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A local fireman who has no significant prior running experience plans to enter a marathon in 7 months. He has 28 weeks to train so he begins running 1 mile every other day. He adds an additional mile weekly to ensure he will be able to successfully progress his running distance to 26 miles in time for the race. After 3 weeks of running, he noted medial shin pain that occurred near the end of his runs or during his cool-down walking period. The leg pain dissipated after sitting and resting for a few hours and was not present upon awakening or throughout the next day. He continued his training, which resulted in a gradual increase and earlier onset of pain. He experienced leg pain at the beginning of runs that would ease with continued running. He ignored the pain and continued his running program. After 6 weeks of training, his leg pain occurred at the beginning of runs and no longer resolved with cessation of running. The pain intensity increased and he could not continue running. He began taking nonsteroidal anti-inflammatory drugs (NSAIDs), which allowed him to complete one more week of painful training. However, the pain increased with continued running despite use of NSAIDs. The patient now had shin pain at rest that increased with standing and walking activities. He also experienced pain while resting in bed. He had mild to moderate discomfort when awakening and the symptoms continued with increasing intensity during and following prolonged standing and walking activities. After prolonged sitting, symptoms eased but remained present. The patient was frustrated and concerned about his ability to run the local marathon so he self-referred to an outpatient physical therapy clinic for evaluation and treatment. At the time of evaluation, the patient had not run for 2 days. As he stood in the waiting area and walked through the therapy office, his gait was notably antalgic, with an exaggerated lean over the more involved side. Strength testing, range of motion (ROM), and visual inspection were all normal. Diffuse medial shin pain was reproduced with ROM and strength testing. The most significant finding on examination was localized tenderness to palpation about 2 cm in length along the medial tibia (right side greater than left). The tenderness was at the junction of the mid- to distal one-third of the tibias. There was also mild bilateral tenderness over the central third of the medial tibias. Other than his recent increase in training, the patient's past medical history was unremarkable. Signs, symptoms, and history are consistent with tibial stress fractures. The fireman's main goal is to return to his training program and run pain-free as soon as possible to meet his goal of completing the local marathon.

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Based on the patient's suspected diagnosis, what do you anticipate may be the contributing factors to the condition?

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What physical examination signs may be associated with this ...

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