Sunday, February 15, 2009

A Simple Review of Shin Splint



MTSS is the short form of medial tibial stress syndrome which is an advanced medical terminology used to describe a group of exercise induced leg pain. Shin splint is one of the exercise induced leg pain. In the following article we will discuss about shin splints.
Ways shin splint presents:
1. Compartment Syndrome: Where an increase in pressure in certain muscles can cause extreme pain and decreases in circulation to the leg.
2. Tendonitis/Periostitis: Abnormal strain placed on the muscles, tendons, and on the covering around the bone that the tendon is attached to.
3. Stress Fractures: When exposed to increased strain and fatigue, minute fractures may result in the bones of the lower leg.
Contributing factors:
• Poor walk/run mechanics
• Inadequate calf flexibility
• Inadequate strength of the dorsi-flexors (muscles of the front of the lower leg)
• A rapid increase in mileage or frequency of aerobic classes
• Poor or worn out footwear
Symptoms include:
• Pain – usually on the inside of the shin bone (tibia) extending over a length of 10-20cm. The pain is usually of gradual onset, and worst with running.
• If you have focal pain (i.e. all the pain is over a 1-2cm area) then it is possible you have a stress fracture, rather than periostitis.
• If your pain is concentrated in the muscles rather than the bone-muscle junction, then it is possible you have compartment syndrome.
Signs include:
• Tenderness – along a 10-20cm length of the inner border of the tibia if it is periostitis. Focal tenderness where a tender spot can be located to one palpating finger on the sore spot is suggestive of a stress fracture. Diffuse muscle tenderness is present in the case of compartment syndrome.
• Hopping on the injured leg is relatively pain free in the case of periostitis, but is very painful if a stress fracture is present.
• Over-pronating flat feet (pronated calcanium) are commonly seen in those who complain of shin splint pain.
Investigations
Usually none are required. If a stress fracture is suspected, then an x-ray may confirm this if symptoms have been present for longer than a month. Otherwise, a bone scan is needed. Compartment pressure studies can help confirm a diagnosis of compartment syndrome.
Treatment:
• First aid – an ice pack or ice massage can be helpful after painful activity.
• Mechanical correction of over-pronating feet is essential. A podiatry referral is recommended.
• Physiotherapy, including myofascial release and a muscle rehabilitation problem is useful.
• Surgery is only required for confirmed compartment syndrome or very severe cases of periostitis lasting many months.
A special sports medicine treatment prospective:
1. Proper shoe selection
2. Laser/Ultrasound
3. Ice
4. Rest
5. Elevation
6. Cross training (ie.if you are in a running sport try rollerblading, cycling, swimming for your fitness to give the running muscles a break
7. Gait or Running analysis (seek help from a Physiotherapist or orthotist who has a specialized training in looking for biomechanical faults in your running technique)
8. Physiotherapy/Massage
9. After the symptoms have decreased a slow build-up of strength of the muscles of the front of the shin especially in their lengthened position is imperative for preventing a reoccurrence
10. Although a difficult muscle to stretch, the muscles can be stretched at the front of the shin by kneeling on the top of the affected foot for a 30 second hold repeating three times (see diagram). Simple ankle circles can also be very helpful for warming up the shin. Calf stretches are important to decrease the resistance to contracting for the muscles on the front of the shin.
11. Tennis requires a lot of stopping and starting and change of direction which results in rapid lengthening and shortening of the muscles and structures on the front of the shin. In the off season it is beneficial to set up a little obstacle course in your gym. It should include a variation of forward, backward, and sideways running and cutting gradually increasing speed and the duration of the work-out. This type of training requires a good warm-up and at least 48 hours recovery time between sessions
ALWAYS seek medical care within 5 days of onset if not resolving with mileage reduction, ice, and stretching.

Recovery time:
Average recovery time is 2-4 weeks for periostitis, 6-8 weeks for stress fracture and several months for compartment syndrome.
Recovery sequence:
• Step 1 Ice packs, pain relief, felt or orthotic footwear correction.
• Step 2 Myofascial release and muscle rehabilitation.
• Step 3 Continue swimming and cycling, and only restart running after at least two weeks when symptoms have settled. Start on grass initially.
• Step 4 Build up pace and add stop-start routines.
• Step 5 Run figure eights.
• Step 6 Perform cutting and turning exercises.
• Step 7 Team training and skill sessions.
• Step 8 Resume playing, half a game at first.
References:
1. www.clubphysioplus.com/articles/shin_splints_...
2. http://blogs.bmj.com/bjsm/2008/10/17/patient-information-sheet-shin-splints-also-known-as-periostitis/
3. www.hughston.com/hha/a_13_4_6.htm



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