How to get rid of Shin Splints

Dec 20, 2018Dec 21, 2018 Ummi NuhuLeave a comment

Introduction.

Welcome to the final part of the three series of my blog post. If you haven’t read the first two you can do so by clicking here for part 1 and part 2. In this part of the blog I will talk about preventive strategies and management of shin splints.

Preventive Measures.

The risk of having shins splints can be reduced. Several preventive strategies have been postulated in textbooks and reviewed articles. Most of these recommended preventive measures are based on expert opinions and the evidence for the effectiveness of a specific intervention is scarce (Thacker et al, 2002 and Yeung et al, 2011).

Yeung et al (2011) conducted a systemic review of intervention for preventing lower limb soft-tissue injury which includes shin splints. The review included diverse population groups and they categorised the intervention into four preventive strategies: exercises, modification of training schedules, use of orthoses, and foot wears (Yeung et al, 2011). A review on the prevention of shin splints in athletes revealed that the most effective strategies involves the use of shock-absorbing insoles (Johnston et al, 2006 and Thacker et al,2002). Nevertheless, none of the studies where able to provide strong evidence in support of management of shin splints due to flaw methodological quality of the studies included in the reviews.

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Image Reference

How to prevent Shin splints.

At first sign of shin splints discontinue work out.
Avoid running on uneven terrain such as hills, hard surfaces.
Lessen the impact on the shin, alternate running with lower impact activities like walking, cycling, swimming.
Consider replacing worn out shoes every 350 to 500 miles (after 560 – 800 kilometers).

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Figure 2: Diagram showing the impact of worn out shoe (photo credit by Body Scientific)

Warming up the limbs and body is recommended before the start of activity (stretching periodically during the day helps).
Modify exercise routine, avoid overloading.
Use of arch support helps especially if u have flat arches (flat foot).

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Figure 3: Arch support layout

Use of shock absorbing insoles.
Lose weight if you are overweight to relieve weight on the hip, knee and shin.

How to manage Shin Splints

First Aid:

Rest– Stop activities that cause shin splints.
Ice– In form of ice wrap, cold spray, or cold pack five to ten minutes one to three times a day.
Seek medical attention.

ist aid

Figure 4: First aid treatment of shin splints

Medical management:

Nonsteriodal anti-inflammatory drugs (Nsaids): Aspirin, Ibuprofen, Diclofenac.
Acetaminophen: Panadol.
Calcium supplement.
Vitamin D supplement.

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Figure 5: Anti-inflammatory method

Physiotherapy management:

Acute Phase: The goal of physiotherapy in the acute phase is to reduce pain and inflammation. This can be done through ice and rest.

Rest: Shin splints normally resolve with rest. Rest allow healing and inflammatory changes to take place. However relative rest is required during the period meaning activity level has to be adjusted but not completely. Cardiovascular fitness should be maintained by trying low impact exercises like walking, biking, swimming.

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Figure 6: Swimming as a low impact activity

Cryotherapy: The use of ice helps increases blood circulation, promote healing and helps with pain relief. This is usually recommended before and after running.

Subacute phase: The goal of physiotherapy in the subacute phase is to modify training regimes and correct biomechanical abnormalities. These includes:

Gait analysis: An analysis of how a person walks is an integral part of treatment. The wrong mechanism of walking can transmit force to the hip and knee through the shin bone therefore correcting abnormal gait is vital.
Stretching and strengthening exercises: Stretching of the calf (both gastrocnemius and soleus muscle) and strengthening of anterior leg muscle (that pulls leg and toes up) helps in preventing muscular strain as shown in figure 7. Muscle strengthening prevent the effect of fatigue on bone and muscle (clement,1974) and stretching as shown in figure 8 maintains the shock absorbing property of the muscle. These exercises help in improving muscle strength, flexibility and endurance and prevents re-occurrence of injury.

Figure 7: strengthening exercise for shin splints (Photo by Michael Behrink)

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Figure 8: Shin Splints Stretches

Correction of biomechanical abnormalities: This depends on the type of abnormality detected. In addressing malalignment of the lower extremities, orthosis such as longitudinal arch supports with or without medial wedge may be indicated. Although review from literature fails to yield any objective evidence for widespread use of any of these interventions, the most encouraging evidence seems to be the use of shock absorbing insoles (Johnston et al, 2006 and Thacker et al, 2002).

Figure 9: Shock absorbing insoles

Surgical management: Rarely indicated except in recalcitrant cases or where increased compartment pressure is thought to be a factor (Bates, 1985). It consists of one or more fascia incisions to relieve pressure.

Thank you for reading my blog on shin splints. In the first part of the blog I talked extensively on shin splints. We learned that shin splints are common overuse injuries that affects a broad range of people (athletes and military personnel) typically resulting from repetitive trauma and associated biomechanical abnormalities. It is among the most frustrating injuries because it makes a basic act like walking impossible.

In the second part of the blog I discuss the differential diagnosis and diagnostic procedures. One interesting thing I found is that there are certain conditions that are sometimes mistakenly diagnosed as shin splints example is stress fracture (an incomplete crack in the bone) which is far more serious than shin splints. Stress fracture often feels better in the morning because the bones have rested all night, shin splints feels worse in the morning because soft tissue tightens overnight. For more information on stress fracture refer to my second post. Imaging studies are not necessary to diagnose shin splints, however when a conservative treatment fails it will be reasonable to take an echo.

Finally this part of the post covers treatment plan which is important because if shin splints are not properly treated and biomechanical abnormalities not addressed, stress fractures as shown in figure 10 and potentially true fractures may occur which will result in further morbidity and more time lost from desired physical activity as well as potential decline in function.

Figure 10: Stress Fracture (Photo credit by Bowser)

Writing this blog has been really useful to me, it has given me more insight on the condition because I see a lot of young active military personnel who often have this problems, and they have it primarily due to their training errors (wearing inappropriate shoes, running on hard surfaces and increasing mileage too rapidly) which provoke the condition. I feel more enthusiastic to go to work and use the current best evidence of managing my patients.

References:

Bates, P. (1985). Shin splints–a literature review. British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.19.3.132

Clement, D. B. (1974). Tibial stress syndrome in athletes. The American Journal of Sports Medicine. https://doi.org/10.1177/036354657400200203

Johnston, E., Flynn, T., Bean, M., Breton, M., Scherer, M., Dreitzler, G., & Thomas, D. (2006). A randomized controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med. https://doi.org/10.7205/MILMED.171.1.40

Thacker, S.B., Gilchrist, J., Stroup, D.F. and Kimsey, C.D., 2002. The prevention of shin splints in sports: a systematic review of literature. Medicine & Science in Sports & Exercise, 34(1), pp.32-40.

Yeung, S.S., Yeung, E.W. and Gillespie, L.D., 2011. Interventions for preventing lower limb soft‐tissue running injuries. Cochrane Database of Systematic Reviews, (7).

Differential diagnosis of shin splints

Dec 18, 2018Dec 20, 2018 Ummi NuhuLeave a comment

Introduction

Welcome to the second part of the three series of my blog on shin splints. Lest I forget, I wish to thank you for reading my first blog; hopefully, I have been able to respond to your questions. If you have not had the chance to read my first blog, click here. I will suggest that you do that to have a good grasp of the topic. This section will be a continuation of the first part.

There are several medical conditions that mimic shin splints and it is important that they are differentiated from shin splints which include using certain diagnostic tests and procedure.

The content of this present blog will be around differential diagnosis and clinical tests of shin splints. First, I will define differential diagnosis, and then the blog will cover the conditions that have similar clinical features like shin splints, followed by the diagnostic procedure for shin splints before concluding. You are more than welcome to drop your comments.

Differential diagnosis

Differential diagnosis is the process of comparing of signs and symptoms to identify the underlying problem so that treatment can be planned as specifically as possible (Goodman et al, 2017). This is important for condition that can present with similar clinical features such as chronic lower leg pain (Edwards et al, 2005).

Chronic lower leg pain can result from various conditions, most commonly are shin splints, stress fracture, chronic exertional compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome (Edwards et al, 2005). Because of the ambiguous nature of the symptoms, it is difficult to differentiate shin splints from the other chronic lower leg pain (Couture and Karlson, 2002). Nevertheless, shin splints is still considered as a distinct clinical entity that is different from other chronic lower limb pain (Edwards et. al, 2005). Table 1 below shows the presenting clinical features of shin splints and other similar conditions.

Conditions	Characteristics	Origin
Shin splints	Pain that starts after exercise but gradually improve with rest. Pain can affect both shins. Pain can be felt over a large part of the shin (an area over 5cm across). Occasional swelling.	Bone/periosteum
Stress fracture	Pain with activity and decreases during rest. Occasional swelling around painful area. Slight pain and/or weakness at fracture point “Pinpoint pain” (tenderness at the site of the fracture when it is touched).	Bone/periosteum
chronic exertional compartment syndrome	Lower limb cramping pain with exercise. Swelling/visibly distended muscle. Tingling sensation. Affected area turning pale and cold.	Muscle/tendon
popliteal artery entrapment syndrome	Aching pain, numbness, and tiredness in the calf with exercise. Symptoms disappear shortly after stopping activity/exercise. Occasional leg swelling.	Vascular

Table 1: Conditions presenting with chronic lower limb pain.

Despite the overlapping nature of the symptoms of shin splint with other conditions, there is a consensus within the literature in using a simple logical approach in establishing a definitive diagnosis (Edwards et al, 2005). This approach requires a detailed history taking and physical examination as well as a good knowledge of anatomy and biomechanics (Brewer and Gregory, 2012). Additionally, interpretation of appropriate diagnostic tools is also essential (Nelson et al, 2015).

Diagnostic Procedure of shin splints

History

Detailed information about the onset and location of the pain is usually the initial line of inquiry. This information includes:

Any pain induced by activity alongside the medial two-third of the distal border of the leg.
History of factors that aggravate or relieve the pain. If pain is aggravated with exercise and relieved with rest (see table 1 above) a shin splint should be suspected.
Additionally, it is also important to eliminate other possible causes of the pain as shown in table 1 above.

Physical examination

Newman et al (2012) reported two categories of clinical test that can be used to establish the diagnosis of shin splint:

Shin palpation test

This involves the examiner palpating the posteromedial tibial border and asking the patient for the presence of any recognizable pain as shown in figure 1 below.

Figure 1: shin palpation test (Newman et al, 2012).

If there is pain upon palpation and the pain is felt in an area over 5 cm then shin splints should be suspected however, if this is not the case, then other conditions such as stress fracture (if the pain is palpated over an area less than 5 cm) should be suspected and the individual is termed as not having shin splints (Nelson et al, 2015).

If other symptoms not typical of shin splints is present (see table 1 above): other leg injury should be considered.

If recognizable pain is present on palpation over 5 cm or more and no atypical symptoms are present, the diagnosis of shin splints is confirmed.

Shin oedema test

Here, the examiner is required to apply a sustained (hold for 5 seconds) palpation of the distal two third of medial surface of the tibia. A positive shin splint requires the presence of pitting oedema.

Figure 2: Shin oedema test (Newman et al, 2012)

Imaging:

Most times, imaging is not necessary to confirm the diagnosis of shin splints. However, it is good clinical practice when in doubt, or conservative treatment failed. Imaging is considered to provide more insight.

Magnetic resonance imaging (MRI) can be used to differentiate between a tumor and a shin splints. It is usually used to depict the periosteal reaction and oedema (Nelson et al, 2015). Additionally, bone scan and x-ray can differentiate between stress fracture and shin splints (Brewer and Gregory, 2012).

Outcome measures:

An outcome measure is an instrument that is used to objectively determine whether a condition is getting better following an intervention. To use an outcome measure, a baseline measurement needs to be established then after the intervention, the same outcome measure is used to determine the efficacy of the treatment (Nelson et al, 2015).

The medial tibial stress syndrome score (MTSS) is a patient-oriented outcome measure. Winters and colleagues (2016) show the validity and responsiveness of MTSS to measure the severity of shin splints among different population that are exposed to exercise-induced lower limb pain including athletes, military personnel. This instrument can be used to guide therapy including its effectiveness (I will discuss the treatment of shin splints in more detail in my next blog).

Shin splints is a chronic debilitating lower limb condition that can be difficult to diagnose due to many conditions that can present with similar clinical features. Detailed history taking, and physical examination are generally used to establish its diagnosis. However, where other conditions such as stress fracture cannot be eliminated from radiographic imaging, MRI are used to differentiate shin splint from other conditions.

References

Brewer, R.B. and Gregory, A.J., 2012. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health, 4(2), pp.121-127.
Couture, C.J. and Karlson, K.A., 2002. Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints’. The Physician and sports medicine, 30(6), pp.29-36.
Edwards Jr, P.H, Wright, M.L. and Hartman, J.F., 2005. A practical approach for the differential diagnosis of chronic leg pain in the athlete. The American Journal of Sports Medicine, 33(8), pp.1241-1249.
Goodman, C.C, Heick, J. and Lazaro, R.T., 2017. Differential Diagnosis for Physical Therapists-E-Book. Elsevier Health Sciences.
Nelson, E.C., Eftimovska, E., Lind, C., Hager, A., Wasson, J.H. and Lindblad, S., 2015. Patient reported outcome measures in practice. Bmj, 350, p. g7818.
Newman, P., Adams, R. and Waddington, G., 2012. Two simple clinical tests for predicting onset of medial tibial stress sysndrome: shin palpation test and shin oedema test. Br J Sports Med, 46(12), pp.861-864.
Winters, M., Moen, M.H., Zimmermann, W.O., Lindeboom, R., Weir, A., Backx, F.J. and Bakker, E.W., 2016. The medial tibial stress syndrome score: a new patient-reported outcome measure. Br J Sports Med, 50(19), pp.1192-1199

What are Shin Splints?

Dec 5, 2018Dec 21, 2018 Ummi Nuhu6 Comments

My name is Ummi, a qualified Physiotherapist with six years of clinical experience. I have spent most of my professional career in a military facility in the Northern part of Nigeria. In this facility, most of patients I come across are presenting with a lower limb disorders, among which shin splints happens to be the most prevalent; thus, my desire to share with you the knowledge I have about it with you.

This is my first blog and I don’t want to miss the opportunity to share with you the information I have about shin splints.

I hope you will find this blog highly informative and I look forward to receiving comments and suggestions from you. Thank you.

Introduction

The shin bone is located in the front surface of the lower leg. This part of the body is usually under increased stress resulting from walking, running and jumping. When a certain threshold of tolerance is crossed, overuse injuries results in a condition called shin splints as shown in figure 1. It is characterised by intense pain in the front, inside, outside or at times back of the leg. If left untreated it can lead to stress fracture.

Shin splints also known as medial tibial stress syndrome is defined as pain along the posteromedial tibial border excluding stress fracture or ischaemic disorder (Newman and Adams,2012). Medial tibial stress syndrome is subdivided into three: Type 1-Tibial micro fracture bone stress reaction, Type 2- Periostalgia from chronic avulsion of the periosteum at periosteal- fascial junction and Type 3-Chronic compartment syndrome (Detmer,1986).

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Figure 1: An illustration of shin splint

Medial tibial stress syndrome is a debilitating condition associated with walking, running and jumping activities. Athletes as shown in figure 2, soldiers and recreational sports participants are affected with incidence varying from 3% -35% of the population developing the condition (Thacker et al 2002; Moen et al,2009). According to Australian Defence Force (Defence injury prevention programme 2001 -2007) 3.2% of all injuries have diagnosis of Medial tibial stress syndrome. At the Australian Defence Force Academy 15.4% of the trainees develop Medial tibial stress syndrome and 53% of these injuries occur in First year officer cadets who engage in training that includes drill parades, loaded marching involving impact of the lower limbs on different surfaces with assorted foot wears (Phil et al,2012).

Figure 2: Athletes running competitions

Shin splints are the most common causes of painful shins. There are two regions where one can get shin splint namely: anterior shin splint and posterior shin splints as illustrated in figure 3.

Anterior shin splints

Anterior shin splints are located within the front of the shin bone involving the anterior tibialis muscle which lifts and lowers the foot. Anterior shin splints cause increased pain in keeping the heels on ground and lifting the toes.

Posterior shin splints

Posterior shin splints are located on the inside rear of the shin bone involving the tibialis posterior muscle. The tibialis posterior lifts and control the medial aspect of the foot arch. When the tibialis posterior is weak the arch collapses. Posterior shin splints cause increased pain from inside rear of shin bone.

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Figure 3: Illustration of anterior and posterior shin splints

Aetiology and pathophysiology

Overstress to bone:

Shin Splints can result from stress to the bone during which the bone undergoes a remodelling process. This process involves the removal of part of the bone matrix and replacing it with a strong bone matrix that can adapt to the increased stress demand (Bates, 1985). This explains tibial cortical hypertrophy seen in young marathon runners (Jackson, 1978). However prolonged stress weakens the bone predisposing it to stress fracture. During this period athletes exhibit features like periostitis, corticol hypertrophy or mixed patterns (Devas 1958; Jackson,1978). It is believed that muscle pull may cause bony stress reaction than impact (Devas,1958).

Compartment syndrome:

The pathology of compartment syndrome is that during exercise excessive force causes muscles to swell up which results in increased pressure against the bone thereby blocking intramuscular blood vessels which results in ischaemia or nerve compression leading to referred distal symptoms but hardly cause diminished distal pulses in healthy blood vessel (Paton 1968; Puranen,1974).

Biomechanical Factors:

Plays a key role in the origin of shin splints (Clement 1974; Sheehaan,1977). This is commonly seen in marathon runners where the feet strike the ground more than 5000 times per hour making a small biomechanical abnormality magnified (Medical News,1978). A knowledge of biomechanics of running plays a significant role in understanding how biomechanics contributes to the development of shin splints (Bates,1985). Running is a smoothly coordinated strides (Slocum and James,1968). The support phase consists three positions: Initial foot contact, mid foot contact and push off. During running the foot hits the ground in supinated position, on striking the ground it primarily does two things; It first adapts to the surface it lands on and disperse the impact resulting from the shock. It then changes from supinated position to pronation. The pronated position enables it to attain maximal flexibility and serves as shock absorber and is maintained throughout the contact and mid stance but changes to supination at push off. These movements are called triple movement and the muscles of the leg are primarily involved, any abnormality in foot motion causes pathology in the shin where the muscles attach (Bates, 1985).

Muscle fatigue:

Shin splints is common in under conditioned athletes who do too much for their potential, hence overuse can be an aggravating factor for the condition (Clement 1974; Jackson,1978). Scientific studies have proven that muscles serves as shock absorber by preventing stress that goes to the bone directly. Athletes who do too much eventually make their muscles lose the shock absorbing property (Clement, 1974). Consequently, the stress goes directly to the bone which causes bone overload and periostitis.

Risk factors of shin splints

Biomechanical abnormalities as shown in figure 4, such as foot arch abnormalities, hyper pronation of the foot, hyper supination of the foot, limb length discrepancy, sacroiliac joint dysfunction, poor buttock control at stance phase, poor core stability are key risk factors of shin splints. Other factors that predisposes one from getting shin splints includes abrupt increase in training techniques, insufficient rest between loads, walking on hard or inclined running surface, inappropriate foot wear and cold weather (Adams and Newman, 2012).

yytrr Figure 4: Biomechanical abnormalities of the foot

Increased body mass index and female gender are also known intrinsic risk factors. Previous history of medial tibial stress syndrome is considered extrinsic risk factors (phil et al, 2012).

Presence of pain at the beginning of exercise usually along the posterior tibial border (distal third) which eases with rest. As symptoms progresses pain can be felt with continued exercise which can stop participation (Maarten et al, 2009). In severe cases performing activities of daily living like walking can provoke symptoms.

Shin splints is an exercise induced pain usually not taken seriously. However, progression of symptoms results in cessation of activity and more complications like stress fracture of the tibia. The cause of shin splints is multifactorial, but most common cause is overuse associated with poor foot and leg biomechanics. Professional guidance is highly recommended in order to differentiate it from other lower limb disorders that mimic it and confirm diagnosis which will come in my next blog. Thank you for reading.

References

Bates, P. (1985). Shin splints–a literature review. British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.19.3.132

Clement, D. B. (1974) “Tibial stress syndrome in athletes”. J.Sports Med. 2 (2): 81-85.

Devas, M. B. (1958) “Stress fractures of the tibia in athletes or “shin soreness” “. J.Bone Joint Surg. 40B (2): 227-239.

Detmer, D. E. (1986). Chronic Shin Splints: Classification and Management of Medial Tibial Stress Syndrome. Sports Medicine. https://doi.org/10.2165/00007256-198603060-00005

Jackson, D. W. (1978) “Shin splints – an update”. Phys. and Sports Med., October: 55-61.

Medical News, 1978 “Padded shoes put runners back on track”. JAMA, 5 May. 239 (18): 1840.

Moen, M. H., Tol, J. L., Weir, A., Steunebrink, M., & Winter, T. C. D. (2009). Medial tibial stress syndrome: A critical review. Sports Medicine. https://doi.org/10.2165/00007256-200939070-00002 Newman, P., Adams, R., & Waddington, G. (2012).

Newman, P., Adams, R., & Waddington, G. (2012). Two simple clinical tests for predicting onset of Medial Tibial Stress Syndrome: Shin palpation test and Shin oedema test. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2011-090409

Paton, D. F. (1968) “The pathogenesis of anterior tibial syndrome”. J.Bone Joint Surg. 50B (2): 383-38

Puranen, J. (1974) “The medial tibial syndrome”. J.Bone Joint Surg. 568 (4): 712-715.

Sheehan, G. A. (1977) “An overview of overuse syndromes in distance runners”. The Marathon: Physiological, Medical, Epidemiological and Psychological Studies. New York Academy of Sciences, New York. Vol. 301

Slocum, D. B. and James, S. L., 1968 “Biomechanics of running”. JAMA 205 (11): 97-104.

Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey, C. D. (2002). The prevention of shin splints in sports: A systematic review of literature. Medicine and Science in Sports and Exercise. https://doi.org/10.1097/00005768-200201000-00006

Two simple clinical tests for predicting onset of Medial Tibial Stress Syndrome: Shin palpation test and Shin oedema test. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2011-090409

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