Shin Splints Dr. Justin C. Lau, DC, CCSP, CSCS Dr. Edward Chu, DC What are shin splints? One of the most common repetitive stress injuries that affects runners is a condition known as shin splints. The term shin splints is often a “wastebasket term” in sports medicine used to describe pain felt between the knee and the ankle after athletic activity. Although there are different reasons why pain is felt in this area, shin splints are considered a cumulative stress disorder as opposed to an acute injury. They occur when the constant pounding and stresses placed on the lower extremity overwhelm the body’s natural ability to repair the damage and restore itself. The pain from shin splints can be due to either problems of the muscles, the bone, or the attachment of the muscle to the bone. Conditions such as tendonitis, periostitis (inflammation of the lining of connective tissue that covers the bone), muscle strain, and strain of the interosseous membrane (the connective tissue that spans from the tibia to the fibula) have all been implicated. Therefore, 'shin splints' is simply the name given to pain over the front of the lower leg. The cause of the pain is what needs to be identified so the correct treatment can be rendered. Classic Presentation: Runners with shin splints typically complain of anterior (lateral) or posterior (medial) lower leg pain that is non-traumatic in onset. The pain is a deep ache that is often worse with weight bearing. The pain is often at the middle or lower third of the tibia and can be accompanied by mild swelling. There are generally two types of Shin Splints: 1. Anterior or Lateral Shin Splints are tender just lateral to the middle of the Tibia. This type of shin splint involves the tibialis anterior, extensor digitorum longus and extensor hallicus longus. These muscles are used for shock absorption during gait. When they are weak or placed under increased demand as in walking or running on hard surfaces or when wearing a shoe that has no shock-absorbing quality, the force is transmitted to the tibia and its attachments. 2. Posterior or Medial Shin Splints (Medial Tibial Stress Syndrome) are tender in the postero-medial portion of the middle or lower Tibia. This type involves the tibialis posterior, flexor hallicus longus, flexor digitorum longus and the soleus. These muscles act as ankle stabilizers and tend to be overstrained when the athlete has excessive pronation. At first, the pain is felt only immediately after the heel strikes the ground during running, walking, skiing, or other similar exercises. When exercising, the pain is usually greater at the beginning of exercise and then eventually works itself out as the tissues warm up and endorphins are being released. Pain typically returns shortly after the cessation of exercise due to the inflammation that has occurred resulting in pain that can range from a dull ache to sharp pain along the shaft of the tibia. If the athlete continues to run, the pain occurs throughout each step, eventually becoming constant. Usually by the time the athlete seeks treatment, the symptoms are felt throughout the day with the shin being tender to touch. Some specific movements, especially resisted plantar flexion (pushing down of the foot against resistance) may also cause an increase of symptoms. What causes shin splints? Pain along the shin or tibial bone is commonly the result of: 1. Training Errors: • “The Terrible Too’s” – Training too hard, too fast or for too long. • Overdoing athletic activities, engaging in sports with a lot of starts and stops, or running down hills excessively • Sudden increase in exercise or running. • Running on a slanted or tilted surface. 2. Structural Causes: • Excessive Pronation – Pronation is a normal movement of the foot that allows the arch to flatten to a degree, which helps the body to absorb and adapt to different ground surfaces. If the foot is weak or tired and/or the footwear is not supportive, then the arch can flatten more than normal, which is excessive pronation. The muscles in the lower leg that control pronation (namely the tibialis anterior and posterior) are now subjected to increased demand and overuse. • Muscular imbalances of lower leg – natural imbalance in the strength of opposing muscles. The anterior leg muscles pull the foot up, and the larger and much stronger calf muscles pull the foot down each time the heel touches the ground during walking or running. The calf muscles exert so much force that they can injure the anterior shin muscles. 3. Other Causes: • Insufficient shock absorption (due to running in old or incorrect footwear). • Running form mistakes (heel striking, forefoot running, slow running cadence, poor biomechanics/improper foot positioning while running). • Running in worn-out footwear (shoes should typically be replaced after 300-500 miles or every 6 months). Other Differential Diagnoses to Consider: • Tibial Stress fractures – It’s easy to mistake shin splints for a stress fracture, another common sports injury that results in a tiny crack in your bone because of overuse. A stress fracture in the lower leg usually causes a more localized pain in the middle of the tibia, directly over the bone. It may not show up on an X-ray until two or three weeks after symptoms of pain and swelling appear. • Exercise Induced Compartment Syndrome – A condition in which there is swelling and an increase in pressure due to tightening of the fascia that surrounds the muscles of the lower leg. This swelling presses on and compromises blood vessels, nerves, and/or tendons that run through the compartment causing symptoms of numbness, tingling and pain. In runners with a Tibial Stress Fracture or Exercise Induced Compartment Syndrome, a good telltale sign is that the pain will usually get worse rather than better the longer the athlete exercises. How is the cause of shin splints determined? As mentioned previously, the term shin splints is not actually a diagnosis, but a group of problems that causes a typical pain. Therefore, the healthcare practitioner you see should perform a careful medical history and physical examination to determine the root cause of your shin splints. The area of maximal tenderness may be different in patients who have different underlying problems causing shin splints. There are also provocative tests that can help determine the cause of the shin splints. In order to determine the underlying cause of your shin splints, an x-ray or a bone scan may be indicated. The x-ray can detect fractures, and occasionally detect long-standing stress fractures. The bone scan will detect areas of high bone turnover; these ‘hot’ areas indicate possible stress fractures or other bone problems. Runners with Medial Tibial Stress Syndrome may also have an abnormal bone scan, but there is usually a difference that can be detected to differentiate Medial Tibial Stress Syndrome and stress fractures. What is the treatment for shin splints? Use the following general treatment guidelines if you are diagnosed with shin splints. It is important to note that the treatment of a stress fracture is not the same, and persistent shin pain should be evaluated by a healthcare practitioner before you begin self treatment. 1. Support • ICE and REST. • Apply ice packs or perform ice massage for up to 20 minutes, three times a day. • Try to avoid excessive impact while recovering. • Supportive taping (such as Kinesiotaping® and Elastikon) to support the arch and facilitate the lower leg muscles during exercise. 2. Stretch • Stretching of the calf (both gastroc and soleus muscles) and achilles tendon. 3. Strengthen - Strengthening of the anterior leg muscles (that pull the foot and toes up). • Wall Shin Raises – Simply stand with your back to a wall, with your heels about the length of your feet away from the wall. Then, lean back until your buttocks and shoulders rest against the wall. Dorsiflex both ankles simultaneously, while your heels remain in contact with the ground. Bring your toes as far toward your shins as you can, and then lower your feet back toward the ground, but do not allow your forefeet to contact the ground before beginning the next repeat. Simply lower them until they are close to the ground, and then begin another repetition. Complete about 12 to 15 reps. Once you can do 3 sets of 15 reps, move onto doing single leg wall shin raises. • Heel Step downs – Begin with a natural, erect body position, with your feet about shoulderwidth apart, and then step forward with one foot. The length of the step should be moderate - as though you were walking in your normal manner. When your heel makes contact with the ground, stop the foot from fully plantar flexing (e.g., use your shin muscles to keep the sole of the foot from making contact with the ground). After heel contact, the ball of your foot should descend no more than an inch toward the floor or ground; your foot is held in check by the eccentric contractions of your shin muscles. Return your foot to the starting position (back by the other foot), and repeat this basic stepping action a total of 15 times. Then, shift over to the other foot and complete 15 steps. As with the wall shin raises, progress to three sets of 15 reps over time. • Outward Rolls – Stand up. Slowly roll the ankle out so that the inner part of the sole is raised off the floor. Slowly lower the sole back to the floor. Do 3 sets of 15. The key word in this exercise is SLOWLY (to avoid causing an inversion sprain). • Perform these rehabilitation exercises (low-impact) regularly. • Swimming and cycling are excellent activities for an individual with shin splints. 4. If you have a foot that excessively pronates, consider footwear with more motion control or obtaining custom orthotics - supporting the foot with proper shoes and insoles, can prevent and eliminate the vast majority of lower leg problems due to overuse. 5. Ultrasound and electric muscle stimulation to restore normal muscle tone, decrease pain, and soften scar tissue. 6. Prescription of a shoe with more motion control for a runner with flat feet/moderate pronation, a shoe with more cushion for a runner with high arches/moderate supination or a semi-rigid orthotic for individuals with excessive or unbalanced pronation or supination. 7. Specific joint manipulations to any fixations found in the lower back, hip, knee and foot to restore proper joint motion of the entire lower kinetic chain. 8. Specific deep tissue therapy to the muscles of the lower leg to free up soft tissue motion and restore strength. Treating Shin Splints with Active Release Technique® Active Release Technique (ART®) is very successful at treating this type of injury since it removes restrictive adhesions between both the superficial and deep tissue structures along the entire kinetic chain. Trained ART practitioners perform a biomechanical analysis of athletes to determine where the restrictions are located along the entire kinetic chain. ART treatments are specific and based upon the individual needs of each athlete. It is not a cookbook approach to treating a non-specific diagnosis. ART® finds the specific tissues that are restricted and physically works them back to its normal texture, tension, and length by using various hand positions and soft tissue manipulation methods. While breaking up the adhesions can be uncomfortable at times, it is important to reproduce the symptoms. Effective treatment of Medial Tibial Stress Syndrome, Anterior/Lateral Shin Splints and Exercise Induced Compartment Syndrome requires an alteration in tissue structure that breaks up the restrictive cross-fiber adhesions and restores normal function to the affected soft tissue areas. When executed properly, this process substantially decreases healing time, treats the root cause of the injury, and improves athletic performance. With ART we often see immediate improvement after treating the involved structures. How can I prevent shin splints? Prevention is best accomplished with smart training. If your sport involves high impact activities, make sure you have days that are low-impact (e.g. cycling or swimming) and no running. Increase the intensity and duration of exercise gradually. When you are increasing your activity, perform more lowimpact exercise in the beginning. Make sure you have proper footwear that has been replaced regularly (life span of most running shoes is about 500 miles or 6 months). If you can run on grass or trails for some of your training (rather than pavement) that will also help prevent shin splints. Also, do not neglect the importance of a proper warm up prior to exercise followed by an adequate cool down and a balanced stretching routine.
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