, and was behaving similarly 
to previous episodes of binging and purging. 
Even though there were several interventions 
between the student-athlete, coaches, and 
medical staff about the importance of 
compliance to the physician’s recommendations, 
she continued to complete additional workouts in 
secrecy. 

DISCUSSION: 

The literature reports an inconsistent prevalence 
of individuals suffering  from exercise 
dependence (EXD), ranging from 0.3% to 77%, 
yet the co-occurrence rate with persons 
diagnosed with anorexia nervosa is three times 
higher than other diagnoses of disordered 
eating.1-4 EXD is often described as a 
manifestation of uncontrollable exercise, 
increased tolerance, and associated anxiety/ 
depression with withdrawal of activity.2-4 A 



Exercise Dependence and Shin Pain in a Division I Cross-Country Runner: A Case Study 

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Copyright © Indiana State University  Clinical Practice in Athletic Training 
ISSN Online 2577-8188 Volume 1- Issue 2 - October 2018

component of EXD related to this patient 
specifically is continuance – the perpetuation of 
exercise despite comprehension of the potential 
to increase the physical deficits and interpersonal 
strains.4 Populations commonly affected by EXD 
include young women, high-performance 
athletes, and high achievers with associated 
body dysmorphia.4-6 Although this patient 
presented with several red flags in relation to 
the female athlete triad, the effects of a possible 
underlying diagnosis of EXD and additional bio-
psychosocial disorders on her initial shin pain 
make this case unique. 

A prominent strength in this case was the close-
knit relationship between the athletic trainers, 
team physician, and coaching staff. By 
maintaining thorough communication, the entire 
staff was able to provide the student-athlete the 
help that she crucially needed. Another strength 
was the willingness of her teammates to discuss 
her irregular eating and exercise patterns with 
the staff. Since it was difficult to know when the 
patient was truthful in her responses, the 
advocacy of her teammates assisted in an 
efficient transition to referral. On the other hand, 
a significant limitation included minimal 
communication with the sports medicine staff and 
the mental health counseling center on campus. 
Since the center is located outside of the athletic 
department, it was difficult for the athletic 
trainers to communicate their concerns and any 
crucial updates directly to the counselors. Another 
limitation includes the inability to control the 
student-athlete’s activity outside of the athletic 
training room and track facilities. Because she 
was able to walk, bike, and run anywhere on 
campus, she had greater capability to complete 
additional workouts, in contrast to someone who 
plays soccer or lacrosse and needs extensive 
equipment or teammates for activity. Lastly, 
there were no patient-reported outcomes 
tracked throughout this patient case beyond 
subjective pain. However, the background and 
psychosocial factors that influenced this case are 
still evident, and can help other athletic trainers 

understand how family and social factors 
influence difficult patient cases.  

CLINICAL BOTTOM LINE: 

Typical red flags in cases related to the female 
athlete triad include accelerated weight loss 
within a short period of time, dark and sunken 
orbitals, brittle nails, dissociation from team 
activities both on and off campus, and co-
morbidities such as depression, anxiety, and 
obsessive-compulsive disorder. Although the 
diagnosis of EXD is rare, there are a number of 
screening tools available for clinicians to utilize 
for the referral process should concerning 
histories present themselves. The Exercise 
Addiction Inventory is a simple survey with 
significant reliability when paired with other 
disordered eating questionnaires.7 Since the 
sports medicine staff did not utilize this scale with 
their current student-athletes, it is something to 
consider for future pre-participation screening, 
especially for student-athletes with relevant 
medical history. In general, athletic trainers 
should be well-educated about the long-term 
health risks of relative energy deficiency in sport, 
and employ supplemental resources when 
working with high-risk teams such as cross-
country, volleyball, and be aware of the effects 
related to aesthetic sports such as gymnastics, 
cheerleading, and swimming on athletes’ mental 
health and overall well-being. 

ACKNOWLEDGEMENTS: 

The author would like to thank all the members of 
the care team for their contributions, guidance, 
and clinical recommendations in providing care 
for this student-athlete. 

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Copyright © Indiana State University  Clinical Practice in Athletic Training 
ISSN Online 2577-8188 Volume 1- Issue 2 - October 2018

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