By Mandy Eagar
Shin splints is a layman’s term used to describe exercise-related pain in the lower leg. However the word does not imply a specific diagnosis. Rather it is a broad term that signifies pain over the anterior tibial area.
As a number of conditions present with the same symptoms namely pain, swelling and inflammation it is important that the massage therapist establishes the aetiology of the symptoms prior to developing a treatment plan. In the absence of a proper diagnosis, the massage therapist should determine whether the muscles, the bone, or the attachment of the muscle is the actual source of the pain.
Massage therapist, Mandy Eagar sheds light on the different types of anterior lower leg pain.
Shin splints often involves damage to either of the two groups of muscles along the tibia. The location of the pain depends on which groups of muscles are damaged.
The most common complaint is pain anterior to the tibia on the lateral edge but it can also occur medial to the tibia. This pain is described as sharp and is usually felt along the tibia while running or doing impact sport such as basketball and aerobics. It may be caused by training on hard surfaces, over-training, excessive uphill or downhill running, sudden increase in the duration or intensity of training and weak postural stabilizers i.e. core muscles including the back muscles and abdominal muscles and the gluteus medius in particular.
The muscle attachments along the tibia become irritated and swelling may occur. The shin area becomes tender to the touch and palpation may reveal thickening of tissue along the tibia. The pain is experienced before, during and/or after exercise.
Depending on the muscles involved, two types of shin splints are described namely anterolateral and posteromedial shin splints.
Anterolateral shin splints
In this case the front and outer part of the muscles of the shins are affected including the anterior tibialis. This muscle is prone to overuse due to its role in deceleration of the foot at the heel strike during the gait cycle. It is particularly affected by an increase in running distance. The pain is first felt when the heel touches the ground during running. Eventually the pain may become constant and the anetrotibial area becomes too painful to touch.
Posteromedial shin splints
Not only the anterior lower leg muscles can become affected, but also the posterior and deeper muscles of the lower leg and the posterior tibialis in particular.
The function of the posterior tibialis is to support the arch of the foot as the body moves over the foot during the gait cycle. Posteromedial shin splints is usually caused by running in inappropriate or worn out footwear that does not support the arch of the foot properly leading to hyperpronation. Hyperpronation of the foot places excessive load on the posterior tibialis and the stress is concentrated at its origin on the tibia. This hyperpronation may result in pes planus (flat foot) with the medial longitudinal arch flattening out.
The pain is worse when standing on the toes or rolling the ankle inwards. As the process progresses, the severity of the pain increases and leads to inflammation.
Treatments for this condition include rest from any jumping or running activity. Patients should be advised to rather participate in non-weight bearing activities such as swimming or cycling and to allow the body enough time to heal.
During the acute stage (first 48 hours) ice massage is effective. Apply ice for 15 to 20 minutes every 45 minutes and elevate the limb to the help prevent swelling.
Massage can be effective in the post acute stage (48 hours to 72 hours). As both types of shin splints results from overuse causing inflammation and swelling, massage is effective in management of this problem.
For anterolateral shin splints, the therapist should concentrate on reducing the tightness in the anterior compartment of the lower leg while posteromedial shin splints is addressed by decreasing the tightness in the gastrocnemius, soleus, achilles tendon and plantar fascia.
The therapist should target all muscles of the lower leg for both conditions to release any muscle imbalances that may be present. Apply pressure according to the patient’s level of tolerance. Also advise the patient that they may experience an increase in soreness following the massage session but that this will be followed by improvement over the next few days.
- Shin splints can also be prevented by wearing well-cushioned and good quality footwear, running on softer surfaces where possible e.g. grass or gravel.
- Advise the patient to increase their workout mileage and intensity gradually and to include sufficient warm up and cool down sessions.
- Demonstrate how to correctly stretch the gastrocnemius and soleus (by dropping their heel off the edge of a step, a straight leg stretch stretches the gastrocnemius and bending the knee will apply a stretch to the soleus). Suggest that they stretch the calf muscles before and after a training session.
- Avoid over-striding as it places more strain on the shin.
- Patients prone to pronation or pes planus, may need orthotics to help support the arches.
Causesof anterotibial pain
The area of maximal tenderness may be different in patients presenting with different underlying problems causing shin splints. Chaitow distinguishes the following causes of shin splints:
1. Stress fracture
Usually the pain is located along the medial aspect of the lower third of the tibia.
2. Medial tibial stress syndrome (MTSS)
MTSS is also known as soleus syndrome or chronic periostalgia and refers to pain on the posteromedial tibial border of the lower leg. It is considered one of the most common leg injuries in athletes and soldiers. According to a study by the Sports Medicine Department of the University Medical Centre Utrecht and Rijnland Hospital in Leiderdorp, in the , the incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes.
This overuse syndrome causes irritation to the tendons and the attachment of these tendons to the bone. It presents with a dull, aching type of pain on palpation of the tibia over a length of at least 5 cm and some swelling is detectable. Resisted plantar flexion (pushing down of the foot against resistance), typically causes an increase of symptoms. In this case the pain radiates further than with a stress facture.
The intrinsic risk factors for MTSS quoted by the Dutch study include:
- excessive pronation of the foot while standing
- being female as women seem to present with the problem more often than men
- higher body mass index
- greater internal and external ranges of hip motion and
- calf girth
A previous history of MTSS was shown to be an extrinsic risk factor.
3. Exertional compartment syndrome (ECS)
Exertional compartment syndrome, also called exercise-induced compartment syndrome or chronic compartment syndrome, causes pain over the front of the tibia usually after a period of activity or exercise. The pain rapidly dissipates with rest. Patients may also experience tingling or numbness in the leg or foot. Often when the symptoms are present, the area over the muscles of the front of the leg feels very tight. Onset is usually gradual.
ECS is caused by pressure that builds up in the muscles of the lower leg in cases where fascia is too tight to accommodate the muscle size that increase as blood flow to the muscle increases during activity. As a result the expanded muscle becomes constricted by the fascia and the blood flow is interrupted. This causes ischemia and pain results. Numbness or tingling is due to a lack of blood flow to the nerves.
• USGyms.com http://www.usgyms.net/chinspl.htm
• Foot.Com http://www.foot.com/info/cond_shin_splints.jsp
• Mama’s Health.com http://www.mamashealth.com/bodyparts/shin.asp
• Chaitow, L & Walker Delany, J 2002. Clinical application of neuromuscular techniques. Churchill Livingstone
• Moen, M H, Tol, J L, Weir, A. Steunebrink, M, De Winter T C. Department of Sports Medicine of the University Medical Centre Utrecht and Rijnland Hospital, Leiderdorp, the .