Medial tibial stress syndrome or shin splints

Cause of pathology

There are two theories for the development of shin splints or medial tibial stress syndrome (MTSS). The first is the traction theory. Whenever the foot lands on the ground during exercise, our calf muscles must absorb a shock. There are certain calf muscles which are directly connected to the shinbone (soleus, flexor hallucis longus, posterior tibialis). These muscles will create a direct traction force on the tibia when landing and this traction force will cause an inflammation and stress in the bone (Moen et al. 2009). The second theory states that as a result of the pulling forces of the calf muscles, the tibia bends and thus becomes overloaded (Beck 1998).

There are various risk factors that contribute to the development of MTSS. They can be divided into internal and external factors.

Internal factors are:

• high BMI
• great mobility in the hip
• overpronation (excessive tilting of the ankle inwards)
• shortened or strained calf muscles

External risk factors are:

• history of MTSS
• an overly demanding training programme
• walking with worn out shoes
• starting training too intensively

Evolution of the pathology

During the acute phase, the patient will mainly experience pain at the start of his sporting activity. This pain will go away during and after sports. During the subacute phase, the pain will be present at the start, but also during and after sports. In the chronic phase, there is severe pain at the start and also pain during and after sports. It is also possible that the tibia is painful at rest or when touched (Yates and White 2004).

Articular

Excessive mobility in the foot may be present. Especially too much active and/or passive pronation (collapse of the foot arch) is a problem.

Neurologic

In medial tibial stress syndrome there are no neurological symptoms. If this is the case, there may be a compartment syndrome or another pinching of a nerve and additional examination is necessary.

Muscular

Tense and / or shortened superficial and deep calf muscles may be present. In addition, correct functioning of the gluteal muscles is necessary in order to reduce the traction forces on the shin bone through muscle control. If the gluteal muscles are working properly, the calf muscles need to work less intensively in order to achieve good stability.

Other symptoms

The main symptom is vague and diffuse pain in the inner/lower part of the tibia.

Physiotherapeutic examination

The physiotherapist will start with an intake interview to evaluate the current complaints and history. The physiotherapist will try to paint a clear picture of the complaints, but also of how they came about and what factors influence them. Next, a thorough physical therapy examination will take place. This is important in order to make a correct diagnosis.

The clinical examination will consist of an inspection of both legs of the patient in standing position. The physiotherapist will examine the leg length, foot position, anatomical abnormalities and evaluate whether the body is aligned (Franklyn and Oakes 2015). Next, the physiotherapist will feel the inside of the tibia for pressure sensitivity (Franklyn and Oakes 2015; Galbraith and Lavallee 2009). They will also check for subcutaneous oedema (oedema is fluid accumulation in places in the body where there is normally little or no fluid). After all, this can indicate periostitis (inflammation of the membrane around the leg). The physiotherapist will also examine other conditions to rule them out (e.g. nerve entrapment, compartment syndrome or potential stress fracture).

In addition, the physiotherapist will examine the strength of the muscles in the lower leg. An examination of the nerves and blood vessels is also important to exclude other disorders. Next, the mobility of the joints (ankle, knee and hip) is examined in detail as well as the length and tension of the muscles (Franklyn and Oakes 2015). When there is a shortening of a muscle at the back of the leg, this causes an increased pressure at the front of the shin during walking (Franklyn and Oakes 2015).

It is also important to evaluate the hip and abdominal muscles (Galbraith and Lavallee 2009). Good control of the muscles ensures good control of the body and lower limbs during exercise. This also allows for a better walking motion which reduces strain on the tibia and the muscles.
Finally, the physiotherapist will look at how the patient moves during sport specific and painful movements (e.g. walking or running).

Manual therapy

Manual therapy will be used to obtain the normal functioning of muscles and joints. When the muscles are excessively tense or the mobility in the joints (e.g. the ankle or foot bones) is disturbed, a combination of techniques will be used. The aim is to reduce muscle tension and its impact on the bone.

The physiotherapist can lengthen the shortened muscles by using passive stretching. Next, the physiotherapist can relax excessively tense muscles by means of massage or dry needling. Finally, there are also mobilisation and manipulation techniques to obtain a normal mobility of the joints. This will allow the load to be better distributed throughout the body.

Physiotherapeutic treatment

The treatment of shin splints is conservative (non-invasive and drug) with physiotherapy. It consists of adapting activities by reducing repetitive strain sports (e.g. walking, hiking or jumping sports). Treatment for MTSS is tailored to the individual patient and focuses on the risk factors identified in the clinical examination.

Pain control

Relative rest will be an important component to reduce pain (Galbraith and Lavallee 2009). This means that pain-provoking movements are avoided. The patient does remain active by making movements that do not provoke symptoms (e.g. cycling or aqua jogging).

Physical therapy

Exercise therapy forms an important part of the treatment. The physiotherapist will draw up an individualised exercise programme to correct any abnormalities identified during the clinical examination and risk factors.

If the calf muscles are shortened, specific stretching exercises are recommended. If muscle endurance or control is insufficient, specific exercises for endurance and control of the calf muscles are designed (Galbraith and Lavallee 2009).

The most important part is to improve the patient's movement pattern during activities. The goal is to reduce the traction forces on the tibia.

Adjusting the training load or build-up is also important because it is often the cause of developing MTSS. Since too rapid a progression in intensity, volume and frequency in the exercise programme is a risk factor, the physiotherapist can help guide the patient and trainers in their training build-up.

To summarise, the physiotherapist provides tailor-made treatments and an individual exercise programme in addition to sports coaching so that the patient can carry it out independently.

Short term

The first objective is pain reduction at rest and during activities. In addition, the sports activities are adjusted and the goal is for the patient to gain a better understanding of the load capacity and important risk factors.

Long term

The aim is for the patient to be able to perform the desired activities again without pain. Furthermore, the aim is to strengthen the patient so that no relapse occurs.