Thursday, 31 January 2013

Shin Splints, all you need to know.

Shin Splints

Shin Splints

Shin splints is the name given to a number of different clinical conditions that cause pain in the shin. There are many different types of shin splints: periostitis, stress fractures, tendonitis, and compartment syndrome to name a few common ones.
Periostitis is the inflammation of the periostium, which is the sheath surrounding a bone. Generally found in weight bearing joints following excessive activity, it is common in the tibia (shin bone) and foot.
A stress fracture is a common overuse injury often seen in athletes. A fracture (broken bone) is usually caused by direct impact to a bone, as you would see following a fall or car crash. A stress fracture however occurs with much lower forces that happen repetitively over a long period of time – they are also known as "fatigue fractures." Stress fractures can occur in any bone, but are usually seen in the foot and tibia (shin bone) as they are the ones supporting your body weight and so usually have the most load.
A tendon is the structure that connects your muscles to your bones and so they endure high loads when you perform ballistic activities like running. Tendonitis is when the tendon becomes inflamed and using its associated muscle (often at high speeds as with running) generates sufficient force that it becomes painful.
Compartment syndrome is usually from extensive muscle use, where pressure from an inflamed muscle builds up within the muscle sheath and causes pain. It is actually quite hard to diagnose, but it can be extremely painful and prevent even the most resilient runner from training.

There are many different causes of shin splints (in its many different forms).  We can separate them into extrinsic and intrinsic causes.

Extrinsic are the forces from outside the body which overload the tibia and surrounding muscles and tendons and are commonly from:
• Type of surface; running on surfaces that are too hard or too soft or even running on a camber.
• Running in inappropriate or worn-out footwear
• Running downhill
• Running technique
• Incorrectly progressed training to allow the body adapt to the increasing loads. This is especially true with beginners but can be seen in seasoned athletes who progress their training too quickly.
Intrinsic causes are from forces within the body.
• Excessive or too rapid over-pronation of the foot, which exerts unaccustomed force through the bone and/or associated muscles.
• Insufficient pronation (supination) which does not therefore adequately absorb shock, which also exerts excessive forces through the bone and/or associated muscles.
• Any intrinsic factor that affects the amount of pronation, like abnormal pelvic biomechanics, leg length discrepancies, tight calves, even spinal problems can affect the amount of pronation.
Usually it is a combination of both the intrinsic and extrinsic causes that produce symptoms; you can often ‘get away’ with just one. So for example an inexperienced runner who increases their mileage too quickly, but also has over pronating feet, will be especially susceptible. Just as an experienced runner who progresses their hill training too quickly, and unknowingly has a pelvic rotation which is causing a leg length discrepancy which influences the amount of pronation occurring in the foot/ankle, would likely have some form of reaction too.

The variety of different types of shin splints is matched by the variety of different symptoms, but they are commonly.

• Tenderness on the front/inside of the shin (tibia)
• The shin is hot and inflamed
• Sometimes there is swelling
• Pain settles after exercise, but recurs on resuming training
• But pain can also persist when at rest

Tests and diagnosis
Differential diagnoses are difficult with shin splints as there is such a high variety. Your medical history is the main factor that your doctor or therapist will be able to diagnose your injury from. However X-rays, MRI scans and pressure tests can all help provide the necessary information to help your specialist decide which is your type of shin splints and therefore how best to manage it.

Self help is critical when managing any injury, and shin splints is no exception and the R.I.C.E (Rest, Ice, Compression and elevation) principles apply here:
Rest. Obviously avoid the activities that cause your pain until it has subsided. Usually though you can continue some form of training to prevent you going ‘stir crazy’, like cycling, rowing, swimming and running in water.
Ice. Ice will help reduce swelling and inflammation. There are different ideas on how long to apply the ice and how, but generally speaking its accepted that you should be icing for 10 – 20 mins and this can be applied 3 – 5 times per day. The re-useable ice packs are very convenient and easy to apply.
Compression. If the shin is swollen then a compressive support can be helpful in combination with the ice pack. If you have compartment syndrome, a compression support will probably not help you.
Elevation. When swollen, elevating the shin can help.
Also look at what you consider could be the causes of your shin pain. Think about the extrinsic factors that could have contributed to your shin pain and take logical steps to avoid them in the future. Factors like wearing the correct shoes for your foot type - get them checked by a suitably qualified and experienced person. Think about getting your foot and pelvic biomechanics checked too. When prescribed correctly, orthotics to correct your foot biomechanics and exercises to help any pelvic or spinal problems that may be causing your shin splints can be very helpful. If you are a supinator (if you do not pronate enough to absorb shock) then shock absorbing insoles can be very helpful too.
Anti-inflammatory drugs and pain killers can sometimes help you over the worst of the pain, so it may be worth discussing this with your GP.
Lower leg stretches can be helpful:
• Kneeling on the floor, point your toes out behind you and slowly sit back on your heels, pressing the top of your feet towards the floor. This will help stretch the anterior tibial muscle on the front of your shins.
• Stand arm length from a wall, put your hands on the wall, place one foot a stride length in front of the other, keep your back leg straight and your heel on the floor, then lean forward to stretch your calf. You can get a better stretch by having your heel turned out slightly from the mid line. This stretches the long calf muscle called gastrocnemius.
• Stand in the same position, with feet flat, one leg in front of the other but instead of leaning forwards to stretch the calf of the back leg, bend your knee to feel the stretch lower down towards the Achilles tendon. This stretches your soleus muscle.
As well as calf stretches, exercises to strengthen the muscles in your shins can also be helpful once the acute pain has subsided. Here are some exercises that you may find helpful (see separate word doc):
As always prevention is better than cure, so do check the causes outlined above and try to avoid them wherever possible.

QA section
I have a 17 year old son who is a sprinter with persistent hamstring problems. He has had them on and off for a long time now and nobody seems to be able to get to the bottom of it. Can you help?
Thankfully as the medical profession understands more about hamstring problems and their causes, these recurrent problems are getting less frequent. Typically, as with most injuries, the causes are split into 2 categories: extrinsic and intrinsic. The extrinsic causes are those which are from external factors. In this case they can be inadequate warm ups, incorrectly progressed intensity of training and poor technique. Intrinsic causes are those that can be found within the body itself. Factors such as tight sciatic nerve (the nerve that runs down the back of your leg) can cause the hamstring to go into spasm to protect the nerve when it is stretched at high speeds when he sprints. Other factors such as lower (and upper) back problems, pelvic biomechanical issues and muscle imbalances are also common causes. It is important to see a specialist sports injury therapist who understands biomechanics and how these factors can affect your hamstrings to see which one is in fact the cause of your son’s problems.
I am a 55 year old runner and have been running all my life. I have recently been getting knee pain on the inside of my knee for no obvious. It aches after a run and is especially sore and stiff after I have been sitting watching TV for a while. Is there anything that I can do to help?
The most likely causes of pain on the inside of the knee are a strain to the medial (inside) ligament of your knee, damage to the cartilage (meniscus) on the inside of your knee and arthritis of the bones on the inside of your knee. If you have recently had any trauma to your knee then it may be either the ligament or the cartilage. If you haven’t, then the most likely cause is arthritis, especially if you have damaged the knee in the past. It sounds like it could be the early stages of arthritis and so sensible measures to slow down the degeneration would probably help. Make sure you are running in the right shoes for your particular foot type, check this out at a local running shop which has a treadmill and so can measure your foot movement and can more accurately predict the right type of shoe for you. Also you can try getting the knee stronger by doing some exercises to strengthen it. (See separate word doc). Trying to vary your training would also help. You don’t say how often or how far you run or indeed at what level, but try to mix up your training as much as possible by having some running sessions, but also ‘cross train’ and try some non weight bearing exercises such as rowing, swimming and cycling. You will most likely find that the more you can mix up your training the longer your knee will last.

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