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Shin Splints | Physio Guide to Medial Tibial Stress Syndrome

Shin Splints | Physio Guide to Medial Tibial Stress Syndrome

by | Nov 27, 2019 | Ankle and Foot, Return to Sport, Running Injuries, Sports Injury

SUMMARY

  • Shin splints are essentially an overuse injury
  • Numerous factors contribute to symptoms but mainly involving the poor control of force through the lower limbs
  • Important to stop symptoms to avoid developing stress fractures, which require lengthier time away from activity
  • Corrective strengthening exercises, relative rest, and workload management all seem to be treatment mainstays
  • Physiotherapy has a significant role to play in getting back to running and sport
Mid Potion Achilles Tendinopathy Location

SHIN SPLINTS

Shin splints, or as it’s referred to as in the literature, medial tibial stress syndrome (MTSS), is a common injury seen in the recreationally active and army populations. Symptoms typically consist of an aching pain to the lower medial (inside) part of the shin, that can be sharp when running or when inflamed. There can also be some pain and stiffness when you first walk around in the morning, or when you first start your activity.

Risk Factors:

Over 100 potential intrinsic risk factors of MTSS were identified in a recent systematic review [1] involving 21 different studies. Of those risk factors, nine were identified as having a moderate to strong occurrence in clinical practice. Out of these nine, the risk factors that result in the greater loads on the body (such as body mass index) or poorer acceptance of load with running were the most important.

A number of range of motion parameters were also identified. For example, larger plantar flexion range of motion (the movement of pointing your foot down) was identified. It has been hypothesized that the increased plantar flexion results in a greater likelihood of the individual landing on their forefoot rather than their rearfoot while running, possibly increasing the strain on the rear inside leg (posteromedial tibia). Forces on the inside of the shin bone explain the why pain may be present in that area.

Treatment:

Most people tend to simply rest which may decrease symptoms in the short-term, but it doesn’t address the direct cause! The condition is very commonly seen in recreational runners and not as much in your higher-level athletes. Why is this? It’s quite simple! As mentioned in our previous running blogs, the adherence to well-planned running workloads is what separates recreational runners from the competitive or non-injured. Planned training leads to adequate adaptation of the body to the demands placed upon it.

One of areas patients with shin splints focus on is poor “foot posture”. It is very common to hear the same old story, “I have shin splints because my feet are flat, I need orthotics to correct that”. The biggest problem with that approach is that not a lot of people realise that the reason that they are flat footed is not necessarily because of a defect in their feet! It may be because they have strength and control of their hips which is in turn is causing over pronation or flattening of their feet.

The diagram below demonstrates that perfectly!

As the hips cannot stay level during running, this may cause the knees to fall inwards and in turn causes pronation or flattening of the foot. Then, voila! You have increased tractional stress on the medial aspect of the tibia/shin bone. Yes, there is some evidence that poor foot posture can cause the problem, but only in combination with extrinsic risk factors such as over-training and rapid increases in workload.

Poor hip control and strength is also a precursor for many other musculoskeletal conditions such as lower back, hip, knee and Achilles pain. So if we could reduce the risk of these outcomes occurring in the future, why wouldn’t we try!

It is possible that MTSS is a condition where the simple treatment of rest is enough to reduce symptoms. Until proven otherwise, relative rest remains the number one treatment option for reducing your symptoms. However, If addressed early, MTSS can be managed with the combination of targeted strength routines, running workloads, manual therapy and ensuring adequate recovery time between training sessions.

If you are experiencing shin splints or are looking to prevent such injuries from reoccurring, please feel free to book online or give us a call (07) 3102 3337. You’ll receive an in depth assessment and treatment plan to help you achieve your goals and run better for longer!

Till next time, Praxis what you preach.

The Praxis Team.

PREVENT | PREPARE | PERFORM

Images:

The above images are owned by the “Trainer Academy (https://traineracademy.org/) ” and used in this article with thanks.

References:

[1] Winkelmann, Z., Anderson, D., Games, K., & Eberman, L. (2016). Risk factors for medial tibial stress syndrome in active individuals: An evidence-based review. Journal of Athletic Training, 51(12), 1049-1052. 10.4085/1062-6050-51.12.13

Fact or Fiction – Strength Training

Fact or Fiction – Strength Training

by | Nov 15, 2019 | Uncategorized

I’ve been doing my exercises for two weeks religiously and I’m no stronger! This will never work!

ANSWER: Fiction

How long does it take to have strength gains? The answer is actually in two parts. Increasing muscle size (hypertrophy) takes a minimum of 6 weeks, and repetitive exposures to fatiguing loads. BUT, neural adaptations can occur over the first 1-2 weeks.

What the heck is neural adaptations? Imaging you have a small car battery trying to start a truck. It will struggle to do a good job again and again and fade easily. Now try using 10 of those same smaller batteries, which makes the engine start easier. A similar type of thing happens with our nervous system as we train. We become much more efficient with our neural firing to the muscle.

As you can see in the picture below, you have a long way to go in your strengthening after those first two weeks. That is often why we often need to see beyond when the pain goes away as we know that there is so much more work to be done!

If you have been troubled by niggles and pains, don’t hesitate to contact us to ensure we can help you prevent prepare perform! Book online or call us on (07) 3102 3337.

#factorfictionfriday #praxisphysio #physioeducation #knowledgeiskey

Sale, D. G. (1988). Neural adaptation to resistance training. Med Sci Sports Exerc, 20(5 Suppl), S135-145. doi:10.1249/00005768-198810001-00009

Why lifting is your missing endurance link: A guide for long distance runners (Part 1)

Why lifting is your missing endurance link: A guide for long distance runners (Part 1)

by | Aug 10, 2018 | Uncategorized

You have the shoes, the GPS watch, training schedule and alarm set for 5am. You are dedicated and that race is right around the corner. Whether it is your first 5km or your 50th marathon, the thrill of crossing the finish line drives us all. Whilst you may know your average km split time like the back of your hand, do you know how strong your lunges or deadlifts are? If you haven’t stepped foot in a gym recently, then research suggests you could be missing out on a host of positive effects on your running. There has been a whole host of research in this area so deciphering the literature can be a difficult task. Thankfully, a recent paper by Blagrove et al [1] has done much of the hard work for us. The paper entitled Effects of Strength Training on the Physiological Determinants of Middle- and Long-Distance Running Performance: A Systematic Review aimed to provide a comprehensive critical commentary on the current literature that has examined the effects of strength training modalities on the physiological determinants and performance of middle and long-distance runners. They also offered recommendations for best practice which you can read about in the Part 2 blog post.
Running is a surprisingly complex task and as such there are many factors that affect performance. Physiological, biomechanical, psychological, environmental, and tactical factors all inter play to result in determining the average runner from the elite. With respect to physiological markers of performance, maximal oxygen uptake (known as VO2max), running economy, and the sustainable percentage of VO2max go a long way to determining performance [2]. In fact, these three elements can predict performance with up to 95% accuracy in well trained runners. The difference between VO2max in the elite running population however is surprisingly marginal. On the contrary, running efficiency displays a high degree of inter-individual variability and thus a potential area to better discriminate between runners and their respective performance [3]. Defined as the oxygen or energy cost of sustaining a given sub-maximal running velocity, running efficiency is underpinned by a variety of anthropometric, physiological, biomechanical, and neuromuscular factors [4]. More specifically to the purpose of this article, force generation and stretch–shortening cycles are the neuromuscular factors that are the most relevant. Whilst force production of a muscle is a straight forward concept, the stretch shortening cycles may not be. Stretch shortening cycles describe the pre-stretch and recoil action of a muscle and tendon unit that occurs in a dynamic action just as jumping. Think of the stretch shortening cycle like a spring whereby energy is stored and released within the spring, or in real terms, the musculo-tendinous unit. To produce higher forces, the more motor units (muscle) are required [5]. There is a strong correlation between the cross-sectional area of a muscle and its ability to produced force. Several other factors are involved, but for the most part, a larger muscle will produce more force than a smaller muscle. However, force production becomes more difficult when activities are dynamic. This is because there is a reduction in force produced per motor unit due to the faster shortening velocity involved in the stretch shortening cycle [5]. In general, strength training activities can positively affect both muscle force as well as improve the stretch-shortening cycle through several different adaptations including muscular and neural changes [6, 7]. Hypertrophy is the term to describe an increase in muscle size. It is the cyclical process whereby muscle cells are exposed to repeated bouts of exercise causing micro damage to the muscle cells. Micro damage causes an inflammatory response and it is the pain you feel for the next 48hrs after a bout of exercise (also called delayed onset muscle soreness or DOMS for short). It is also the stimulus for the body to mitigate future damage by repairing the damaged tissue and adding more muscle cells. This is what is commonly known as the super compensation cycle. Hypertrophy is aided by rest, dietary protein, certain hormones (e.g testosterone) and has a very strong genetic component as well [7].
Neural adaptation tends to be one of the earliest changes and accounts for most of the strength increases observed in the initial stages of all strength training [8]. Those who are exposed to repeated bouts of resistance training generate significant strength gains with minimal hypertrophy early in the process. The body achieves this via synchronous activation (the ability to recruit more muscle cells in a simultaneous fashion) and reduction in neural inhibition (a natural response of the central nervous system to feedback signals arising from the muscle) [9]. Inhibition allows muscle to avoid overworking and potentially damaging itself due to unaccustomed load. This response is rapid as it utilises the nerve and muscle cells already present. These adaptations are in direct contrast to the untrained muscle in which atrophy (muscle wastage) and reduced neural drive are typical. What this all boils down to is that following a period of strength training there is an increase in absolute motor unit recruitment resulting in a lower relative intensity of that muscle unit to deliver the same outcome as previous. If the bouts are habitual and frequent enough, muscle cells hypertrophy and become larger, increasing their ability to generate force. As a result, the trained muscle will be able to recruit a higher threshold of larger motor units. Combine all of this with an enhanced stretch shortening cycle and you have some excellent adaptations to improve running efficiency.

With respect to the dosage, the Blagrove paper suggested, a strength training intervention, lasting 6–20 weeks, added to the training program of a distance runner appears to enhance running efficiency by 2–8%. In real terms, an improvement in running efficiency of this magnitude should theoretically allow a runner to operate at a lower relative intensity and thus improve training and/or race performance. Improvements were observed in moderately-trained, well-trained and highly-trained participants, suggesting runners of any training status can benefit from strength training. For the particulars of the dosage, exercise selection and periodisation, check out Part 2 blog post.

Until next time, continue to Praxis What You Preach…

Prevent. Prepare. Perform.

References:

  1. RC. Blagrove, G Howatson, PR. Hayes. Effects of Strength Training on the Physiological Determinants of Middle- and Long-Distance Running Performance: A Systematic Review, Sports Med. 2018; 48(5):1117-1149
  2. McLaughlin JE, Howley ET, Bassett DR Jr, et al. Test of the classic model for predicting endurance running performance. Med Sci Sports Exerc. 2010;42(5):991–7
  3. Morgan DW, Craib M. Physiological aspects of running economy. Med Sci Sports Exerc. 1992;24(4):456–61.
  4. Saunders PU, Pyne DB, Telford RD, Hawley JA. Factors affecting running economy in trained distance runners. Sports Med. 2004;34(7):465–85.
  5. Barnes KR, Kilding AE. Running economy: measurement, norms, and determining factors. Sports Med. 2015;1(1):8–15
  6. Denadai BS, de Aguiar RA, de Lima LC, et al. Explosive training and heavy weight training are effective for improving running economy in endurance athletes: a systematic review and meta-analysis. Sports Med. 2017;47(3):545–54
  7. Schoenfeld BJ, Ogborn D, Krieger JW. Effects of resistance training frequency on measures of muscle hypertrophy: a systematic review and meta-analysis. Sports Med. 2016;46(11):1689–97
  8. Aagaard P , Simonsen EB , Magnusson SP , Andersen JL , Dyhre-Poulsen P. .Enhanced motoneuron activation as effect of heavy-resistance strength training in man.Med Sci Sports Exerc 29: S23-1997.
  9. Aagaard, P., E. B. Simonsen, J. L. Andersen, S. P. Magnusson, J. Halkjær-Kristensen, and P. DyhrePoulsen. Neural inhibition during maximal eccentric and concentric quadriceps contraction: effects of resistance training. J Appl Physiol 89: 2249–2257, 2000