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Sports
Medicine Advisor
by Neal
Sand M.S., A. T. C.
The term
"shin splints" is an inadequate and misleading term used to
describe a dull aching pain that is experienced in the shins, most
commonly along the anterior crest of the tibia and fibula during running
type activities. Included in the term "shin splints" is anterior
tibialis tendonitis, medial tibial stress syndrome, stress fractures, and
compartment syndrome.
Shin
splints are the result of overuse. Some general preventative measures an
athlete can take in an attempt to prevent shin-splints are to increase
training mileage gradually, as a rule of thumb training mileage should not
increase by more than 5% weekly. Running shoes lose 2/3's of their shock
absorbency at 100 miles, and are down to about 55% at500 miles. Typically,
an athlete needs a new pair of shoes every six months. A lack of
flexibility resulting in a foot that can not dorsiflex (bring foot towards
the shin) more than 10 degrees past perpendicular can contribute to the
cause of shin splints.
Before any
treatments can be started, a specific diagnosis should be made.
Differential diagnosis would include:
Anterior
Tibialis Tendonitis - causes
pain along the anterior lateral tibia (front of the shin). If the athlete
tries to point the foot up towards the shin (dorsi-flexion) the muscle
will be stressed and cause discomfort. When running, the anterior tibial
muscle prevents the foot from slapping the ground after the heel strikes
the ground. It is common with runners, running up hills and with soccer
players who have suddenly increased kicking with their instep. Athletes
with a tight achilles tendon, weakness of the anterior tibialis muscle, or
little foot protection on hard surfaces seem to be more susceptible.
Treatment
would consist of decreasing or resting from the offending activity,
stretching the achilles tendon and strengthening exercises from the
anterior tibial muscle. When training resumes, hills and hard surfaces
should be avoided until pain is completely gone.
Medial
Tibial Stress Syndrome -otherwise
known as posterior shin splints. Typically, when someone says they have
shinsplints, this is the injury they are usually referring to. The pain is
on the inside of the shin where the tendon attaches to the periostium
(lining of the bone). Typically, the pain seems worse as exercise is begun
then it subsides as exercise continues. The exact muscle involved is
controversial. In the past, it was believed to be the posteror tibialis.
It is now believed to be the soleus muscle.
Athletes
that over-pronate and have tight achilles tendons are susceptible to this
injury. Pronation is when the feet slant inward while standing. Runners
that run in only one direction on roads, may put one shin at risk because
of the slant of roads that allows water to run off them.
Treatment
for this type of shin splint is rest, ice, stretching the achilles tendon,
and strengthening exercises for the arch. Chronic conditions that come
back year after year may need orthotics to correct foot over-pronation. As
a rule of thumb an athlete should rest until he/she can press on the
shin and not cause pain. This can take anywhere from one week to six
weeks. When the running program is started again, it should be with
gradual increases in mileage, not where the athlete left off prior to the
injury.
Tibial
Stress Fractures - can result with a shin splint condition where the
athlete continues to train through the pain. The pain is extremely point
tender over a small area, usually on the proximal (top) or distal (bottom)
of the tibia (shin bone). The pain usually starts with exercise and
becomes more intense with exercise. Many times the fracture is not seen on
the initial x-rays, and not until three weeks later is new bone seen
indicating there was a fracture This is why it is often misdiagnosed as
atypical shin splint (tendonitis). Stress fractures happen most often with
an inactive person who begins a running program and over does it.
Treatment
is rest with no running for about four to eight weeks. During that time,
the athlete is permitted to swim and cycle.
Compartment
Syndrome - Can be a potentially
serious problem. This syndrome occurs when the leg muscles become swollen
from exercise causing blood supply to be restricted. The foot and lower
leg may become numb. A full blown compartment syndrome produces severe
pain. There will be no improvement with rest or ice, the shin gets
"woody hard". This is a surgical emergency requiring immediate
release.
A chronic
compartment syndrome is more common in runners. Sometimes the runner can
tell you at what distance in the run the pain will start. Pain will
increase during activity with rapid improvement when running stops. When
examined, there is often no tenderness. If suspected, compartment
pressures can be measured before and after exercise showing increased
pressure of the specific compartment. Treatment consists of resting from
the off ending activity, icing, stretching, and physical therapy lasting
six to twelve weeks. If conservative treatment fails, then a surgical
release may be needed.
In
conclusion, the term "shin-splints" is a vague term that can
mean a number of different ailments of lower leg pain from overuse.
Prevention is the best cure. Recognizing signs and symptoms, gradually
increasing mileage, proper foot wear, and a flexibility program of the
achilles tendon can help to prevent shin splints to some degree. But when
an athlete has shin splints, the type should be determined before a rehab
program can begin.
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