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.
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).
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).
- 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.
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.
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.
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)
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).
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