Tag Archives: lower cross syndrome

Shin Splints 101

This blog post is long overdue. I have had countless people – friends, family members, athletes, clients – all ask me about shin splints. OK, before the Athletic Trainers, Physicians, PTs and other health care providers jump down my throat. Yes, shin splints is a junk term. I am talking about MTSS. I understand this, but the people you treat know them as MTSS, so relax. What are they? How can I get rid of them? Can they be prevented? Despite being one of the most common athletic injuries, recreational or competitive, shin splints are easily treatable and very preventable. Too often sufferer’s deal with the pain and never fix the problem. My goal with this blog is to provide tips to fix the problem and resolve shin splint pain.

Shin splints, or Medial Tibial Stress Syndrome (MTSS), is a chronic injury typically described as dull-ache on the medial, mid-to-lower-third portion of the lower leg. Pain is common during or after activity. In severe cases pain may last for several hours after activity and occasionally the individual will experience nighttime throbbing in the lower leg.

The pain from MTSS is attributed to irritation of the periosteum – a saran wrap like covering around bone – or a stress reaction to the underlying bone. Repetitive pounding or muscle pulling from these structures precipitates the injury. Popular belief is that shin splints are due to poor shoes, training intensity, and training surfaces. However, a critical review article written by Moen, Tol, et al., published in 2009 Sports Medicine found this was not the case. MTSS is often caused by poor joint movement and muscle imbalance.  These movement patterns and muscle imbalances are easily identifiable. The best part is that you can fix these problems at home by following a simple flexibility and strengthening program.

IMG_2285

Blue lines illustrate normal hip-knee-ankle-foot alignment.
Red Lines illustrate femoral and tibial adduction and foot external rotation.
Green arrows show knees caving in and foot arch flattening.

First, let’s see if you have these movement dysfunctions. Observe yourself (in a mirror) walking or doing repeated squats. Do you see one or more of these four things: hips in, knees in, feet flatten, or toes point out? You may have one or all of these patterns; some may be extremely pronounced or could be very subtle. The image here shows a moderate to severe movement. If you observe this, even to the slightest degree, you are at risk for developing shin splints. Overtime, these movement patterns create a muscle imbalance, where some muscles become overactive and some become underactive.

Using the above figure as an example, here are the typical overactive and underactive muscles we would see in a person with shin splints or with these movement patterns.

OVERACTIVE

UNDERACTIVE

Hip Flexors and Tensor Fascia Latae Gluteal  Group (Maximus, Medius)
Lateral calf (lateral gastrocnemius / soleus) Medial Gastrocnemius
Groin muscles (anterior adductor complex) Anterior and Posterior tibialis
Biceps Femoris Medial Hamstrings

Our goal is simple, turn-off the overactive and turn-on the underactive; simple as that. Below is a basic 3-step program that can help correct this issue, step 1 -Turn-off, step 2 – elongate, and step 3 – turn-on. This program can be done daily and would take no longer than 30 minutes from start to finish. Here is what a basic program would look like.

Step 1: Turn-off the overactive muscles using self-myofascial release

  • Gastrocnemius/Soleus
  • Adductors
  • TFL/IT-band
  • Hip Flexors

Foam rolling is the best way to do this if you go at it alone. If you have a  qualified therapist, manual release of these muscles will do the trick. When foam rolling, roll each muscle for 90 seconds and hold tender areas for 20-30 seconds. A YouTube playlist I created, provides good examples and tips on how to perform these techniques.   

Step 2 – Elongate the overactive muscles with static stretching

  • Gastrocnemius/Soleus Static Stretch
  • TFL/IT Band Stretch
  • Kneeling Hip Flexor Static Stretch
  • Adductor Static Stretch

Perform 1-2 sets of the stretch per muscle group and hold the stretch for a maximum of 30 seconds. Brent Brookbush, has a good static stretching playlist that demonstrates these exercises.

Step 3 – Turn on the underactive with isolated strengthening

The above exercises are just examples. There are many exercises to choose from. The important thing is to target the right muscles. Fix the core, attack the glute medius and glute maximus, and work the tibialis anterior and posterior.

In summary, too often I see individuals with shin pain ceasing activity, buying new shoes, investing hundreds of dollars in custom orthotics, or giving themselves an ice bath. Shin splints do not have to be the end of training. They are easily preventable and curable as long as you fix the problem. Following a simple and structured program to correct of common movement dysfunction patterns can eliminate shin splints and many other lower body injuries like Achilles pain, runner’s knee or hip pain.

15 Minute Rehabilitation: It’s Time to Unplug

While working as an athletic trainer I was frustrated and furious with the constant flow of athletes ‘needing’ certain treatment. I was tired of students and support staff hooking athletes up to every biophysical modality in the athletic training room. Why? They had no clue – it felt good to the athlete, it ‘worked’, it was easy, the coach said to – my blood beginning to boil.

It seemed every injury for all athletes was treated by the wonderful benefits of electrical stimulation. After a quick evaluation the injured body part is surrounded by electrodes and covered with a comfy hot or cold pack. For 20 minutes the athlete sat there with a special tingly, prickly feeling that gives those in pain a warm fuzzy feeling. As a health care provider there is nothing easier than slapping on a few electrodes and walking away for 20 minutes; it’s easy and clients love it. I must admit that I have fallen victim to the persuasive effect of e-stim as both an athlete and health care provider. But it was time to unplug. The overuse of modalities coupled with the under usage of manual therapy and rehabilitation was sickening. So what did I do?

I unplugged it all. I took all of the modalities and put them in one room with one table. It was not to be used unless a valid reason existed to do so. Holy s***, did I make some people mad. Instantly, coaches and athletes, became health care experts saying it was needed. But for the fellow athletic trainers – they understood. It made them learn reasons why to use modalities. It also help them look at the treatment of injuries in another way. This method also enhanced their ability to identify and correct common human movement dysfunction than causes pain.

Before I go further and before those in support of  modality usage start throwing data at me, stop. E-Stim (along with the other biophyscial modalities) is a versatile modality, has few contraindications and is a quick easy way to reduce pain in most clients. For this reason e-stim is often the first tool of choice.  The effectiveness and subsequent overuse of e-stim, is secondary to pain relief. A structure called the substantia gelatinosa (SG), lies in the IV Laminae of the dorsal horn in the spinal cord. This structure is where nociceptive (pain) fibers terminate and decisions with regards to how pain should be handled are determined. Also terminating in the SG are A Delta fibers (sensory fibers). E-stim has several modulations, but the most common is for a theory called “Gate Control Theory”. Essentially, electrical impulses from e-stim therapy bombard the SG through the A Delta Sensory fibers and over-ride the nociceptive fibers and ‘turn-off’ pain. The pain relief can last from minutes to several hours.

Unfortunately, all too often, athletic trainers try to control pain rather than fix the problem. Rather than spending 20 minutes turning off pain, why not allocate the time to long-term pain relief and correcting dysfunction? Why not spend 20 minutes correcting a muscle imbalance, which will lead to lifelong change and keep athletes out of your athletic training room? All you are doing is putting a band-aid on a problem, unfortunately you have to keep putting that band-aid on everyday for the entire season. I said it before and will say it again – Athletic Trainers need to transition from triage to rehabilitation and optimizing functional movement. However, I understand the problem: it is a time crunch. Athletic training rooms are vastly understaffed – making it difficult to dedicate 20 minutes of rehabilitation time to one athlete, when 3oo are lined up at the door. So we have a time crunch, but there is a solution…

Almost all injuries we see in the athletic training room are a result of:  altered length tension relationships, altered arthrokinematics, altered neuromuscular recruitment. Collectively, these issues are what makes up human movement dysfunction. You name the injury – tendonitis, ACL tears, PFPS, fasciitis, MTSS, impingement, rotator cuff pathologies, you get the point – can be linked back to human movement dysfunction. The good is that human movement dysfunction is identifiable, preventable and correctable. The better is that the strategies to correct human movement dysfunction can be done in less than 15 minutes per day.

Yes, I said it – you can perform a 15 minute rehabilitation session. I presented on this topic at the NATA District 10 and District 2 conference and even did a few customized workshops. A colleague presented on the topic at the June 2012, NATA conference. Imagine correcting a problem, preventing injury, or rehabilitating an athlete in 15 minutes per day. That would be better than slapping on a pair of electrodes and setting up hi-frequency biphasic sensory-level stimulation. You will fix the problem and reduce pain. How you ask?

As I said above, human movement dysfunction is often composed of three problems, all which are identifiable during human movement assessments. The assessments will indicate where human movement impairments exist. But lets say for example we have a patient with patellar tendonitis, we would likely see functional impairments somewhere along the lower extremity. Below is a sample program I would do in 15 minutes.

Decrease neurological drive to hypertonic tissue – 3 minutes 

Exercise: Self-Myofascial Release or Manual therapy

  • Gastrocnemius/Soleus – 60 seconds
  • Adductors – 60 sec
  • TFL/IT-band – 60 sec

Lengthen hypertonic muscle or joint tissue – 3 minutes

Exercise: Static stretch or joint mobilization

  • Gastrocnemius/Soleus Stretch – 1 set @ 30 sec
  • Kneeling Hip Flexor Stretch – 1 set @ 30 sec
  • Adductor stretch – 1 set @ 30 sec
  • Posterior joint mobilizations at the ankle – 90 seconds

Increase neurological drive to hypotonic tissue – ~ 6 minutes

Exercise: Isolated Strengthening or positional isometrics

  • Resisted Ankle Dorsiflexion – 2 sets x 15 reps (slow) (2 minutes)
  • Resisted Hip Abduction and External Rotation- 2 sets x 15 reps (slow) (2 minutes)
  • Resisted Hip Extension – 2 sets x 15 reps (slow)  (2 minutes)

Integrated Dynamic Functional Motion – ~ 3 minutes

Exercise: Integrated movements

  •  Ball Squats w/Resistance Band Around Knees – 2 sets x 15 reps (slow)

Note this is just a sample program. In the above instance I assumed the client had limited ankle dorsiflexion and muscle imbalance at the hip musculature. The specific human movement impairment will be client and injury dependent. That said, you can follow the same formula and perform rehab in the same amount of time that it takes to perform e-stim. Too often we use the time crunch as an excuse for our failure to perform due diligence as health care practitioner. We have a job – that is to keep athletes healthy. Let’s choose the path that works – not the band-aid.