PATIENT EDUCATION

• Coaches Corner
• Preventing Shin Pain
• Patellofemoral Pain
• Beating the Heat

COACHES CORNER

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Preventing Shin Pain in Athletes

With the start of the spring track season, many of your runners and jumpers will experience some type of shin pain. In many of the cases the shin pain can be prevented, and sometimes totally avoided. Shin pain will not only affect runners, but also jumpers and field event athletes. Especially those athletes that incorporate plyometrics in their training programs. In most cases of shin pain, the athlete will experience pain along the inside of the tibia( shin bone). Pain will run along the whole length of the bone or may be localized to the lower third of the of the leg . This type of shin pain is called Medial Tibial Stress Syndrome. It affects the posterior tibialis tendon and the periostiom of the medial tibia( periostitis; inflammation of periostiom). Its main causes are overuse, poor foot biomechanics, improper footwear and training errors. This time of year many shin problems come from changing running surfaces. Most indoor track athletes train on hard surfaces all winter, and the change to outdoor surfaces brings on symptoms. These symptoms may appear because of an increase of training volume when going outdoors, and because of muscle, tendon and bone are adapting to the new stresses of softer surfaces.

Improper Foot Biomechanics

Most cases of anterior shin pain are a associated with improper foot biomechanics. Abnormal foot and ankle pronation is one of the main factors in the cause of shin pain in athletes. When an athlete over pronates, there is traction put on the posterior tibialis tendon and the Soleus muscle is put in a mechanical disadvantage. Over pronation also leads to stressing the arch of the foot and to having the load transfer to the bones of the shin instead of the musculature of the foot and shin. The ankle and foot musculature act as shock absorbers to the lower extremities, and if they are compromised, shin pain and injury are possible.

Prevention of Shin Pain and Shin Splints

In most cases of shin pain and shin splints training errors and lack of recovery are two reasons athletes suffer through this preventable condition. It is important that training volumes and intensities are not increased at too fast a rate. Training distance should not increase more than 10% a week. So if an athlete is running 30 miles a week, the next training week should not be more than 33 miles. This of course also has to take into account the athletes ability to recover and injury history. If an athlete has had a history of shin problems, training volume may have to increase at a slower rate. Running athletes should also incorporate strength training and a comprehensive flexibility program to the calf muscles, hamstrings and hip musculature.

Treatment of Shin Pain and Shin Splints

Early intervention is key in treating anterior shin pain. Coaches and athletes alike need to understand that once pain and symptoms start, that training needs to be modified immediately, use of ice and elevation needs to be started immediately. Calf stretching and stretching to the front of the lower leg need to done three to four times daily. Arch strengthening exercises such as towel crunches and marble pick ups should be done twice a day three to four times a week. Athletes should also be wearing a rigid arch support. If symptoms are chronic orthotics may be indicated. Athletes also need to be in the correct foot wear; those that over pronate should be in stability or motion control shoe depending on the severity of pronation. When going back to running, athletes should alternate days of running and non-weight bearing activity, such as swimming, cycling or stair climber work.

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Patellofemoral Pain in The Athlete

Patellofemoral , or knee cap pain is the most common injury to the knee joint. Eighty percent of all knee injuries occur to the articulation between the patella and the femoral condyles. In the athlete these injuries are caused by direct contact, overuse, muscle imbalances, and poor flexibility. However, quadracep weakness and fatigue is probably the primary factor in the cause of patellofemoral pain.

Activities that put the athlete at risk:

Distance runners probably experience kneecap pain more than any other athlete, and maybe competitive cyclists. Jumping athletes such as basketball players as well as long and high jumpers incur injuries the patellafemoral joint and the patella tendon. Usually in the jumping athlete the patellar tendonitis is more prevelant than kneecap pain. In most cases overuse is the underlying mechanism of injury. Other factors such as poor foot biomechanics, and improper foot ware also may contribute to the onset of these injuries.

Prevention:

Like any overuse injuries, training errors are the main cause. We see most of these injuries at the beginning of sport seasons, particularly with the high school athlete. These injuries are seen in many athletes after a long lay off of activity, for instance fall athletes starting preseason work outs in August. Many of those injured probably didn't start training soon enough in the preseason, and come to double sessions in poor physical condition. Because the volume and intensity of preseason practices are so high, those athletes that are not prepared will end up with some kind of injury, and it is usually an overuse injury to the knee joint. Athletes need to make sure that a proper warm up and warm down are part of their workouts. It is also important that hamstring and calf stretching are done after practice or a work out. Strength training is also important; especially for quadraceps, and hip musculature.

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Beating the Heat

Heat illness is probably the most preventable condition that involves an athletes health. In upstate New York, the months of July and August bring the most risk to training. Coaches and athletes must understand that exercising in heat stress situations may bring the risk of death to athletes participating in hot and humid conditions.

Who is at risk?

Football players are more at risk to heat illness than any other athlete. Deaths from heatstroke occur more in football, than in any other sport. Due to the equipment and uniform requirements of the sport, cooling and heat dissipation is very much compromised. These factors contribute to conditions to deteriorate quite quickly in adverse conditions. The helmet and shoulder pads are the culprits in this problem. Heat escapes the body from the head and neck areas. It is important that all coaches at all levels of football understand that during water breaks and rest periods athletes are encouraged to take off their helmets and shoulder pads. Athletes that have a large body mass, are obese and are in poor condition are those individuals that are most prone to heat illness. Those athletes that have had previous episodes of heat illness are more prone to it than other athletes, and coaches need to red flag those individuals. Heat illness or heat stress is caused by a combination of the body's inability to regulate and maintain its cooling.

Thermal Regulation:

Body temperature is maintained by the balance of heat loss and heat production. In the training athlete, body heat is produced by specific dynamic action and muscular contractions. Heat loss occurs in five ways.

Conduction: heat is transferred from the warmer body to a cooler object, for example a cold wet shirt
Convection: when cool air moves across the body surface, heat is moved to the cooler air, warming the air and cooling the body
Evaporation: when water on the body surface is transformed from liquid, thus the body loses heat. Vaporization of 1gram of water equates to 0.6kcal of heat by persperation.
Radiation: Heat can be radiated by the body to the environment

When the air temperature is less than skin temperature heat is lost from the body by convection and radiation. As the ambient temperature reaches skin temperature and exceeds 87 degrees F, loss of body heat through convection and radiation is sharply curtailed. Cooling is then achieved by evaporation. Evaporation over most of the body surface directly cools the blood that runs through the cappillaries in the skin.

The tables above were adopted from Fox and Mathews, 1981, these are guide lines that coaches should use to modify practices and workouts.

Types of Heat Illness: Heat Cramps - Painful cramps involving the abdominals and extremities caused by intense, prolonged, exercise in a hot and humid environment. Cramps are caused by the depletion of electrolytes from profuse sweating.
Heat Synacope - Weakness and fatigue due to electrolyte and water loss from exercising in the heat, precursor to heatstroke.
Heat Exhaustion(WaterDepletion) - Excessive weight loss, reduced sweating elevated skin and core temperature, excessive thirst, weakness, headache and sometimes unconsciousness.
Heat Exhaustion(Salt Depletion) - May encompass heat cramps,nausea,muscle cramping and dizziness due to profuse sweating and inadequate replacements of electrolytes.
Heat Stroke - A true medical emergency related to, body is unable to regulate its cooling. Nausea,seizures,disorientation and possible coma. Heat stroke has a high mortality rate. In football, it is second only to head injuries as the most frequent cause of fatalities.

Prevention:

Heat illness or heat stress is the most preventable condition that involves an athlete's health. All athletes should have a preparticipation physical before the start of the season. In the medical history it should be noted if athletes have had a previous episode of heat illness. Climate and environmental conditions are not controllable, however, practice times, water breaks, practice intensity and athlete acclimitization are. As stated before athlete fitness is a major factor in the prevention of heat illness. Those individuals that are deconditioned and overweight are the most prone to heat illness. Even the larger athletes that are in good physical condition are prone because of their large body mass. Coaches need to have a handle of all athletes physical condition and plan practices accordingly. It takes an individual at least 8 weeks to see improvement in physical fitness, do not expect your athletes do get in shape during double sessions, eight week of conditioning can not be jammed into two. All coaches conducting double and triple sessions should take certain precautions. Try to practice at the coolest parts of the day, early morning or late evening. The hours between 2 and 4 pm are the hottest and most stressful. Give athletes liberal water breaks, and if they are football players give them a chance to get their helmet and football pads off during those breaks. Advise your athletes to bring a change of tee shirts. Tee shirts saturated in perspiration prevent the body's cooling by evaporation. Have athletes wear light colored clothing, and keep intensity of the practice sessions low in high stress situations. Athletes should be given a 10 minute break every half hour if temperature is between 80 and 90 degrees F and humidity over 70%. If temperatures are over 90 degrees and humidity is over 70%, practice should be suspended. A shortened practice in tee shirts and shorts could be established. Athletes are obviously going to compete in hot and humid conditions, so they need to be acclimatized to those conditions. Acclimatizing for an athlete should be gradual and should take place over a two week period. Athletes should be gradually exposed to hot and humid conditions. Some experts agree that two weeks of heat exposure for only 90 minutes a day will acclimatize an athlete. Where full acclimatization may take 2 months, the affects of being acclimatized will last up to 6 weeks.

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