shin splints

Whilst on my musculosketal prac I treated a patient with anterior shin pain, not having come across shin pain before I had very little treatment ideas and advice for this patient in regards to managing his pain and preventing it in the future. I thought in my blog I could elabourate on what shin splints is and give some evidence based treatment advice If other student s treate a similar patient.

Shin splints are described as pain and discomfort in the leg from repetitive activity on hard surface, or due to forceful, excessive use of foot flexures. The term shin splints have historically been used as an umbrella term for shin pain which is not stress fractures. More recently descriptive terms of Medial tibial traction periostitis MTTP and Medial tibial stress syndrome MTSS have been used to more accurately description the involved anatomy and presumed pathophysiology of this common condition Beck (1998). Published studies report that shin splints accounted for 6-16% of injuries among runners, this been the third most common injury reported among runners. There is still no clear consensus of the pathophysiology in this condition thus naming of this condition may change with further research.

Differential diagnosis
• Medial tibial traction syndrome
• Bone stress reaction or stress fracture
• Chronic exertion compartment syndrome
• Popliteal artery entrapment
• Muscle-tendon injuries, strains and tendinopathy.

Signs and symptoms of Medial tibial traction syndrome
• Dull ache in over the distal one third posterior medial cortex of the tibia.
• Pain may decrease with warm up
• Pain typically worse with loading and resistance
• No focal area of pain present as that may indicate stress fracture

Diagnosis is made through
Hallmark clinical features - tenderness over a 4 to 6 cm area at the posteromedial margin of the middle to distal third of the tibia
Ruling out other pathology - Special test for stress fracture. Using a tuning for over the site of tenderness can provoke pain in the presence of a stress fracture
X-ray - indicated to rule out TSF, infection or neoplasm but findings are generally normal with MTTS
Triple phase Tc bone scan - scan is highly sensitive for tibial stress injuries with the added advantage of being able to distinguish between MTTS and TSF
MRI - has become an increasingly utilized modality for assessing tibial stress injuries.

Patho-anatomy
Neither the exact pathophysiologic mechanism nor the specific pathologic lesions are completely understood in MTP. Traditionally researcher believed the underlying mechanism was repetitive microtrauma to the periosteum and fascial attachments as a result of traction forces from the soleus and the flexor digitorum longus musculature. Although more resent research Beck (1998) is suggesting MTTS like TSF is a bone stress reaction caused by chronic repetitive loads that induce tibial bending forces. It is believed MTP is merely a symptomatic expression of normal periosteal modelling at the site of maximal tibial strain whilst under load.

Evidence based Treatment
The foundation of treatment is based on symptomatic relief, identification of risk factors and treating underlying pathology.
• Activity modification - relative rest and activity modification
Level 2 evidence
• Cushioned orthoses with a semi rigid medial arch support to assist with shock absorption and support pronated foot – can significantly reduce the overall incidence of and specifically prevent medial tibial periostitis
• Level 1 evidence
• Appropriate footwear
• Resolve acute inflammation and promote analgesia - Non-steroidal anti-inflammatory, ice, massage, ultra sound whirlpool baths and acupuncture.
Level 2 evidence
• Soft tissue therapy – digital ischemic pressure, sustained myofacial tension and transverse frictions.
Insufficient literature
• Vacuum cupping
Insufficient literature
• Surgical release – in very resistant cases, has a projected success rate of 70% improvement in high-performace elite athletes

Returning to Sport
The return to activity for athletes after treatment for MTTS must be gradual and individualized. Cross training (eg cycling, swimming, deep water/pool running) and altered training is essential to resolve with conditijavascript:void(0)on. Athletes must adhere to the “start low and go slow” mantra. Once athletes are asymptomatic, it is recommended to start at 50 percent of their baseline training load and increase the frequency/intensity/duration by 10 to 15 percent per week. They should avoid back-to-back days of repetitive impact activity for the first two to four weeks, depending on the severity of the case. If symptoms recur, two additional weeks of rest are recommended and should be followed by a “downgraded” training regimen. Patients can often achieve a return to full, unrestricted activity in three to six weeks. However, a delayed return is not uncommon for this often refractory condition.

I hope this information helps any other students if they treat anterior shin pain.