Shin Splint Discussion: Part III

This is Part III of a discussion on Shin Splints. The links to Part I and II are attached. Here we will talk about treatments when the pain is all in the leg. Even though this discussion is geared for the podiatrist, patients can get a favor of what is important in their treatment.

https://www.drblakeshealingsole.com/2020/08/shin-splints-discussion-part-i.html

https://www.drblakeshealingsole.com/2020/08/shin-splint-discussion-part-ii.html

Common Mechanical Changes for Shin Splints

1. Strengthening of Involved Muscle Group

2. Stretching of the Involved Muscle Group

3. Reducing the Suspected Pronation or Supination Tendencies

4. Stretching the Achilles Complex

5. Strengthening the Achilles Complex

6. Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment Issues Involved

7. Training Decisions

8. Consideration of Bone Involvement

Strengthening of Involved Muscle Group is crucial in all 4 types of Shin Splints.

What is important is good muscle testing principles and you will need to learn

how to differentiate the muscles in each group. It is well taught how to

differentiate testing of the gastrocnemius (knee straight) and soleus

(knee bent) in the posterior group with the other groups *equally

challenging. It is important to know if it is the posterior tibial,

flexor hallucis longus,or flexor digitorum longus giving the medial ankle

pain. Or, if it is the peroneus longus or brevis that hurts when testing against

resistance the lateral compartment. Or, if it is the anterior tibial or another

one of the extensors producing the anterior shin splint. 

Stretching of the Involved Muscle Group is typically only done for the

anterior or posterior muscle/tendon groups. You should know the general

rules for stretching,but remember stretching should never hurt or the tightness

actually gets worse. I recommend stretching an involved group 3 times a day

so I can get to 100 stretches within a month for my next followup visit

generally. It typically takes stretching 3 times a day to gain.

Reducing the Suspected Pronation or Supination Tendencies with varus

or valgus wedges, taping, arch supports, shoe changes, custom orthotics,

and strengthening exercises occurs when youthink the pronation or supination

observed in gait or activity is related to the type of shin splint. 

Stretching the Achilles Complex is vital to most sports injuries when

there is equinus forces. However, it is so important to be able to reliably

measure for this equinus because over stretching a normal or hyper flexible

achilles tendon will do more harm than good. Tight achilles has been known

to be involved in all 4 shin splint types. 

Strengthening the Achilles Complex is vital when the achilles is weak.

The acid test for normal achilles strength is 25 single leg heel raises with

the knee straight (gastrocnemius) and 12 single leg heel raises with the knee

bent (soleus). These are typically done in the evening. 

Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment

Issues Involved is your classic Root design. Doctors not trained in Root

biomechanics tend to use more metatarsal pads and anterior orthotic bars and

posts, and combinations of all may be needed. Not only is forefoot support great

for the correction of pronation or supination tendencies, the metatarsal support

provided can be crucial for long flexor or extensor produced medial or anterior

shin splints. 

Training Decisions for shin splints is universally to lighten the load on the

injured tissue. And for those athletes who seek treatment, the chance of a

stress fracture is high. The runner must cross train with biking as the

mainstay alternative. Since both hill work and speed work are more stressful,

slow distance training is the first goal to accomplish. Each sport involved

will have different strategies at lightening the stress first, and then

gradually re-introducing these same stresses. 

Consideration of Bone Involvement is very important in shin splints.

There are yearly reported cases of compound fractures in runners ignoring

the shin splint symptoms only to have the stress fracture become a through

and through fracture. I have had 27 year olds with shin splints have the bone

density of 80 year olds. It is important to remember Shin Splints can be bone

pain primarily, and verifying the patient has good bone health is crucial. 

Shin Splint Discussion: Part II

This is Part II of a discussion on Shin Splints. The link to Part I is attached.

https://www.drblakeshealingsole.com/2020/08/shin-splints-discussion-part-i.html

One of the number one causes of shin splints that do not seem to improve is undiagnosed stress fractures. The young inexperienced cross country runners (or other athletes) who are not responded to shin splint treatment should be worked up for tibial (anterior or medial shin splints) stress fractures or fibular (lateral shin splints) stress fractures. This is still a version of the same process of overload. The overload in shin splints goes to the weakest link in the chain: the bone and a fracture occurs, the periosteum of the bone (which is the classic shin splint), the muscle belly, or the tendon.

The five most common types of stress fractures which are mistaken for shin splints are: posterior tibial (posterior or medial shin splints), distal tibia (medial shin splints), anterior tibial (anterior shin splints), fibula (lateral shin splints), or proximal tibial (either medial or anterior shin splints). Of course, if you do make the diagnosis a stress fracture, always think about the overall bone health. Did this bone break not only due to the mechanical overload of hills, pronation, supination, tight muscles, etc, but is the bone actually healthy? An unhealthy bone becomes the weak link in the chain. 

I mentally use the Rule of 3 in overuse injuries. The Rule of 3 means look for at least 3 legitimate reasons why a certain structure started hurting. Overuse picks on the weakest link in the chain, and many times a structure is weak because of 3-5 factors working against it. For example, since we are talking about stress fractures, remember that 40 years ago they were thought only to be related to impact shock. Then, article after article came out regarding stress fractures related to muscle contraction or bony torque. And, recently, the role of overall bone health has been more publicized. Therefore, if we use the common example of lateral shin splints actually being undiagnosed fibular stress fractures, the common rule of 3 includes:

• Inadequate bone health with eating problems or low Vitamin D

• Excessive supination causing excessive peroneal strain or simply increased lateral body weight

• Weak Peroneal Tendons increasing the strain or pull on the fibula

• Old lateral ankle sprains increasing the supination moments of force

With shin splints, the game for me is trying to figure out what muscle group is involved and what could be the cause of the overuse of that muscle/tendon. If we take the extensors as a group, they give us anterior shin splints. What causes general overload of the extensor group? The extensor group is again overloaded with a very tight achilles tendon complex which makes it work  harder to flex the ankle joint. Also running hills makes you use the extensors differently than what you are used to, especially eccentrically as you run downhills as they avoid foot slap. Typically our bodies will get used to the activity, so shin splints are usually from new activities or changes in some routine. When shin splints occur in a seasoned runner for example, I think bone over tendon, therefore I want to rule out a stress fracture first. And, to add an extra twist, there are 4 individual extensor tendons. The anterior tibial tendon can cause a shin splint particularly if the foot pronates too much. The anterior tibial is straining to decelerate contact phase pronation. The peroneus tertius and extensor digitorum longus get painful with over supination especially in midstance or propulsion. While the extensor hallucis longus is fairly neutral to the subtalar joint, it can overload in functional hallux limitus as it tries to lift the big toe off the ground, or in painful big toe joints (perhaps hallux rigidus) as protection. 

The lateral shin splint syndrome is commonly caused by over firing of the peroneals to protect the lateral ankle. Common causes of normal lateral or foot overload are: laterally worn shoes, running on banked road (foot held supinated), shoes laterally unstable (70% of all supination problems are not in supinators structurally), and foot types like pes cavus that overly supinate. One of the exceptions to this concerns the function of peroneus longus tendon to raise the medial arch by plantar flexing the first metatarsal. Here lateral shin splints can develop from over pronation when the peroneus longus is strained. 

The posterior shin splint is typically the soleus fibers or a tibial stress fracture. The pain is deep to the calf muscle belly, so given the name shin splint since it does not seem to be a calf strain. The stress fracture may never show up on xray, and not seem serious enough to get a conclusive MRI or Tc99 bone scan. 

In Part III of our discussion on Shin Splints, I will talk about general mechanical treatments

Shin Splints Discussion: PART I

                         Shin Splints 

 

     I love shin splints for the academic challenge to figure out

what is wrong and what muscle/tendon is involved. Since shin splints are so common at the start of cross country season, it is easy to get a little lazy with treatment since most get better. You have to take the approach that the athlete will not get better without your treatment, and that should inspire you. I breakdown shin splints into medial, lateral, anterior, and posterior. The muscles and tendons involved are summarized below for each. This discussion of shin splints will be broken down into 3 parts, today PART I.

Medial Shin Splints

Involves the posterior tibial tendon, flexor hallucis longus tendon, or the flexor digitorum longus tendon

Lateral Shin Splints

Involves the peroneus longus tendon or the peroneus brevis tendon

Anterior Shin Splints

Involves the anterior tibial muscle, extensor hallucis longus tendon, extensor digitorum longus tendon, or the peroneus tertius tendon

Posterior Shin Splints

Involves the gastrocnemius muscle or the soleus muscle

Common Location Anterior Shin Splints

Common Location Medial Shin Splints

Shin splints actually can be defined as pain between the ankle and the knee. There are a lot of structures that can be involved which are important when treating these symptoms. When we treat shin splints, we can simply use activity modification, some ice, general leg strengthening, cross training, and most patients will do fine. However, if will treat it will a little more zest, we can prevent it from reoccurring. This can mean an athletic will have a longer running career. For the patient who does not respond to simple measures, they could have compartment syndrome or tibial/fibular stress fractures. Muscle testing sometimes helps, but most cases of shin splints are related to the muscle fatiguing when tiring. This is hard to test in the office when the patient is rested, although I do normally have patients workout hard, or workout to the threshold of pain, before their appointment last in the day. One muscle testing principles is to test the muscle in two basic positions: patient has advantage and examiner has advantage. You can pick up subtle weaknesses this way. 

A thorough understanding of shin splints starts with you defining it as one of these 4 types and then delving into the function of the muscles and how the patient may have overused that muscle or muscle group. Today, this blog post, will focus on medial shin splints.

If the patient presents with medial shin splints, the muscles involved are posterior tibial, flexor digitorum longus, and flexor hallucis longus. We then have to look for overuse in one of its functions. So, what do these muscles do actually? These tendons have many functions, but let us look at what they do at the ankle. Since they all arise from the deep compartment, they are ankle plantar flexors and ankle invertors. What is the primary ankle plantar flexor? That is the achilles tendon, but anything that makes the achilles tendon weak can cause you to overuse one of the 3 muscles causing medial shin splints as they try to help the achilles perform its job. Typical weakness in the achilles is simply fatigue from the new sport they are engaging in, or just adding hills to their running program can fatigue the achilles. But, an over stretched achilles or excessive tight achilles, is considered weak by force length physics. With the recent craze of zero drop shoes, I have also seen more achilles and anterior or medial shin splints. 

The ankle inverter function is probably the more common cause of medial shin splints. What taxes the inversion strength of these muscles? Excessive pronation can cause these 3 muscles to fatigue and strain as they attempt to decelerate the pronation. As the arch collapses in pronation, the medial 3 are strained, but especially the posterior tibial and peroneus longus (a cause of lateral shin splints). 

So, what are some of the causes of excessive pronation? Running itself with landing on the lateral side of the heel will cause 2-4 times more pronation than walking in many runners. Another one of the common causes of severe foot pronation is achilles tightness called equinus. This tightness can be the cause of posterior shin splints, but also anterior and medial shin splints. This is why a complete understanding of achilles strength and flexibility is crucial. If the achilles is tight, it is harder for the anterior (extensors) to dorsiflex the foot (thus causing anterior shin splints). If the achilles is tight, the foot can pronate and the arch collapses (medial shin splints), both putting strain on the functions of the deep posterior compartment. If the achilles is tight, the forefoot is forcibly loaded by ground reactive force, making it difficult to bend the toes in propulsion. Stress is placed on the long flexors (medial shin splints) and long extensors (anterior shin splints).

So when a patient comes into my office with shin splints, I need to see what type they have (medial, lateral, anterior, or posterior) and if I can figure out what they did wrong other than add a new sport. I need to check if their pronation is excessive (and you have to watch them run since running and walking for a patient can be totally the same or different). I need to measure for achilles tightness or over flexibility since the achilles tendon can be the source of both power and problems for athletes. I need them in their normal running shoes. If they are a pronator, I also want to categorize them as mild, moderate, or severe, so I can determine what level of support needed in my treatment to lower the tissue stress threshold so they can heal. This is where podiatry usually excels since proper shoes, custom or OTC insoles, appropriate strengthening exercises, and taping can speed up the rehabilitation and prevent re-occurrences. PART II will discuss stress fractures, anterior and lateral shin splints, and other general rules.

The video below is on posterior tibial strengthening when a weak muscle is found in medial shin splints.

https://youtu.be/w3FXx4OFqec

Good videos for Shin Splints

https://youtu.be/-tHXkt5JZMc  This is a good video, but I personally do not like the stair exercise. 



https://youtu.be/sekBTg7cowo  This is my video and just look at the beginning which shows the anterior tibial strengthening.

Shin Splints: A Possible Resource

I received this email advertisement. I briefly reviewed it only, so can not recommend it in part or whole. I can say that I am impressed by the some of the thoughts, and hated not to pass the information along. Sorry, but you will have to use your own judgement on this. Dr Rich Blake

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Shin Splints: Basic Treatment Tips

    Injuries to the lower leg are quite common with compartment syndrome being the hardest to diagnosis, and one of the only non-traumatic injuries in the leg that may require surgery. Many cases of Shin Splints are actually tibial or fibular stress fractures which may be quite self limiting (time is a great cure for these). Severe calf cramping (with the meaning of “severe” different from patient to patient and doctor to doctor can be a warning sign of a venous blood clot (not to be ignored). I will focus here on the common injuries/pain syndromes that a podiatrist will treat in the leg on a daily basis called shin splints, but could be stress fractures, muscular strains, acute tears of the muscles ( “Tennis Leg”), and the less common DVTs and compartment syndromes that one needs to be on the lookout for.

Shin Splints

Shin Splints: What are they? What is the basic treatment?

Shin Splints literally means pain somewhere between below the knee joint and above the ankle joint. There are a lot of structures that can produce pain in that area, so the treatments range from simple to complex. Mostly, shin splints is an overuse of one group of muscles/tendons that start (originate) in the leg, and end up (insert) into part of the foot. Each one of these muscle/tendon has various functions around various joints. It can be one of these muscle functions that has been forced to work in an overuse fashion that produces pain. Podiatrists, physical therapists, orthopedists, chiropractors, and physiatrists (rehab specialists) tend to be the most qualified to recognize the exact muscle/tendon involved when treatment is stalling.

Shin splints is so common, and normally responds so well to basic treatment, that most clinicians do not get too involved in its complexities. The basic treatment of shin splints involves:

1. Reduce activity to pain free levels for at least one week.
2. Ice the involved area for 30 minutes 3x/day.
3. Change your athletic shoes if they may be worn down.
4. Minimize your speed workouts and hill workouts.
5. Consider if levels of Calcium and Vitamin D may be low.
6. Attempt 3 to 4 days/week alternative exercises as long as it is pain free (i.e. cycling, elliptical, walking, swimming, court sports, etc.)
7. Stretch the achilles tendon 2 positional (knee straight and knee bent) for 1 minute each 3x/day.
8. Experiment with an ankle brace or ankle taping if it is painful to walk.
9. Wear tie-on supportive athletic shoes full time while the shin is healing (although you may experiment with clogs as an alternative).
10. Attempt pain free muscle strengthening of the muscle group involved.

As your symptoms get better, gradually increase your activity back to normal levels (normally 15% increase per week if you were still able to exercise, and 10% per week if you had to shut it all down). A walk/run program may be an appropriate starting point.

http://www.drblakeshealingsole.com/2010/03/walkrun-program-for-injury.html

Now, let us review the anatomy of Shin Splints. The 4 basic types of shin splints are Medial (most common), Anterior (2nd), Lateral (3rd), and Posterior (4th).

Medial shin splints involve a group of muscles (with most commonly associated muscle function) including the posterior tibial (controls over pronation), flexor hallucis longus (stabilizes the big toe), and the flexor digitorum longus (stabilizes toes 2 to 5). Photo below shows where medial shin splints occur. Since over pronation, bunions (unstable big toes), and hammertoes (unstable lesser toes) are all common problems, this type of shin splint is the most common. More specific treatments of these problems include various methods in controlling pronation, stablizing the big toe area or stablizing the lesser toes.These include toe separators/spreaders, shoe inserts with Morton’s extensions, big toe spica taping to stabilize the big toe area, and toe crests, toe taping, reverse Morton’s extensions all to stabilize the lesser 4 toes.

Many patients purchase shoes too wide in the toe box leading to marked instability, especially when they have bunions. Too much room with resultant sliding around is just as bad on bunions and hammertoes as having too little room with resultant crowding. To help stabilize, the patient will grip with the toes, possibly producing medial shin splints. Even good fitting shoes initially can begin to loosen up as it breaks down. Try power lacing to help gain stability. Runners can also get medial shin pain commonly from tibial stress fractures. The 2 most common places for tibial stress fractures are distal medial (just above the ankle) and posterior (presently as calf pain or medial shin splints).

The 2nd most common form of shin splints is anterior shin splints (see photo above). The muscles (functions) involved all help to control foot slap after heel strike, and then to help lift the foot off of the ground at toe off. Overuse situations can easily occur with hill running and increases in the speed of workouts. It is the most commonest form of shin splints in the first month of cross country season, so common that most coaches ignore since the muscles due tend to get strong. The muscle/tendons involved are the anterior tibial (controls over pronation and stabilizes the first metatarsal), extensor hallucis longus (stabilizes big toe and lifts toe up at toe off), extensor digitorum longus (stabilizes lesser toes and lifts these toes up at toe off), and the peroneus tertius (stabilizes the outside of the foot including the cuboid , 4th metatarsal and 5th metatarsal). When the peroneus tertius is involved there can be a problem with over supination just like lateral shin splints.

This muscle group is normally the weakest of the 4 groups and has to constantly pull against the more powerful Achilles tendon. As the calf/Achilles gets too tight/too strong with vigorous exercise, it is hard for the anterior group to keep up. These muscles will strain under the added stress of working against the tight Achilles. Hopefully, when someone has anterior tibial shin splints, treatment should be directed towards:

• Stretching of the calf

• Decreasing hills/speed for awhile

• Stabilizing pronation (medial support) or stabilizing supination (lateral/cuboid area support)

• Stabilizing any digit appearing unstable (with toe separators, taping, toe crests, etc.)

The 3rd most common form of shin splints is lateral shin splints (see photo above). The muscle/tendons (functions) involved are the peroneus longus (stabilizes the lateral ankle against excessive supination and stabilizes the cuboid and the first metatarsal), and the peroneus brevis (stabilizes the lateral ankle against supination and stabilizes the cuboid and fifth metatarsal). So together they stabilize the lateral ankle, and both sides of the midfoot area. Ankle braces, ankle proprioceptive exercises (see post below on flat footed balancing), power lacing, and stable shoes if you pronate or supinate too much can all be part of the treatment.

The 4th common form of shin splints is posterior shin splints (see photo above). The upper 2/3 of the calf is considered a shin splint if the pain is deep. This can be a stress fracture on the posterior aspect of the tibia (very common in runners) and often misdiagnosed as calf muscle strain. It may also be a strain of the soleus muscle (deep part of the calf) where it originates on the tibia. The gastrocnemius (or gastroc) is the bigger, more superficial, muscle of the calf. The soleus muscle starts deep to the gastroc and becomes the other ½ of the Achilles tendon below. Therefore, the soleus functions to lift the heel. It also attempts to slow down pronation at heel contact, so over pronators may strain the muscle. It is harder to strengthen the soleus then the gastroc, so weaknesses may develop and muscle strains can occur with relatively minor overuse situations.

In general, soleus strengthening is done with the knee bent 45 to 90 degrees and the ankle is then plantarflexed with resistance (pointed downward like a ballerina on her pointe shoes). Treatment of this type of shin splints must initially rule out a tibial stress fracture which requires other treatments and concerns. Once tibial stress fractures are ruled out by x ray or bone scan typically, functional changes include decreasing ankle plantarflexion (extension) and stabilizing pronation. Also, avoiding activities that produce a negative heel effect where your heel is unsupported and drops below the plane of the forefoot, like getting off your seat in cycling. A slight biomechanical change in activities to minimize heel lift (ie. walking more flatfooted even when going up hills, or lowering the seat on your bike) can greatly speed up treatment.

 This time of the year (September and October especially) is made for Shin Splints. Cross Country season is starting and all high school and some college coaches are drowning in Shin Pain. Most of the time the athlete's pain is related to the bone and muscles not being used to the activity and overuse occurs. A shin splint technically is when the muscle pulls so hard on the bone that the lining of the bone (called the periosteum) is pulled away from the bone causing bleeding between the bone and bone covering. This normally is improved with time, icing, some stretching, and activity modifications.

However, when the bone is weaker (poor base of running, low Vit D or Calcium, low estrogen, abnormal bone structure) than the muscle, the bone may actually be the weakest link in the chain and break. This break in the bone normally remains a stress hairline fracture not detectable by normal xrays. Only in rare cases does the bone break all the way through into a complete fracture. The complete fractures are easy to diagnosis, due to the intense pain. A hairline stress fracture, also called a fatigue fracture of the bone, can at times be run on for weeks and even months. Top athletes, with apparently high pain thresholds, have presented to our office with 3 to 5 stress fractures and still running with so-called "shin splint pain". More reading below on the Weakest Link in the Chain concept.

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-3.html

So, when shin splints are not improving with the simple measures of relative rest, ice, shin sleeves, cross training, shoe changes, stretching and strengthening, etc, I advocate the use of a bone scan. It is positive within several days of a stress fracture, and is less expensive than an MRI. In our hospital, for the same price you get both legs for comparison, where MRIs are now being charged for only one side at a time and small areas at a time.

Christina, a freshman X-Country runner in high school presented with significant pain right greater than left tibias. Definitely she could not run through this pain. Bone Scans below documented a stress fracture only on the left side. The right tibia had generalized increase uptake of the dye which we call pre-tibial stress fracture or tibial stress reaction. Stress reactions can hurt just as much as a stress fracture, although heal quicker.

On this front view of the tibias, see the intense dye uptake in the middle of the left tibia. Since Christina is fourteen, she is still growing so her growth plates near the knees and ankles are still very active.

Here is a side view of both tibias with the left again showing the spot where the tibia broke.

This is also a good example of why MRIs probably would have mislead us in Christina's case. Christina had more pain on her right side. Due to the expense of MRIs, and the fact that each side has a separate cost, I probably would have only done the right side. I would not have found the fracture, and probably allowed her to run sooner. We never will know. So consider getting a limited bone scan instead of an MRI when shin splints are not improving. Thank you Christina for being a good model, but sorry your shins hurt.