Pathology and functional impairment:

Medial tibial stress syndrome (more commonly known as shin splints) is an inflammatory condition caused by repetitive overuse of tissue structures of the lower leg.

These tissue structures (mostly muscles) create a muscular imbalance between the tissue of the lower leg and the normal biomechanical alignment of the forces transmitted from the ground reaction when the foot contacts the ground during running. The tissues involved in the lower leg are the anterior tibialis, gastrocnemius , soleus muscles, and the periosteum of the tibia bone.

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Shin splints are micro-injuries to the anterior tibialis muscle or the periosteum of the tibia which can be caused by lack of flexibility, muscular imbalances and overuse activity1. When an athlete is training improperly (i.e. not incorporating antagonist strengthening of the lower extremity), muscle imbalances will occur.

Muscle imbalances in the lower leg can cause decrease performance and prevent the athlete to train for his or her event. According to Tolbert et. al, medial tibial stress syndrome is caused by under activity of the medial soleus muscle and the over activity of the Achilles heel cord2.

Improper biomechanical alignment can be caused by the foot over pronating which causes the longitudinal arch of the foot to collape3. When the longitudinal arch becomes lengthened, the Navicular bone (a bone that is distal and medial from the talus bone in the foot) will drop down and touch the ground during weight bearing on the foot.

As a result of the loss of the arch in the foot; the shock absorbing ability to attenuate the ground reaction forces during running will decreases significantly. This causes the plantar flexors of the foot such as the gastrocnemius and soleus to become a dominate muscle group in the lower leg and cause a imbalance of the muscles.

The overpowering of the plantar flexes will cause the dorsiflexors of the foot (the major one being the tibialis anterior) to become actively insufficient and unable to hold the foot in proper position during running.

The foot then over pronates and everts. This gives the foot the presentation of “flat feet”3,4. Another contributing factor is the experience of the runner. Runners that engage in running 2-4 times a week and have been running for years do not have a high incidence of shin splint.

A beginning runner that runs sporadically throughout the year is at risk for developing shin splints because of de-conditioning of the ankle/foot complex. Running athletes, recreational athletes, and tactical athletes complain of pain along the distal 1/3 of the posterior medial aspect of the tibia during or after prolonged activity in which running is involved.

The most common symptom that runners feel is a dull achy pain during activity such as running and it will cease when the person discontinues the activity. The pain is caused by the inflammation of the periosteum of the tibia or muscles3. The tibia may experience a stress fracture due to the repetitive stress and the increased ground reaction forces absorbed from the foot and tibia.

The periosteum of a bone is the thin layer of membrane that covers the outer surface of a bone. The periosteum has both a blood supply and nerves that innervate the area. This is one reason why there is swelling and pain which goes along with shin splint symptoms. There is growing evidence that shin splints can be created by low bone density4.

The solution is a combination of increased flexibility and strengthening of the muscles of the lower leg

1. Flexibility:

An effective method to increase flexibility of the plantar flexors (gastroc/soleus complex)is to inhibit the shortened areas of the muscle using a foam roller (figure 1).

figure 1 Keith Chittenden

Figure 1

Start by placing the foam roller just distal to the popliteal fossa of the knee. Place the involved leg on top of the foam roller and place the non-involved leg over the involved leg. Using both arms lift your buttocks off the ground and roll toward the heel. When a tight/tender point is reached hold the tension on the area for 10 seconds; then continue to roll toward the heel. Repeat on the opposite if needed. complete 1-2 sets both before and after running activity.

2. Strengthening

The muscles that are weak and need to be strengthened are the anterior tibialis and the posterior tibalis. Both of these muscles become actively insufficient and cannot dorsiflex and invert the foot. A theraband or cable machine can be used to strengthen these muscles.

To strengthen the anterior tibilis muscle, assume a long sitting position. Attach the theraband or cable around the foot(if using a cable machine; back sure the line of pull is facing away from the foot). Pull the foot towards your head, hold for a second, and slowly release (figure 2).

figure 2 Keith Chittenden

Figure 2

To strengthen the posterior tibialis muscle, lie on your side. The medial side of the involved foot is facing up towards the ceiling. The theraband or cable is around the foot (if using a cable machine, the line of pull is under the lateral aspect of the foot pointing toward the ground). Invert the foot towards the ceiling, hold for a second, and slowly release (figure 3).

figure 3 Keith Chittenden

Figure 3

Do both exercises for 10 reps, 3 sets.

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References:

1. Reuter BH, Glen W. Overuse Injury Prevention in Triathletes. Strength & Cond. 1996;18(3): 11-14

2. Tolbert T, Binkley HM. Treatment and Prevention of Shin Splints. Strength & Cond. 2009: 31(5): 69-72

3. Raissi GRD, Afsaneh DS, Kourosh DM, Mohammad DR. The Relationship between Lower extremity alignment and Medial Stress Syndrome among non-professional athletes. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2009; 1(11): doi:10.1186/1758-2555-1-11.

4. Hubbard TJ, Carpenter EM, Cordova M. Contributing Factors to Medial Tibial Stress Syndrome: A Prospective Investigation. Medicine & Science in Sports & Exercise. 2009; 41(3): 490-496

5. Clark MA, Lucett SC. NASM Essentials of Corrective Exercise Training. 1st ed. 2011. Lippincott Williams & Wilkins. Philadelphia, PA

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