Rehab for shin splints: Biomechanical Assessments & Treatment

UNDERSTANDING SHIN SPLINTS

To understand the rehab process for shin splints, its important to understand the correlation between running biomechanics and its effect on the tibia.

Shin splints or Medial tibial stress syndrome (MTSS) or most specifically, medial tibial traction periostitis is a leading cause of exercise-induced leg pain (Moen MH et al 2009).

It is described as a diffuse pain at the posteromedial border of the tibia caused by excessive loading during physical activities such as running and jumping. The middle and distal portion of the leg is most affected.

INJURY RATES

With an incidence of 4% to 35%, shin splints account for accounts for 30% of all running injuries (Newman et al 2013).
Females are around 1.5 to 3.5 times more affected than males.
Studies also suggest significant correlation between higher BMI & shin splints. (Plisky et. al, 2007)
Common among runners, military personnel, dancers, gymnasts, & recreational sports participants. (Bradshaw C et al 2008)

PATHOPHYSIOLOGY

The exact underlining etiology of MTSS is unclear. Hypothetically, fascial traction induced periostitis or a local bone stress reaction is considered to be the cause. (Lohrer et al 2018)

Continuous traction over the bony periosteum (by the muscle fibers that attach along the length of the medial border of the tibia and even possibly by the deep crural fascia), which also attaches to the same location, is thought to be responsible for symptoms of MTSS (Brown AA, 2016).

Moreover, this pain aggravates due to continuous impact loading of Running or jumping activities, which create additional stress within the tibia (Winkelmann ZK et al 2016).

CLINICAL PRESENTATION

Tenderness on palpation along the distal medial border of the tibia extending up to ≥5cm (Lohrer et al 2018).
Pain is diffuse in nature and often continues for a longer duration.
Duration of pain: Initially, the pain is experienced at the onset of activity and subsides with continued exercise. However, as the condition worsens the pain may persist even during and after the cessation of the activity (Brown AA, 2016).

DIFFERENTIAL DIAGNOSIS

MTSS falls under an umbrella category of exercise-induced leg pain. Thus, differentiating it from other possible conditions is necessary. The following entities should be strictly ruled out before proceeding with any treatment program. (Bradshaw C et al 2008, Lohrer et al 2018)

Common conditions: Stress Fracture (localized pain;<5cm), Chronic Exertional Compartmental Syndrome (short duration post-exercise pain);
Rare conditions: Tendinopathy, nerve entrapments, popliteal artery entrapment syndrome, DVT, osteomyelitis, bone tumors, etc.

Moreover, MTSS can co-exist in combination with two or three of these conditions. Therefore, it is important to use historical cues, clinical findings, and characteristics of pain for differentiation.

Lastly, specifically targeted imaging (radiographs, MRI, MR angiography) and diagnostic studies (dynamic intracompartmental pressure measurement, nerve conduction analyses, electromyography can be used for final confirmations.

POTENTIAL CAUSES OF SHIN SPLINTS

Like any running injury, MTSS can be caused due to any musculoskeletal impairment, training errors, biomechanical faults & extrinsic factors like footwear etc. In this section, we will be discussing assessments we can conduct to investigate each of these 4 aspects. As a clinician, if we are able to figure out the root cause behind the injury, we can provide effective rehab for shin splints.

PART 1: TRAINING ERRORS

Training errors appear to be the most common factors involved in MTSS, especially as athletes attempt to do ‘‘too much, too fast’’. Common training errors include:

A recent onset of increased activity, intensity, or duration. Such errors can be easily minimized by ensuring a gradual increase in activity. Training guides like ‘UW Health Sports medicine runners book‘ can be extremely useful to advise training tips to runners.
Continuous running on hard surfaces & uneven surfaces.
Individuals with previous lower extremity injuries and running more than 20 miles per week are especially predisposed to MTSS. (Galbraithet all 2009)

Training errors can be understood by taking a detailed injury & training history of the runner. Here’s sample ‘Runner intake form‘ you can use to understand the patient better.

PART 2: EXTRINSIC FACTORS (FOOTWEAR)

Footwear can hugely affect posture & biomechanics. Hence, an evaluation of the runner’s footwear is extremely helpful in designing an effective rehab program for shin splints. An ‘incorrect’ pair of shoes can lead to several injuries, even if there is no physical limitation in the body. A Clinical Assessment of the runner’s feet & shoe helps assess if the footwear needs to be replaced or while prescribing a new shoe. Here’s a comprehensive guide you can refer to for a shoe assessment of runners.

PART 3: FAULTY BIOMECHANICS LINKED WITH SHIN SPLINTS

A Clinical video analysis of running enables the clinician to characterize the patient’s running biomechanics and estimate the resulting joint loads. Faults in the running mechanics can increase the loading at certain areas of the body & expose the runner to injuries. Hence, detection of these faults should form an integral part of a rehab program for shin splints. Gait analysis is the most accurate way to detect these biomechanical faults. All you need is a video camera/smartphone along with a video analysis software to get started.

1. Overstriding

Running with a vertical orientation of the tibia at foot strike is an excellent way to reduce tibial stress. However, a lot of amateur runners tend to extend their tibia at foot strike (initial contact), displaying an overstriding pattern. This strategy is helpful from an immediate performance point of view as it is increases the stride length. However, it results in increase of ground reaction forces at the tibia, leading to shin splints or stress fractures. In addition to tibial extension, overstriding is also associated with reduced knee flexion which is another variable associated with with tibial stress fractures (Milner et all, 2006).

CORRECTIONS

Taking shorter steps or increasing cadence is a widely used strategy in reducing overstriding. Moreover, a mere 10% reduction in stride length has proved to reduce tibial contact force, which may have implications for preventing tibial stress injuries (Edwards et al, 2009)
Secondly, a rehab program for shin splints should also include running to reduce overstriding. Refer to this link by Stanford Health for some good drills.

2. Crossover Gait

In addition to increased tibial stresses, a crossover gait pattern has also been linked with Iliotibial Band pain in runners. Crossover gait can be best identified from the posterior view. As the name suggests, runners with crossover gait tend to land across an imaginary vertical line passing through the center of the body. Just like other biomechanical faults, crossover gait might also be a strategy to increase performance by reducing the net lateral movement of the body.

CORRECTIONS Runners with the crossover sign tend to benefit from step width manipulation, which includes increasing the step width to reduce the overall tibial loads (Meardon et al 2014). Verbal cues to run with a wider base of support have also been helpful for runners. For some retraining strategies that can be included for correcting crossover, refer to this link

3. Medial Collapse

‘Medial collapsers’ are runners who exhibit excessive contralateral pelvic drop accompanied with excessive hip adduction, dynamic genu valgum, and knee internal rotation. This gait pattern shifts the load to the side of the lateral femoral condyle of the knee & exerts a bending moment on the tibia. Consequently, such runners become vulnerable to higher stresses at the postero-medial aspect of the tibia. (Pohl et al 2008) The primary driver of the problem can either be proximal (lumbopelvic control) or distal (reduced ankle range of motion) and a thorough examination needs to be done to determine the cause. Runner’s with such a pattern often complain that they kick their shins or that their knees knock together.

CORRECTIONS In addition to a rehab program, providing visual feedback to help the runner maintain a level pelvis is very helpful to prevent excessive contralateral pelvic drop. A verbal cue to encourage the knees to stay apart can also be helpful in reducing excessive hip adduction.

4. Excessive & Prolonged Rearfoot Eversion

During the first half of stance phase, rearfoot pronation is considered normal. However, any prolonged and excessive eversion beyond midstance makes the foot soft & flexible at push off (instead of a rigid lever). Secondly, this alteration requires a greater effort from the intrinsic and extrinsic foot muscles to both stabilize the foot and generate sufficient torque during push-off (Becker J et al 2017). Consequently, the continuous repetition of this process during running (without proper recovery), ultimately leads to a bony stress injury (Becker J et al 2018).

CORRECTIONS

In addition to a rehab program, studies also recommend the use of orthotics (Kannus VP,1992) or higher level of support shoes to correct subtalar overpronation.

To learn more about these biomechanical faults along with their corrections, refer to this running injuries course here.

PART 4: MUSCULOSKELETAL IMPAIRMENTS LINKED WITH SHIN SPLINTS

A detailed musculoskeletal examination helps in understanding if the injury is due to a physical limitation in the body or due to any other factor mentioned above. Mentioned below are some common tests that are useful in examining MTSS in Runners. 1. Check for bony tenderness: Palpate with firm thumb & check if it elicits periosteal tenderness at the distal 1/3 to 1/2 of the anteromedial tibial surface (Franklyn and Oakes, 2015). 2. Ankle motion: Check for all talocrural and subtalar joint motions. Limited ankle motion is a common finding in shin splints. Special emphasis should be paid to the presence of foot overpronation as it is a well-documented risk factor. 3. Muscle inflexibility: Look for tightness or muscle imbalance of the hamstring, quadriceps and triceps surae (gastrocnemius, soleus, and plantaris muscles). A simple knee to wall test can detect calf tightness, if any. 4. Muscular strength: Look for adequate hip, pelvis, and core muscle strength as it is an important link in maintaining control and proper mechanics between the ‘‘core’’ and lower extremity. This can be tested by the patient’s ability to maintain a controlled, level pelvis during a pelvic bridging test or a single leg standing knee bend test.

REHAB FOR SHIN SPLINTS

Conservative management is the mainstay of rehab process of shin splints. Before initiation of the rehabilitation program, a comprehensive history should be obtained to evaluate the athlete’s weekly exercise routine and running mileage, intensity, pace, terrain, and footwear, with careful attention to recent changes in training regimens. The conservative treatment of MTSS is divided into 2 phases (Galbraith RM et al 2009):

Acute, and
Sub-acute.

ACUTE

Relative rest and cessation of sport for prolonged periods of time (from 2 to 6 weeks) depending on the severity of symptoms
Cryotherapy directly on painful area for 10-15 min.
Lastly, crutches may be necessary for temporary non-weightbearing in more severe cases of MTSS and tibial stress fractures

SUB – ACUTE

Avoid painful exercises.
Stretching exercises for calf and strengthening invertors and evertors of foot.
Begin low impact exercises such as running in pool, gait retraining, proper technique etc.
Proprioceptive balance training
Slowly progress to sport-specific activities, jumping exercises, and hill running in a graded fashion.

EXERCISES FOR REHAB OF SHIN SPLINTS

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The information found within this site is for general information only and should not be treated as a substitute for professional advice from a licensed Physiotherapist. Any application of exercises and diagnostic tests suggested is at the reader’s sole discretion and risk.

ABOUT THE AUTHOR

DR TEENA ELSA JOSEPH

Dr. Teena is a Sports Physiotherapist who has completed her BPT from Amity University & her MPT (Sports) from Indraprastha University. Her field of clinical expertise in sports & musculoskeletal physiotherapy includes manual therapy, dry needling & myofascial release. Apart from her work at Auptimo, she is also active as clinical researcher in a various of health & sports science research work at Indian Spinal Injuries Center, Delhi. She has achieved several awards for academic excellence along with professional certifications such as Dry Needling (Basic & Advanced), AHA certified BLS provider, NAEMT certified PHTLS provider, IRCS certified Senior professional in first aid, & NIDA certified Good Clinical Practitioner.

REFERENCES:

A-M

Becker J, Nakajima M, Wu WFW. Factors Contributing to Medial Tibial Stress Syndrome in Runners: A Prospective Study. Med Sci Sports Exerc. 2018;50(10):2092–2100.
Bradshaw C, Hislop M, and Hutchinson M. Shin Pain. In Clinical Sports Medicine; 3^rd 2008.
Brown AA. Medial Tibial Stress Syndrome: Muscles Located at the Site of Pain. Scientifica (Cairo). 2016.
Edwards WB, Taylor D, Rudolphi TJ, Gillette JC, Derrick TR. Effects of stride length and running mileage on a probabilistic stress fracture model. Med Sci Sports Exerc. 2009;41(12):2177–84.
Franklyn M, Oakes B. Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. World J Orthop. 2015;6(8):577–589.
Franklyn M, Oakes B. Tibial Stress Injuries: Aetiology, Classification, Biomechanics and the Failure of Bone. In: Zaslav KR. An International Perspective on Topics in Sports Medicine and Sports Injury. Rijeka: InTech, 2012: 509-534.
Galbraith RM, Lavallee ME. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009;2(3):127–133.
Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 2015; 49:362-369.
Lohrer H, Malliaropoulos N, Korakakis V, Padhiar N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. Phys Sportsmed. 2019;47(1):47–59.
Meardon, S.A., Derrick, T.R., Effect of step width manipulation on tibial stress during running. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.04.047
Milner CE, Ferber R, Pollard CD, et al. Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc. 2006; 38(2):323–8. [PubMed: 16531902]
Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC. Medial tibial stress syndrome: a critical review. Sports Med. 2009;39(7):523–546.

N-Z

Newman P, Witchalls J, Waddington G, Adams R. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013;4:229–241.
Oakes BW. Tibial pain or shin soreness (“shin splints”)-its cause, differential diagnosis and management. In: Draper J, editor. Second Report on the National Sports Research Program. Canberra, Australia: Australian Sports Commission; 1986: 47-51.
Plisky MS, Rauh MJ, Heiderscheit B, Underwood FB, Tank RT. Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. J Orthop Sports Phys Ther. 2007;37(2): 40–47.
Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retrospective tibial stress fractures in runners, J Biomech.2008;41(6):1160-5. doi: 10.1016/j.jbiomech.2008.
Winkelmann ZK, Anderson D, Games KE, Eberman LE. Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. J Athl Train. 2016;51(12):1049–1052.

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2 thoughts on “Rehab for shin splints: Biomechanical Assessments & Treatment”

Darwin Podiatry January 21, 2022 Reply

Thank you for this blog. this is a very useful and informative blog about shin splints.
- SidSingh October 12, 2022 Reply
  
  Thank you for your appreciation! We are glad you found it useful.