by Dr. Scott Greenapple, D.C., C.C.S.P., F.I.A.M.A.
Kathy is a 32 year old female who comes to us for an opinion as to
what treatment options are there for her on going problems, which have
been diagnosed as shin splints. We are set up at Ironman Wisconsin, to
provide treatment, and biomechanical evaluations of athletes if needed.
On a side note, congratulations to the 25 athletes from Charlotte who
competed this year, in what I called the Ironman Bonk of 2005. The
conditions were extremely tough, hot, and windy, on a hard course. I
was there trying to lend a hand, (and laser, and kinesio tape) to all
our Team Charlotte participants. To all who competed, be proud of the
accomplishment, the next one has to be easier. Kathy presents as a
seasoned marathoner, and entering her second Ironman race. She states
she has had shin splints on her left leg for approximately two years
and also occasional Achilles tendonitis on the same side.
Kathy was diagnosed two years ago and has been through the standard treatments. Rest, ice, anti-inflammatories, physical therapy, and orthotics. First, let us explain what shin splints are. Over the years the term shin splints have been mislabeled and overused as to anything above the ankle and below the knee. A true shin splint is on the medial or inside of the leg, above the ankle and below the knee, lower on the leg. Shin splints are actually more of a symptom than a diagnosis. There are lots of things in the lower leg, muscle, fascia, bones, nerves, tendons and ligaments that can all lead to pain. The differential diagnosis or a possible list of what could be wrong is listed below. Due to the complexity of all that could be wrong, we will keep the list to the few most probable ailments.
An injury to the bone usually from over use and repetitive force applied to otherwise normal tissue. Typically from an increase in distance or speed, with inadequate rest. Rest is when tissues adapt to increase and become stronger. When muscles are overworked with lack of recovery, they can pull on bone and cause some damage to that bone resulting in micro fractures. Other factors to consider, are bone diseases such as osteoporosis, or hormonal imbalances. X-rays will show a healing stress fracture, not typically a fresh one. MRI or bone scan are the better ways to diagnose. The pain is more pinpoint on the bone, and the patient will have a positive jump test. Hopping on the injured leg will produce pain when landing, verses when pushing off, which is more typical of shin splints or muscular problems.
The lower leg is made up of four compartments, front, outside, and two in the back. The compartments are enclosed by fascia, a very tight dense tissue. During exercise, the muscles fill with blood, but the bones and fascia restrict how much expansion can take place. If the fascia will not stretch enough, pain, and numbness can happen. Pain typically increases with activity and decreases with rest. If the symptoms are severe enough you can diagnose this condition by inserting a probe in the lower leg and take a pressure reading during rest and exercise. There are normal pressure differences at certain thresholds that are considered for the diagnosis.
Shin Splints: (Medial Tibial Stress Syndrome, MTSS):
Most common cause of shin pain in the runner, jumper. Pain deep on the inside of the lower leg and back of tibia. Pain in the beginning of the run usually eases up during the run and returns when you stop. Covering the bone is a tissue called the periosteum; this intertwines with tendons and muscles that insert on the bone. Some believe that the muscle is pulling on the tendon causing an inflammation of the periosteum. If not treated properly, and the inflammation does not heal, there is a chance shin splints can turn into a stress fracture. Rest, therapy to reduce inflammation, and proper biomechanics are the key to healing. We have found that Active Release Technique to the tibialis posterior muscle, the flexor digitorum muscle, and muscles of the calf work best to alleviate and help restore normal function. Most current Sports Physicians will avoid the use of non steroidal anti-inflamatories such as Motrin, Advil and prescription drugs such as celbrex for a number of reasons. Masking the symptoms will allow the athlete to run through the pain and cause further irritation. The way anti-inflamatiories work actually will decrease the rate of healing in both a stress fracture and muscular injury. There is new evidence that supports the use of micro electrical currents, and possible laser wavelengths to increase ATP production which expedites healing. When Kathy was treated with ART (active release technique) her symptoms seemed to resolve only to return after the next run. This was typical of the last two years with standard physical therapy. When I watched her run, broke down her mechanics through video with slow motion, we were able to see that her hip flexion was weak through the push off and swing phase, her quads extended her knee too soon, and her hamstrings pulled too soon and short, causing an abrupt and hard impact on ground contact. The forceful foot plant was more then likely causing her constant shin pain and Achilles problems. When using ART to the above listed muscles, then videotaping her current stride, the leg moved smoother, her angles increased, effort seemed to decrease, and her hard foot slapping had disappeared. If she were a current patient, I then would follow up with more ART treatment, Cold Laser therapy and Frequency Specific Micro Current. I feel confident that her symptoms would fully resolve, and do to the improved biomechanics her speed should also improve. Dr. Scott Greenapple is a Certified Chiropractic Sports Physician. He has been a treating Physician at Ironman races, including the Hawaiian Ironman, since 1992. He is also a five time member of USA Triathlon Medical Staff. Dr. Greenapple is a credentialed Instructor of the Active Release Technique System and holds current certification in Biomechanics. Dr. Greenapple has recently returned from the Canadian Athletics Centre in Edmonton, for a four day World Class Biomechanics symposium working with members of the Canadian Olympic Team in track and field and triathlon.