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How can you help athletes prevent and treat shin splints?
Encourage patients who are concerned about shin splints to decrease the intensity of their running; suggest rest and ice and foot orthoses, to treat the condition. Reducing running intensity probably reduces lower extremity soft tissue injuries (strength of recommendation [SOR]: B, low-quality randomized controlled trials [RCTs]), although doing stretching exercises doesn’t. Rest and ice alone promote faster recovery than rest and ice combined with nonsteroidal anti-inflammatory drugs (NSAIDs), a walking cast, or heel-cord stretching. (SOR: B, low-quality RCT). Although foot orthoses or insoles don’t prevent lower limb injuries (SOR: A, systematic review), they do significantly relieve symptoms and promote return to running (SOR: C, poor-quality cohort studies). Lower limb fasciotomy can reduce symptoms caused by shin splints in athletes, but the rate of return to previous level of sports activity is modest at best (SOR: C, case series).
Review, rest, follow-up
Doug Aukerman, MD
Pennsylvania State University, State College
Shin splints are an early indicator of abnormal stresses that cause periostitis along the tibia. Medial tibial stress syndrome (MTSS) is best thought of as part of a continuum, with shin splints at the mild end and tibial stress fracture at the severe extreme. I find that reviewing biomechanical forces and training schedules often helps prevent and treat injury. Aging footwear and training errors, including a rapid increase in training volume, are common culprits when biomechanics are normal. Adequate rest to allow the body to respond to the stresses of training can help prevent stress-related injuries.
My treatment regimen for shin splints includes a period of relative rest that allows the runner to remain active but reduces the stresses placed on the tibia and musculature of the lower leg. Relative rest may comprise either reducing running distance and intensity or changing the mode of exercise to deep water running or cycling. Consider follow-up examination to ensure that the tibial pain doesn’t become more localized, indicating a possible stress fracture.
Evidence summary
MTSS, or shin splints, is the most common cause of exertional leg pain in athletes. MTSS is an overuse injury characterized by pain along the posteromedial aspect of the distal two-thirds of the tibia.
Reduced running time, frequency, and distance may prevent injury
A systematic review of 12 trials of 8806 mostly young male military recruits, evaluated nonsurgical interventions to prevent lower limb soft tissue running injuries, including MTSS.1 Five trials investigating stretching and 4 trials of shoe insoles showed no benefit. Three studies showed that reducing the duration of running (to between 15 and 30 minutes), frequency (to 1 or 3 days a week), or distance (to 16.5 fewer kilometers over 12 weeks) reduced the risk of all injuries. Methods and outcome measures of the studies were heterogeneous, limiting the generalizability of these results.
A prospective RCT of custom semi-rigid shoe orthoses in the boots of Danish army recruits found a significantly lower prevalence of MTSS at 3-month follow-up in the intervention group (13% compared with 24%, P=.005; NNT=5).2 However, a systematic review of methods to prevent MTSS in sports found no high-quality studies in nonmilitary populations.3 No difference in the incidence of MTSS was noted with shoe inserts, different combat boots, or stretching routines.
To treat shin splints, consider orthotics, rest, and ice
Two studies retrospectively surveyed runners about their response to orthotics to treat MTSS.4,5 In one study, 16 of 41 collegiate cross-country runners were prescribed orthotics; 14 (88%) reported relief or improvement in their symptoms and return to running within 4 weeks.4 The other survey, of long-distance runners, found that 70% who had used or were using orthotics for a presumed diagnosis of MTSS reported complete relief or great improvement.5
A study of 97 US naval midshipmen who developed MTSS during summer training programs compared randomly assigned treatments of rest and ice to rest and ice plus anti-inflammatory medication (aspirin or phenylbutazone), rest and ice plus heel-cord stretching, or use of a short walking cast for 1 week.6 Subjects assigned to a treatment program of rest and ice alone lost significantly fewer days from running than the other treatment groups (P<.03).
A recent RCT of soldiers with MTSS compared treatment with a leg orthosis with no orthotic use; all subjects underwent icing and activity modification.7 No significant differences in outcome measures (days to completion of a 0.5-mile run, global rating of change, or number of treatment sessions) were noted between the treatment groups. Small sample size, high dropout rate, and small effect size limit the power of this study.
Fasciotomy can relieve symptoms but may not improve postop activity
Three case series reported on deep posterior compartment fasciotomy to treat MTSS in athletes.8-10 Surgery significantly reduced pain levels (P<.001) by an average of 72% on the visual analog pain scale for 46 patients who had failed conservative therapy for at least 12 months.8 However, only 41% returned to their pre-symptom level of sports activity. Another case series of mostly running athletes reported that 21 (78%) of 27 patients exhibited excellent or good healing after surgery.9 In a series of 9 patients with an average of 39 months of symptoms, 5 reported complete relief at follow-up (42±6 months), and 7 trained more than they had preoperatively.10
One case series of superficial posterior compartment fasciotomy for MTSS in 35 athletes reported that, among the 32 athletes available for follow-up, 72% (23) reported improved symptoms, but 69% (22) had a lower level of activity postoperatively.11
Recommendations
The American College of Sports Medicine (ACSM) recommends at least 7 to 10 days of rest from painful activities to treat MTSS.12 Running in a pool and cycling to maintain aerobic fitness during the rest period are considered safe activities. Stretching and strengthening exercises are not recommended while symptoms persist. Patients should return to running gradually. ACSM also suggests that orthotics are useful for preventing injury and treating some patients.
1. Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue injuries in runners. Cochrane Database Syst Rev. 2005;(4):CD001256.-
2. Larsen K, Weidich F, Leboeuf-Yde C. Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther. 2002;25:326-331.
3. Thacker SB, Gilchrist J, Stroup DF, et al. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34:32-40.
4. Eickhoff CA, Hossain SA, Slawski DP. From the field. Effects of prescribed foot orthoses on medial tibial stress syndrome in collegiate cross-country runners. Clin Kinesiol. 2000;54:76-80.
5. Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 1991;19:409-412.
6. Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg Am. 1974;56:1697-1700.
7. Johnston E, Flynn T, Bean M, et al. A randomized controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med. 2006;171:40-44.
8. Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. J Bone Joint Surg Am. 2003;85-A:1974-1980.
9. Järvinnen M, Aho H, Niittymäki S. Results of the surgical treatment of the medial tibial syndrome in athletes Int J Sports Med. 1989;10:55-57
10. Wallenstein R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. .J Bone Joint Surg Am. 1983;65-A:1252-1255.
11. Holen KJ, Engebretsen L, Grontvedt T, et al. Surgical treatment of medial tibial stress syndrome (shin splint) by fasciotomy of the superficial posterior compartment of the leg. Scand J Med Sci Sports. 1995;5:40-43.
12. Beck BR. Exercise-induced leg pain. Current Comment. March 2002. American College of Sports Medicine. Available at: www.acsm.org/AM/Template.cfm?Section=Search§ion=20026&template=/CM/ContentDisplaycfm&ContentFileID=299. Accessed December 14, 2006.
Encourage patients who are concerned about shin splints to decrease the intensity of their running; suggest rest and ice and foot orthoses, to treat the condition. Reducing running intensity probably reduces lower extremity soft tissue injuries (strength of recommendation [SOR]: B, low-quality randomized controlled trials [RCTs]), although doing stretching exercises doesn’t. Rest and ice alone promote faster recovery than rest and ice combined with nonsteroidal anti-inflammatory drugs (NSAIDs), a walking cast, or heel-cord stretching. (SOR: B, low-quality RCT). Although foot orthoses or insoles don’t prevent lower limb injuries (SOR: A, systematic review), they do significantly relieve symptoms and promote return to running (SOR: C, poor-quality cohort studies). Lower limb fasciotomy can reduce symptoms caused by shin splints in athletes, but the rate of return to previous level of sports activity is modest at best (SOR: C, case series).
Review, rest, follow-up
Doug Aukerman, MD
Pennsylvania State University, State College
Shin splints are an early indicator of abnormal stresses that cause periostitis along the tibia. Medial tibial stress syndrome (MTSS) is best thought of as part of a continuum, with shin splints at the mild end and tibial stress fracture at the severe extreme. I find that reviewing biomechanical forces and training schedules often helps prevent and treat injury. Aging footwear and training errors, including a rapid increase in training volume, are common culprits when biomechanics are normal. Adequate rest to allow the body to respond to the stresses of training can help prevent stress-related injuries.
My treatment regimen for shin splints includes a period of relative rest that allows the runner to remain active but reduces the stresses placed on the tibia and musculature of the lower leg. Relative rest may comprise either reducing running distance and intensity or changing the mode of exercise to deep water running or cycling. Consider follow-up examination to ensure that the tibial pain doesn’t become more localized, indicating a possible stress fracture.
Evidence summary
MTSS, or shin splints, is the most common cause of exertional leg pain in athletes. MTSS is an overuse injury characterized by pain along the posteromedial aspect of the distal two-thirds of the tibia.
Reduced running time, frequency, and distance may prevent injury
A systematic review of 12 trials of 8806 mostly young male military recruits, evaluated nonsurgical interventions to prevent lower limb soft tissue running injuries, including MTSS.1 Five trials investigating stretching and 4 trials of shoe insoles showed no benefit. Three studies showed that reducing the duration of running (to between 15 and 30 minutes), frequency (to 1 or 3 days a week), or distance (to 16.5 fewer kilometers over 12 weeks) reduced the risk of all injuries. Methods and outcome measures of the studies were heterogeneous, limiting the generalizability of these results.
A prospective RCT of custom semi-rigid shoe orthoses in the boots of Danish army recruits found a significantly lower prevalence of MTSS at 3-month follow-up in the intervention group (13% compared with 24%, P=.005; NNT=5).2 However, a systematic review of methods to prevent MTSS in sports found no high-quality studies in nonmilitary populations.3 No difference in the incidence of MTSS was noted with shoe inserts, different combat boots, or stretching routines.
To treat shin splints, consider orthotics, rest, and ice
Two studies retrospectively surveyed runners about their response to orthotics to treat MTSS.4,5 In one study, 16 of 41 collegiate cross-country runners were prescribed orthotics; 14 (88%) reported relief or improvement in their symptoms and return to running within 4 weeks.4 The other survey, of long-distance runners, found that 70% who had used or were using orthotics for a presumed diagnosis of MTSS reported complete relief or great improvement.5
A study of 97 US naval midshipmen who developed MTSS during summer training programs compared randomly assigned treatments of rest and ice to rest and ice plus anti-inflammatory medication (aspirin or phenylbutazone), rest and ice plus heel-cord stretching, or use of a short walking cast for 1 week.6 Subjects assigned to a treatment program of rest and ice alone lost significantly fewer days from running than the other treatment groups (P<.03).
A recent RCT of soldiers with MTSS compared treatment with a leg orthosis with no orthotic use; all subjects underwent icing and activity modification.7 No significant differences in outcome measures (days to completion of a 0.5-mile run, global rating of change, or number of treatment sessions) were noted between the treatment groups. Small sample size, high dropout rate, and small effect size limit the power of this study.
Fasciotomy can relieve symptoms but may not improve postop activity
Three case series reported on deep posterior compartment fasciotomy to treat MTSS in athletes.8-10 Surgery significantly reduced pain levels (P<.001) by an average of 72% on the visual analog pain scale for 46 patients who had failed conservative therapy for at least 12 months.8 However, only 41% returned to their pre-symptom level of sports activity. Another case series of mostly running athletes reported that 21 (78%) of 27 patients exhibited excellent or good healing after surgery.9 In a series of 9 patients with an average of 39 months of symptoms, 5 reported complete relief at follow-up (42±6 months), and 7 trained more than they had preoperatively.10
One case series of superficial posterior compartment fasciotomy for MTSS in 35 athletes reported that, among the 32 athletes available for follow-up, 72% (23) reported improved symptoms, but 69% (22) had a lower level of activity postoperatively.11
Recommendations
The American College of Sports Medicine (ACSM) recommends at least 7 to 10 days of rest from painful activities to treat MTSS.12 Running in a pool and cycling to maintain aerobic fitness during the rest period are considered safe activities. Stretching and strengthening exercises are not recommended while symptoms persist. Patients should return to running gradually. ACSM also suggests that orthotics are useful for preventing injury and treating some patients.
Encourage patients who are concerned about shin splints to decrease the intensity of their running; suggest rest and ice and foot orthoses, to treat the condition. Reducing running intensity probably reduces lower extremity soft tissue injuries (strength of recommendation [SOR]: B, low-quality randomized controlled trials [RCTs]), although doing stretching exercises doesn’t. Rest and ice alone promote faster recovery than rest and ice combined with nonsteroidal anti-inflammatory drugs (NSAIDs), a walking cast, or heel-cord stretching. (SOR: B, low-quality RCT). Although foot orthoses or insoles don’t prevent lower limb injuries (SOR: A, systematic review), they do significantly relieve symptoms and promote return to running (SOR: C, poor-quality cohort studies). Lower limb fasciotomy can reduce symptoms caused by shin splints in athletes, but the rate of return to previous level of sports activity is modest at best (SOR: C, case series).
Review, rest, follow-up
Doug Aukerman, MD
Pennsylvania State University, State College
Shin splints are an early indicator of abnormal stresses that cause periostitis along the tibia. Medial tibial stress syndrome (MTSS) is best thought of as part of a continuum, with shin splints at the mild end and tibial stress fracture at the severe extreme. I find that reviewing biomechanical forces and training schedules often helps prevent and treat injury. Aging footwear and training errors, including a rapid increase in training volume, are common culprits when biomechanics are normal. Adequate rest to allow the body to respond to the stresses of training can help prevent stress-related injuries.
My treatment regimen for shin splints includes a period of relative rest that allows the runner to remain active but reduces the stresses placed on the tibia and musculature of the lower leg. Relative rest may comprise either reducing running distance and intensity or changing the mode of exercise to deep water running or cycling. Consider follow-up examination to ensure that the tibial pain doesn’t become more localized, indicating a possible stress fracture.
Evidence summary
MTSS, or shin splints, is the most common cause of exertional leg pain in athletes. MTSS is an overuse injury characterized by pain along the posteromedial aspect of the distal two-thirds of the tibia.
Reduced running time, frequency, and distance may prevent injury
A systematic review of 12 trials of 8806 mostly young male military recruits, evaluated nonsurgical interventions to prevent lower limb soft tissue running injuries, including MTSS.1 Five trials investigating stretching and 4 trials of shoe insoles showed no benefit. Three studies showed that reducing the duration of running (to between 15 and 30 minutes), frequency (to 1 or 3 days a week), or distance (to 16.5 fewer kilometers over 12 weeks) reduced the risk of all injuries. Methods and outcome measures of the studies were heterogeneous, limiting the generalizability of these results.
A prospective RCT of custom semi-rigid shoe orthoses in the boots of Danish army recruits found a significantly lower prevalence of MTSS at 3-month follow-up in the intervention group (13% compared with 24%, P=.005; NNT=5).2 However, a systematic review of methods to prevent MTSS in sports found no high-quality studies in nonmilitary populations.3 No difference in the incidence of MTSS was noted with shoe inserts, different combat boots, or stretching routines.
To treat shin splints, consider orthotics, rest, and ice
Two studies retrospectively surveyed runners about their response to orthotics to treat MTSS.4,5 In one study, 16 of 41 collegiate cross-country runners were prescribed orthotics; 14 (88%) reported relief or improvement in their symptoms and return to running within 4 weeks.4 The other survey, of long-distance runners, found that 70% who had used or were using orthotics for a presumed diagnosis of MTSS reported complete relief or great improvement.5
A study of 97 US naval midshipmen who developed MTSS during summer training programs compared randomly assigned treatments of rest and ice to rest and ice plus anti-inflammatory medication (aspirin or phenylbutazone), rest and ice plus heel-cord stretching, or use of a short walking cast for 1 week.6 Subjects assigned to a treatment program of rest and ice alone lost significantly fewer days from running than the other treatment groups (P<.03).
A recent RCT of soldiers with MTSS compared treatment with a leg orthosis with no orthotic use; all subjects underwent icing and activity modification.7 No significant differences in outcome measures (days to completion of a 0.5-mile run, global rating of change, or number of treatment sessions) were noted between the treatment groups. Small sample size, high dropout rate, and small effect size limit the power of this study.
Fasciotomy can relieve symptoms but may not improve postop activity
Three case series reported on deep posterior compartment fasciotomy to treat MTSS in athletes.8-10 Surgery significantly reduced pain levels (P<.001) by an average of 72% on the visual analog pain scale for 46 patients who had failed conservative therapy for at least 12 months.8 However, only 41% returned to their pre-symptom level of sports activity. Another case series of mostly running athletes reported that 21 (78%) of 27 patients exhibited excellent or good healing after surgery.9 In a series of 9 patients with an average of 39 months of symptoms, 5 reported complete relief at follow-up (42±6 months), and 7 trained more than they had preoperatively.10
One case series of superficial posterior compartment fasciotomy for MTSS in 35 athletes reported that, among the 32 athletes available for follow-up, 72% (23) reported improved symptoms, but 69% (22) had a lower level of activity postoperatively.11
Recommendations
The American College of Sports Medicine (ACSM) recommends at least 7 to 10 days of rest from painful activities to treat MTSS.12 Running in a pool and cycling to maintain aerobic fitness during the rest period are considered safe activities. Stretching and strengthening exercises are not recommended while symptoms persist. Patients should return to running gradually. ACSM also suggests that orthotics are useful for preventing injury and treating some patients.
1. Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue injuries in runners. Cochrane Database Syst Rev. 2005;(4):CD001256.-
2. Larsen K, Weidich F, Leboeuf-Yde C. Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther. 2002;25:326-331.
3. Thacker SB, Gilchrist J, Stroup DF, et al. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34:32-40.
4. Eickhoff CA, Hossain SA, Slawski DP. From the field. Effects of prescribed foot orthoses on medial tibial stress syndrome in collegiate cross-country runners. Clin Kinesiol. 2000;54:76-80.
5. Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 1991;19:409-412.
6. Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg Am. 1974;56:1697-1700.
7. Johnston E, Flynn T, Bean M, et al. A randomized controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med. 2006;171:40-44.
8. Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. J Bone Joint Surg Am. 2003;85-A:1974-1980.
9. Järvinnen M, Aho H, Niittymäki S. Results of the surgical treatment of the medial tibial syndrome in athletes Int J Sports Med. 1989;10:55-57
10. Wallenstein R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. .J Bone Joint Surg Am. 1983;65-A:1252-1255.
11. Holen KJ, Engebretsen L, Grontvedt T, et al. Surgical treatment of medial tibial stress syndrome (shin splint) by fasciotomy of the superficial posterior compartment of the leg. Scand J Med Sci Sports. 1995;5:40-43.
12. Beck BR. Exercise-induced leg pain. Current Comment. March 2002. American College of Sports Medicine. Available at: www.acsm.org/AM/Template.cfm?Section=Search§ion=20026&template=/CM/ContentDisplaycfm&ContentFileID=299. Accessed December 14, 2006.
1. Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue injuries in runners. Cochrane Database Syst Rev. 2005;(4):CD001256.-
2. Larsen K, Weidich F, Leboeuf-Yde C. Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther. 2002;25:326-331.
3. Thacker SB, Gilchrist J, Stroup DF, et al. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34:32-40.
4. Eickhoff CA, Hossain SA, Slawski DP. From the field. Effects of prescribed foot orthoses on medial tibial stress syndrome in collegiate cross-country runners. Clin Kinesiol. 2000;54:76-80.
5. Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 1991;19:409-412.
6. Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg Am. 1974;56:1697-1700.
7. Johnston E, Flynn T, Bean M, et al. A randomized controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med. 2006;171:40-44.
8. Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. J Bone Joint Surg Am. 2003;85-A:1974-1980.
9. Järvinnen M, Aho H, Niittymäki S. Results of the surgical treatment of the medial tibial syndrome in athletes Int J Sports Med. 1989;10:55-57
10. Wallenstein R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. .J Bone Joint Surg Am. 1983;65-A:1252-1255.
11. Holen KJ, Engebretsen L, Grontvedt T, et al. Surgical treatment of medial tibial stress syndrome (shin splint) by fasciotomy of the superficial posterior compartment of the leg. Scand J Med Sci Sports. 1995;5:40-43.
12. Beck BR. Exercise-induced leg pain. Current Comment. March 2002. American College of Sports Medicine. Available at: www.acsm.org/AM/Template.cfm?Section=Search§ion=20026&template=/CM/ContentDisplaycfm&ContentFileID=299. Accessed December 14, 2006.
Evidence-based answers from the Family Physicians Inquiries Network
When should you order a Lyme titer?
Lyme titers should be ordered for patients with signs or symptoms of disseminated Lyme disease, but who do not have the pathognomonic erythema migrans rash (strength of recommendation [SOR]: C, based on expert opinion). Symptomatic patients with erythema migrans should be treated without being tested, given the high probability of having Lyme disease.
Serologic testing within the first week following potential infection is justified only if antibiotics will be withheld and a repeat serologic study will be performed 8 to 14 days after an initial negative test (SOR: C, based on expert opinion).1 Testing should be 2-tiered, including an initial highly sensitive test (enzyme-linked immunosorbent assay [ELISA]) followed by a supplemental highly specific test (Western blot) (SOR: C, based on expert opinion and small case-control study).2
Strict use of these rules would lead to fewer false positives but would miss atypical forms
Drew E. Malloy, MD
University of Arizona Campus Health Services, Tucson
The use of testing as described in this article is consistent with the recommendations of the CDC, academic infectious disease experts, and insurance companies. Other indications for ordering a Lyme test include the presence of oligoarthritis, cranial neuropathy (facial nerve palsy is most common), heart block, or meningitis. There is significant controversy about testing, treatment, and even defining late Lyme disease. The universe of people with positive Lyme serology who have fatigue, memory impairment, myalgias, and arthralgias far exceeds those with erythema migrans. A quick Google search reveals numerous patient support groups whose mission is to support those unfortunate people who believe they are afflicted with late Lyme disease. Strict use of these lab-ordering rules would lead to fewer false positives but also risks missing persons with forme fruste (atypical or variant forms) of this disease who may benefit from antimicrobial therapy. This is a highly controversial area of medicine and the limited evidence is conflicting. The cost of the Lyme test is not trivial, with a reflex panel (sensitive ELISA followed by specific Western blot) billed at over $250.
Evidence summary
Many Lyme disease serologic tests are ordered inappropriately, often influenced by patient demand. In a prospective, crosssectional survey of Wisconsin physicians, only 20% of ordered tests were appropriate. Tests were classified as inappropriate if ordered (1) for asymptomatic patients, (2) for patients with physician-diagnosed erythema migrans, (3) for patients receiving empiric antibiotic treatment, or (4) as test-of-cure.3
The positive predictive value of a test the likelihood that a person who tests positive actually has the disease) depends on the prevalence of that condition. Available Lyme serology tests vary in their sensitivity and specificity. Selecting patients with signs or symptoms of disseminated Lyme disease theoretically increases the pretest probability, thus improving the positive predictive value of the test.
In a prospective study of 46 treated patients with culture-proven erythema migrans, 91% had a positive ELISA or immunoglobulin M (IgM) immunoblot result at 8 to 14 days after baseline. Peak IgM antibody levels were seen at this time among patients with localized or disseminated disease. Detectable IgM levels appeared within a few days of onset of erythema migrans and were found in most individuals with disease of at least 2 weeks duration.4 Another small study of 55 treated patients similarly found peak antibody response at 8 to 12 days into treatment.5
A recent review article recommends serologic testing for patients with a moderate pretest probability (ie, patients with objective signs of Lyme disease from a highly or moderately endemic area). Patients from highly endemic areas who present with erythema migrans have a high enough pretest probability to make the diagnosis of Lyme disease without serologic testing.6
Recommendations from others
The Centers for Disease Control and Prevention (CDC) defines a case of Lyme disease as physician-diagnosed erythema migrans ≥5 cm in diameter, or at least 1 objective manifestation of late Lyme disease (eg, musculoskeletal, cardiovascular, or neurologic symptoms) with laboratory confirmation of Borrelia burgdorferi infection using a 2-tiered assay.7 Thus, the CDC notes that Lyme disease is a clinical diagnosis and accordingly recommends against testing patients who are asymptomatic or who have proven disease (erythema migrans).
The American College of Physicians Clinical Guidelines recommend performing serologic testing for patients with an intermediate pretest probability between 20% and 80%.8 Low pretest probability scenarios (<20%) include patients with nonspecific symptoms of myalgia such as fatigue, stiffness, and diffuse muscle aches and tenderness. High pretest probability scenarios (>80%) include patients with erythema migrans. Intermediate pretest probability scenarios include patients with possible disseminated Lyme disease findings such as recurrent oligoarticular inflammatory arthritis (TABLE). Cost effectiveness analyses support this approach.9
Guidelines established by a joint CDC/Association of State and Territorial Public Health Laboratory Directors commission require a 2-tiered laboratory approach to diagnosis.2 A highly sensitive initial test (ELISA) is followed by a highly specific supplemental test (Western blot). These guidelines have good clinical applicability (overall sensitivity 50%, specificity 100%).10 The relatively low sensitivity is likely due to antibiotic treatment of several subjects resulting in reduced humoral response.
TABLE
Pretest probability scenarios for suspected Lyme disease
| CLINICAL SCENARIO | TEST? | RATIONALE |
|---|---|---|
| Erythema migrans | No | Pretest probability high; clinical diagnosis of Lyme disease (treat without testing) |
| Signs/symptoms of disseminated Lyme disease, live in endemic region | Yes | Pretest probability intermediate; high prevalence yields high PPV |
| Signs/symptoms of disseminated Lyme disease, live in non-endemic region | Yes | Pretest probability intermediate; cost-effective |
| Nonspecific myalgias | No | Pretest probability too low |
| Asymptomatic patient | No | Pretest probability too low |
| Empiric antibiotic response; treatment | No | Antibiotic treatment decreases humoral testing not cost effective |
| Test-of-cure | No | Test remains positive after treatment |
| Immunized | No | ELISA will be positive (Western blot could assess exposure) |
1. Bunikis J, Barbour AG. Laboratory testing for suspected Lyme disease. Med Clin North Am 2002;86:311-340.
2. From the Centers for Disease Control and Prevention Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. JAMA 1995;274:937.-
3. Ramsey AH, Belongia EA, Chyou PH, Davis JP. Appropriateness of Lyme disease serologic testing. Ann Fam Med 2004;2:341-344.
4. Aguero-Rosenfeld ME, Nowakowski J, Bittker S, Cooper D, Nadelman RB, Wormser GP. Evolution of the serologic response to Borrelia burgdorferi in treated patients with culture-confirmed erythema migrans. J Clin Microbiol 1996;34:1-9.
5. Engstrom SM, Shoop E, Johnson RC. Immunoblot interpretation criteria for serodiagnosis of early Lyme disease. J Clin Microbiol 1995;33:419-427.
6. Depietropaolo DL, Powers JH, Gill JM, Foy AJ. Diagnosis of Lyme disease. Am Fam Physician 2005;72:297-304.
7. Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention. MMWR Recomm Rep 1997;46(RR-10):1-55.
8. Tugwell P, Dennis DT, Weinstein A, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med 1997;127:1109-1123.
9. Nichol G, Dennis DT, Steere AC, et al. Test-treatment strategies for patients suspected of having Lyme disease: a cost-effectiveness analysis. Ann Intern Med 1998;128:37-48.
10. Ledue TB, Collins MF, Craig WY. New laboratory guidelinesfor serologic diagnosis of Lyme disease: evaluation of the two-test protocol. J Clin Microbiol 1996;2343-2350.
Lyme titers should be ordered for patients with signs or symptoms of disseminated Lyme disease, but who do not have the pathognomonic erythema migrans rash (strength of recommendation [SOR]: C, based on expert opinion). Symptomatic patients with erythema migrans should be treated without being tested, given the high probability of having Lyme disease.
Serologic testing within the first week following potential infection is justified only if antibiotics will be withheld and a repeat serologic study will be performed 8 to 14 days after an initial negative test (SOR: C, based on expert opinion).1 Testing should be 2-tiered, including an initial highly sensitive test (enzyme-linked immunosorbent assay [ELISA]) followed by a supplemental highly specific test (Western blot) (SOR: C, based on expert opinion and small case-control study).2
Strict use of these rules would lead to fewer false positives but would miss atypical forms
Drew E. Malloy, MD
University of Arizona Campus Health Services, Tucson
The use of testing as described in this article is consistent with the recommendations of the CDC, academic infectious disease experts, and insurance companies. Other indications for ordering a Lyme test include the presence of oligoarthritis, cranial neuropathy (facial nerve palsy is most common), heart block, or meningitis. There is significant controversy about testing, treatment, and even defining late Lyme disease. The universe of people with positive Lyme serology who have fatigue, memory impairment, myalgias, and arthralgias far exceeds those with erythema migrans. A quick Google search reveals numerous patient support groups whose mission is to support those unfortunate people who believe they are afflicted with late Lyme disease. Strict use of these lab-ordering rules would lead to fewer false positives but also risks missing persons with forme fruste (atypical or variant forms) of this disease who may benefit from antimicrobial therapy. This is a highly controversial area of medicine and the limited evidence is conflicting. The cost of the Lyme test is not trivial, with a reflex panel (sensitive ELISA followed by specific Western blot) billed at over $250.
Evidence summary
Many Lyme disease serologic tests are ordered inappropriately, often influenced by patient demand. In a prospective, crosssectional survey of Wisconsin physicians, only 20% of ordered tests were appropriate. Tests were classified as inappropriate if ordered (1) for asymptomatic patients, (2) for patients with physician-diagnosed erythema migrans, (3) for patients receiving empiric antibiotic treatment, or (4) as test-of-cure.3
The positive predictive value of a test the likelihood that a person who tests positive actually has the disease) depends on the prevalence of that condition. Available Lyme serology tests vary in their sensitivity and specificity. Selecting patients with signs or symptoms of disseminated Lyme disease theoretically increases the pretest probability, thus improving the positive predictive value of the test.
In a prospective study of 46 treated patients with culture-proven erythema migrans, 91% had a positive ELISA or immunoglobulin M (IgM) immunoblot result at 8 to 14 days after baseline. Peak IgM antibody levels were seen at this time among patients with localized or disseminated disease. Detectable IgM levels appeared within a few days of onset of erythema migrans and were found in most individuals with disease of at least 2 weeks duration.4 Another small study of 55 treated patients similarly found peak antibody response at 8 to 12 days into treatment.5
A recent review article recommends serologic testing for patients with a moderate pretest probability (ie, patients with objective signs of Lyme disease from a highly or moderately endemic area). Patients from highly endemic areas who present with erythema migrans have a high enough pretest probability to make the diagnosis of Lyme disease without serologic testing.6
Recommendations from others
The Centers for Disease Control and Prevention (CDC) defines a case of Lyme disease as physician-diagnosed erythema migrans ≥5 cm in diameter, or at least 1 objective manifestation of late Lyme disease (eg, musculoskeletal, cardiovascular, or neurologic symptoms) with laboratory confirmation of Borrelia burgdorferi infection using a 2-tiered assay.7 Thus, the CDC notes that Lyme disease is a clinical diagnosis and accordingly recommends against testing patients who are asymptomatic or who have proven disease (erythema migrans).
The American College of Physicians Clinical Guidelines recommend performing serologic testing for patients with an intermediate pretest probability between 20% and 80%.8 Low pretest probability scenarios (<20%) include patients with nonspecific symptoms of myalgia such as fatigue, stiffness, and diffuse muscle aches and tenderness. High pretest probability scenarios (>80%) include patients with erythema migrans. Intermediate pretest probability scenarios include patients with possible disseminated Lyme disease findings such as recurrent oligoarticular inflammatory arthritis (TABLE). Cost effectiveness analyses support this approach.9
Guidelines established by a joint CDC/Association of State and Territorial Public Health Laboratory Directors commission require a 2-tiered laboratory approach to diagnosis.2 A highly sensitive initial test (ELISA) is followed by a highly specific supplemental test (Western blot). These guidelines have good clinical applicability (overall sensitivity 50%, specificity 100%).10 The relatively low sensitivity is likely due to antibiotic treatment of several subjects resulting in reduced humoral response.
TABLE
Pretest probability scenarios for suspected Lyme disease
| CLINICAL SCENARIO | TEST? | RATIONALE |
|---|---|---|
| Erythema migrans | No | Pretest probability high; clinical diagnosis of Lyme disease (treat without testing) |
| Signs/symptoms of disseminated Lyme disease, live in endemic region | Yes | Pretest probability intermediate; high prevalence yields high PPV |
| Signs/symptoms of disseminated Lyme disease, live in non-endemic region | Yes | Pretest probability intermediate; cost-effective |
| Nonspecific myalgias | No | Pretest probability too low |
| Asymptomatic patient | No | Pretest probability too low |
| Empiric antibiotic response; treatment | No | Antibiotic treatment decreases humoral testing not cost effective |
| Test-of-cure | No | Test remains positive after treatment |
| Immunized | No | ELISA will be positive (Western blot could assess exposure) |
Lyme titers should be ordered for patients with signs or symptoms of disseminated Lyme disease, but who do not have the pathognomonic erythema migrans rash (strength of recommendation [SOR]: C, based on expert opinion). Symptomatic patients with erythema migrans should be treated without being tested, given the high probability of having Lyme disease.
Serologic testing within the first week following potential infection is justified only if antibiotics will be withheld and a repeat serologic study will be performed 8 to 14 days after an initial negative test (SOR: C, based on expert opinion).1 Testing should be 2-tiered, including an initial highly sensitive test (enzyme-linked immunosorbent assay [ELISA]) followed by a supplemental highly specific test (Western blot) (SOR: C, based on expert opinion and small case-control study).2
Strict use of these rules would lead to fewer false positives but would miss atypical forms
Drew E. Malloy, MD
University of Arizona Campus Health Services, Tucson
The use of testing as described in this article is consistent with the recommendations of the CDC, academic infectious disease experts, and insurance companies. Other indications for ordering a Lyme test include the presence of oligoarthritis, cranial neuropathy (facial nerve palsy is most common), heart block, or meningitis. There is significant controversy about testing, treatment, and even defining late Lyme disease. The universe of people with positive Lyme serology who have fatigue, memory impairment, myalgias, and arthralgias far exceeds those with erythema migrans. A quick Google search reveals numerous patient support groups whose mission is to support those unfortunate people who believe they are afflicted with late Lyme disease. Strict use of these lab-ordering rules would lead to fewer false positives but also risks missing persons with forme fruste (atypical or variant forms) of this disease who may benefit from antimicrobial therapy. This is a highly controversial area of medicine and the limited evidence is conflicting. The cost of the Lyme test is not trivial, with a reflex panel (sensitive ELISA followed by specific Western blot) billed at over $250.
Evidence summary
Many Lyme disease serologic tests are ordered inappropriately, often influenced by patient demand. In a prospective, crosssectional survey of Wisconsin physicians, only 20% of ordered tests were appropriate. Tests were classified as inappropriate if ordered (1) for asymptomatic patients, (2) for patients with physician-diagnosed erythema migrans, (3) for patients receiving empiric antibiotic treatment, or (4) as test-of-cure.3
The positive predictive value of a test the likelihood that a person who tests positive actually has the disease) depends on the prevalence of that condition. Available Lyme serology tests vary in their sensitivity and specificity. Selecting patients with signs or symptoms of disseminated Lyme disease theoretically increases the pretest probability, thus improving the positive predictive value of the test.
In a prospective study of 46 treated patients with culture-proven erythema migrans, 91% had a positive ELISA or immunoglobulin M (IgM) immunoblot result at 8 to 14 days after baseline. Peak IgM antibody levels were seen at this time among patients with localized or disseminated disease. Detectable IgM levels appeared within a few days of onset of erythema migrans and were found in most individuals with disease of at least 2 weeks duration.4 Another small study of 55 treated patients similarly found peak antibody response at 8 to 12 days into treatment.5
A recent review article recommends serologic testing for patients with a moderate pretest probability (ie, patients with objective signs of Lyme disease from a highly or moderately endemic area). Patients from highly endemic areas who present with erythema migrans have a high enough pretest probability to make the diagnosis of Lyme disease without serologic testing.6
Recommendations from others
The Centers for Disease Control and Prevention (CDC) defines a case of Lyme disease as physician-diagnosed erythema migrans ≥5 cm in diameter, or at least 1 objective manifestation of late Lyme disease (eg, musculoskeletal, cardiovascular, or neurologic symptoms) with laboratory confirmation of Borrelia burgdorferi infection using a 2-tiered assay.7 Thus, the CDC notes that Lyme disease is a clinical diagnosis and accordingly recommends against testing patients who are asymptomatic or who have proven disease (erythema migrans).
The American College of Physicians Clinical Guidelines recommend performing serologic testing for patients with an intermediate pretest probability between 20% and 80%.8 Low pretest probability scenarios (<20%) include patients with nonspecific symptoms of myalgia such as fatigue, stiffness, and diffuse muscle aches and tenderness. High pretest probability scenarios (>80%) include patients with erythema migrans. Intermediate pretest probability scenarios include patients with possible disseminated Lyme disease findings such as recurrent oligoarticular inflammatory arthritis (TABLE). Cost effectiveness analyses support this approach.9
Guidelines established by a joint CDC/Association of State and Territorial Public Health Laboratory Directors commission require a 2-tiered laboratory approach to diagnosis.2 A highly sensitive initial test (ELISA) is followed by a highly specific supplemental test (Western blot). These guidelines have good clinical applicability (overall sensitivity 50%, specificity 100%).10 The relatively low sensitivity is likely due to antibiotic treatment of several subjects resulting in reduced humoral response.
TABLE
Pretest probability scenarios for suspected Lyme disease
| CLINICAL SCENARIO | TEST? | RATIONALE |
|---|---|---|
| Erythema migrans | No | Pretest probability high; clinical diagnosis of Lyme disease (treat without testing) |
| Signs/symptoms of disseminated Lyme disease, live in endemic region | Yes | Pretest probability intermediate; high prevalence yields high PPV |
| Signs/symptoms of disseminated Lyme disease, live in non-endemic region | Yes | Pretest probability intermediate; cost-effective |
| Nonspecific myalgias | No | Pretest probability too low |
| Asymptomatic patient | No | Pretest probability too low |
| Empiric antibiotic response; treatment | No | Antibiotic treatment decreases humoral testing not cost effective |
| Test-of-cure | No | Test remains positive after treatment |
| Immunized | No | ELISA will be positive (Western blot could assess exposure) |
1. Bunikis J, Barbour AG. Laboratory testing for suspected Lyme disease. Med Clin North Am 2002;86:311-340.
2. From the Centers for Disease Control and Prevention Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. JAMA 1995;274:937.-
3. Ramsey AH, Belongia EA, Chyou PH, Davis JP. Appropriateness of Lyme disease serologic testing. Ann Fam Med 2004;2:341-344.
4. Aguero-Rosenfeld ME, Nowakowski J, Bittker S, Cooper D, Nadelman RB, Wormser GP. Evolution of the serologic response to Borrelia burgdorferi in treated patients with culture-confirmed erythema migrans. J Clin Microbiol 1996;34:1-9.
5. Engstrom SM, Shoop E, Johnson RC. Immunoblot interpretation criteria for serodiagnosis of early Lyme disease. J Clin Microbiol 1995;33:419-427.
6. Depietropaolo DL, Powers JH, Gill JM, Foy AJ. Diagnosis of Lyme disease. Am Fam Physician 2005;72:297-304.
7. Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention. MMWR Recomm Rep 1997;46(RR-10):1-55.
8. Tugwell P, Dennis DT, Weinstein A, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med 1997;127:1109-1123.
9. Nichol G, Dennis DT, Steere AC, et al. Test-treatment strategies for patients suspected of having Lyme disease: a cost-effectiveness analysis. Ann Intern Med 1998;128:37-48.
10. Ledue TB, Collins MF, Craig WY. New laboratory guidelinesfor serologic diagnosis of Lyme disease: evaluation of the two-test protocol. J Clin Microbiol 1996;2343-2350.
1. Bunikis J, Barbour AG. Laboratory testing for suspected Lyme disease. Med Clin North Am 2002;86:311-340.
2. From the Centers for Disease Control and Prevention Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. JAMA 1995;274:937.-
3. Ramsey AH, Belongia EA, Chyou PH, Davis JP. Appropriateness of Lyme disease serologic testing. Ann Fam Med 2004;2:341-344.
4. Aguero-Rosenfeld ME, Nowakowski J, Bittker S, Cooper D, Nadelman RB, Wormser GP. Evolution of the serologic response to Borrelia burgdorferi in treated patients with culture-confirmed erythema migrans. J Clin Microbiol 1996;34:1-9.
5. Engstrom SM, Shoop E, Johnson RC. Immunoblot interpretation criteria for serodiagnosis of early Lyme disease. J Clin Microbiol 1995;33:419-427.
6. Depietropaolo DL, Powers JH, Gill JM, Foy AJ. Diagnosis of Lyme disease. Am Fam Physician 2005;72:297-304.
7. Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention. MMWR Recomm Rep 1997;46(RR-10):1-55.
8. Tugwell P, Dennis DT, Weinstein A, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med 1997;127:1109-1123.
9. Nichol G, Dennis DT, Steere AC, et al. Test-treatment strategies for patients suspected of having Lyme disease: a cost-effectiveness analysis. Ann Intern Med 1998;128:37-48.
10. Ledue TB, Collins MF, Craig WY. New laboratory guidelinesfor serologic diagnosis of Lyme disease: evaluation of the two-test protocol. J Clin Microbiol 1996;2343-2350.
Evidence-based answers from the Family Physicians Inquiries Network