AUTHOR: MATTHEW CRAIG, BOUNCEREHAB PRINCIPAL PHYSIOTHERAPIST
CO-AUTHOR: JEFF STEWART, PODIATRIST BOUNCEREHAB
Shin Splints…
Shin pain is an extremely common complaint in exercise, particularly long distance runners. “Shin splints” is a term that is often used to describe pain along the medial border of the tibia. Physiotherapists at bounceREHAB describe it to be very agitating among fun-runners trying to go for the odd healthy jog.
A better medical or scientific term for this pain is “medial tibial stress syndrome”, which is a spectrum of conditions that can cause this type of pain, including:
Bony stress (ranging from bone strains, traction to stress fractures)
Inflammation (medial tibial periostitis)
Musculotendinous injury/degeneration (tendinopathy, strains)
“THIS SYNDROME ACCOUNTS FOR NEARLY 60% OF ALL OVERUSE INJURIES SEEN IN THE LEG”
Other causes of shin pain outside of medial tibial stress syndrome include:
Compromised blood supply to the lower leg due to a trapped artery
Raised pressure within the muscle “compartments” of the lower leg
Nerve entrapment
An accurate diagnosis is an essential step in treating shin pain, so it’s important to allow a qualified health professional such as a physiotherapist or podiatrist to assess your symptoms and work with you to appropriately manage and prevent the pain from recurring.
WHAT IS MEDIAL TIBIAL PERIOSTITIS?
One of the common causes of medial tibial stress syndrome is periostitis, which is an inflammatory overuse injury of the tibia induced by exercise. While it isn’t a very serious condition, it can be very debilitating and if not managed properly can lead to more serious complications such as a tibial stress fracture.
Bones are surrounded by a layer of connective tissue called the “periosteum”. Muscles attach along the periosteum via Sharpey’s fibres, which fuse with the periosteum’s fibrous layer. The word periostitis means inflammation of the periosteum. In medial tibial periostitis, dysfunction of the lower leg muscles (especially the soleus and flexor digitorum longus)* during repetitive loading (for example, in prolonged running) causes them to constantly pull at their sites of insertion at the periosteum (known as chronic “traction”). This causes inflammation and pain on the middle to lower thirds of the tibia.
WHAT CAUSES MEDIAL TIBIAL PERIOSTITIS?
Onset of this condition is usually due to multiple factors that interact to create inflammation and stress at the tibia (bone).
1.ABNORMAL BIOMECHANICS
Muscle dysfunction:
The lower leg muscles are designed to control movement and act as shock absorbers during walking and impact exercise. When these muscles are weak and lack endurance, they tend to fatigue quickly during prolonged exercise. This interferes with their ability to act as shock absorbers, and instead the forces are transferred to the tibia.
Muscle dysfunction (decreased strength, motor control and/or flexibility) around the lower limb, knee, hip, pelvis or spine can alter the normal biomechanics of walking and running (especially when performed over long periods of time). This can cause abnormal bending and strain on the tibia, as well as overworking of the muscles that control and stabilise the foot.
Excessive pronation of the foot:
During walking and running, the soleus muscle in particular works to control the amount of pronation of the foot. Pronation means the flattening of the arches of the foot, and is important in helping the foot adapt to uneven terrain.
When pronation is excessive, such as in exercisers who have pes planus (“flat feet”), soleus is one of the muscles that has to work harder to maintain a healthy arch each time the foot contacts the ground.
With repetitive loading, such as in long distance running, this muscle is overworked and is constantly pulling where is attaches to the tibia, causing inflammation of the periosteum and shin pain.
Mechanically, pronation is the most likely cause of shin splints. As the foot pronates it stretches the medial muscles and therefore placing a greater stress where these muscles attach to the bone.
With repetitive activity such as running or walking the muscles that attach to the tibia become overworked, causing inflammation of the periosteum and shin pain.
Having your biomechanics and gait assessed by a podiatrist is an important part of the management plan when treating shin splints. A podiatrist can prescribe the right footwear for your feet and may also use taping and orthotics to correct any biomechanical issues.
2. TRAINING ERRORS
Recreational and elite athletes will recall their pain starting after making a change in their usual exercise routine. For example:
Doing too much too soon, where there is a sudden increase in intensity, frequency or volume of training, and the body doesn’t have time to adapt to the changeThere is a change in training surfaces to non compliant (e.g. concrete) or uneven (e.g. sand) terrain, which increases the amount of force going through the tibia/challenges joint stabilityChanging footwear, or running with old shoes that lack shock absorption
Poorly controlled arch height (ie due to inappropriate footwear) during running.
3. NORMAL METABOLIC BONE HEALTH
Research indicates that athletes with shin pain from medial tibial periostitis have low bone mineral densities. This is common in women who have the condition, when they have osteoporosis, nutritional deficits or hormonal disruptions (evident by changes in the menstrual cycle), that can affect bone health. It’s important also to consider that inflammation can interfere with osteoblastic activity (the cells responsible for creating new bone), which can decrease bone mineral density and make an individual more susceptible to bony stress reactions and fractures.
WHAT ARE THE SYMPTOMS OF MEDIAL TIBIAL PERIOSTITIS?
Hurts “here”!
A vague, diffuse lower limb pain, along the middle to lower portion of the tibiaPain is exacerbated by exerciseAt first, pain is felt at the start of exercise, and gradually goes away during the session/quickly once the session is finishedIf the condition isn’t treated early, symptoms often start with less exercise, and can occur even at rest
WHO IS MOST AT RISK OF MEDIAL TIBIAL PERIOSTITIS?
“Studies show that women are 3 x more likely to develop the condition compared to men”.
Medial tibial periostitis is commonly seen in people who engage in prolonged impact and/or ballistic exercise (ranging from recreational to elite level), including:
Long distance runners Military personnelSoccer, football & basketball playersDancers
You are also at a higher risk if you have:
Greater hip internal and external rotation range of motion Lower calf muscle girthHigher BMI (>20.2)Running history of less than 8.5 yearsPrevious history of medial tibial stress syndrome/periostitis/stress fracture
HOW MEDIAL TIBIAL PERIOSTITIS IS DIAGNOSED:
Diagnosis should be made by a qualified clinician, such as one of our physiotherapists or podiatrist at bounceREHAB.
Scans usually aren’t necessary, as medial tibial periostitis is a condition that can typically be diagnosed clinically based on symptoms, history and clinical assessment findings alone.
A bone scan or MRI may be needed if the diagnosis is unclear and other issues need to be excluded, such as a tibial stress fracture. Often scans are negative for medial tibial periostitis, or they may be positive in individuals who don’t have the condition.
Evidence of the condition usually includes an inflammatory reaction of the periosteum (on an MRI), or a diffuse, increased uptake of the radioisotope around the area of pain on the tibia (on a bone scan).
a bouncerehab physio & podiatrist will assess you for:
The risk factors outlined aboveAny training errors that indicate possible overloading of the lower limb:
Running mileage, intensity, pace, terrainFootwear and/or need for orthotics or if referral to our podiatrist is necessary
Abnormal biomechanics at the hip, knee and foot
Tenderness when the tibia is palpatedPain when hopping
Muscle inflexibility and weakness, especially of the calf muscles, quadriceps and hamstrings
Weakness of the muscles of the “core”, hip and pelvis
Expert fitting of compression bracing, cryo-therapy, taping and micro-current settings
TREATMENT OF MEDIAL TIBIAL PERIOSTITIS AT BOUNCEREHAB:
Treatment can be divided into two phases: acute and sub-acute treatment
1. ACUTE TREATMENT PHASE
Goal: allow time for the body to heal and for the inflammation to subside
Relative rest from activities that cause pain. The amount of rest usually ranges from 2-6 weeks but depends on:
How far the condition has progressed,
severity of symptoms,
training requirements and context of your presentation to physiotherapy
Ice for approximately 12 minutes, several times a day to relieve pain and reduce swelling
Compression garment
Anti-inflammatory medication (NSAIDs) or natural remedies such as TheraActive Pain
Low impact exercise to maintain fitness:Clinical Pilates (supervised with bounceREHAB physiotherapist)
Stationary bike
Elliptical
Swimming
Underwater running
Physiotherapy:
Soft/deep tissue massage
Dry needling
TENS/Low Level Microcurrent Unloading the foot during walking, using crutches or a CAM bootTaping to prevent excessive foot pronation
Assessment of foot alignment and biomechanics to help with designing an appropriate rehabilitation program in the second phase of treatment.
Clinical Pilates to improve biomechanical strength/length tension imbalances and bone health
2. SUBACUTE TREATMENT PHASE
Goal: to gradually resume exercise that is pain free, and prevent the symptoms from recurring (as there is a high risk of recurrence)
Modifying training:
Running distance, frequency and intensity is often decreased to 50% initially, and is gradually built up over a period of weeks as exercise becomes more pain free (usually 10% increase per week)
Training should start and finish with a warm up/down and stretchingAvoiding hill running initiallyTraining on a treadmill or synthetic track as opposed to running on very hard or uneven terrain
Addressing biomechanical abnormalities:
Gait retraining & improving running techniqueFootwearOrthotic prescription to support foot arches
Addressing lowered bone mineral density:
Nutrition supplements
Multidisciplinary review (e.g. seeing a nutritionist at bounceREHAB)
Physiotherapy rehabilitation program to restore maximal function:
Developing motor control and proprioception of the lower limb
Strengthening calf muscles, and other foot stabilising muscles
Increasing core and pelvic stability
Increasing calf muscle flexibility with stretching and soft tissue massage
Manual therapy to restore normal joint range of motion
Surgical intervention usually isn’t required, and is only considered if there is no significant improvement with conservative treatment first. The most common surgical procedure is a “posterior fasciotomy”. The majority of individuals recover from medial tibial periostitis with either a significant or complete resolution of their symptoms.
PREVENTION & SUMMARY OF MEDIAL TIBIAL PERIOSTITIS:
A key priority in rehab from medial tibial periostitis is to prevent it from recurring. Some points to remember:
Avoid doing “too much too soon” with your exercise routine
Avoid training with shoes that are old, poorly fitted or lack supportIncorporate strength/stretching into your exercise routine
PRODUCTS AND SERVICES OFFERED AT BOUNCEREHAB TO HELP PREVENT AND TREAT MEDIAL TIBIAL PERIOSTITIS:
Our Podiatrist Jeff Stewart can assess your biomechanics and gait. Recommend the appropriate footwear and prescribe orthotics if required
Foam roller & trigger balls: to release tight muscles such as the calves, ITB, glutes and lower back and to improve the respective muscle-tendon flexibility
Advice by our resident nutritionist Caroline Zanelli, on nutrition & Bioceutical supplements:
Vitamin D, C, K and Calcium supplements:
to help support bone growth and development
Chondroplex: provides key nutrients glucosamine, chondroitin & MSM to support joints and relieve inflammation
TherActive: contains curcumin which has anti-inflammatory and pain relieving properties
Omega Trienol: contains fish oil to help relieve inflammation
Probiotics: have anti-inflammatory properties
CAM boots: if symptoms are severe, a CAM boot may be needed at the start of treatment to offload the bone to allow it to heal
Dry needling
Clinical Pilates: exercises to specifically target weakness, inflexibility and poor motor control, reformer to strengthen the body while minimising the effects of gravity
Compression garments of the bones, tendons, muscles.
Kinesiotherapy (K)
Rocktape
Resources:
https://www.youtube.com/watch?v=HL16tIPLe3c (Learning about Pronation and Orthotics)
Bibliography:
Galbraith, Michael R. & Lavallee, Mark E. Contributing Factors to Medial Tibial Stress Syndrome: A Prospective Investigation. Med Sci Sports Exerc. 2009 Mar;41(3):490-6. doi: 10.1249/MSS.0b013e31818b98e6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848339/ .Ato Ampomah Brown, “Medial Tibial Stress Syndrome: Muscles Located at the Site of Pain,” Scientifica, vol. 2016, Article ID 7097489 (2016). doi:10.1155/2016/7097489 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811262/Beck, BR., & Osternig, LR. “Medial tibial stress syndrome. The location of muscles in the leg in relation to symptoms”. J Bone Joint Surg Am. Jul:76(7):1057-61 (1994). http://www.ncbi.nlm.nih.gov/pubmed/8027114/ Brukner P., Khan K. Clinical Sports Medicine. 3rd. McGraw-Hill Professional; 2006.Galbraith, Michael R. & Lavallee, Mark E. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med (2009) 2: 127. doi:10.1007/s12178-009-9055-6 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848339/http://orthoinfo.aaos.org/topic.cfm?topic=a00407 Accessed 25/07/16.Kortebein, Patrick M.; Kaufman, KentonR.; Basford, Jeffrey R.; Stuart, Michael J. “Medial tibial stress syndrome”. Medicine & Science in Sports & Exercise. 32 Supplement 2:S27-S33, March (2000).Franklyn, M., & Oakes, Barry. “Aetiology and mechanisms of injury in midial tibial stress syndrome and future developments”. World J orthop 6(8): 577-589. Sep (2015). doi: 10.5312/wjo.v6.i8.577http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573502/