Armstrong Podiatry & Sports Health's Blog

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My perspective on “Shin Splints”

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Frustrating and painful

 

Recently, I have been seeing lots of blog articles about shin splints, which I believe have been rather generic in nature.  I would like to submit my thoughts about the subject, which are a little more unique in nature.

“Shin splints” is a common problem, affecting athletes of all ages.  The pain in the shins can be gradual in intensity and debilitating in nature.  It can be an injury that gets worse and could lead to a stress fracture.

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There’s the spot!

“Shin splints” is really a “catch-all” terms that refers to pain on the inside of the shin bone (tibia).  It really seems to be caused by tension of three muscles on the fascia of the bone.  This friction between the muscles and the fascia causes an inflammatory state (fasciitis), which can occur during walking or running.  If this inflammation continues, the bone could get involved, and you can get periositis (inflammation of the covering of the bone) and then potentially a stress reaction/fracture of the bone itself.

Like any overuse injury, the adage, “Doing too much, too soon”, certainly applies to “shin splints”.  The body that is unaccustomed to increased stress will breakdown. It is usually seen in overweight individuals who are beginning to run as exercise, especially on hard surfaces, i.e., sidewalks.  The pain appears when starting out for a run and gradually disappears, only to reappear after the run is complete.  The pain can usually be replicated by hopping on the affected side.

Individuals prone to this injury may have either a “flat foot” or “high arch foot”.  A “flat foot” already has  increased tension of two of the muscles involved in “shin splints”, in addition to increased internal (turning in) rotation of the legs. Running or walking places increased force on the feet, exacerbating the “flat foot” position, i.e., increasing the muscular tension and internal leg rotation.  A “high arch foot” places tension on the other muscle involved in “shin splints”, in addition to the commonly restricted ankle joint motion.  This type of foot is rigid and running/walking activity creates more forces, leading to more pressure on the foot and more muscular tension.

Treatment and prevention of this injury involves a multifaceted approach. The key is that the inflammation must be reduced and controlled. One way to do this is the usual ice, rest, compression and elevation; the other way is by reducing the tension of the affected muscles causing the inflammation. I usually do both of these and tailor the treatment plan according to the individual. To reduce the muscular tension, an insole or even an orthotic can be used to allow the affected muscles to “rest” for up to six to eight weeks. Activity modification is also emphasized, i.e., limited exercise-related weightbearing activity.

Ice is good!

Ice is good!

Individuals with “flat feet” can benefit from hip strengthening exercises, specifically hip abductor strengthening    (http://runninginjuryclinic.com/resources/exercise-videos/), short foot protocol (http://vimeo.com/43187129) and intrinsic foot exercises (http://www.youtube.com/watch?v=2OOJ9AQ1AEg).  Individuals with “high arch feet” benefit from hip strengthening exercises, specifically hip adductor strengthening and calf muscle stretching.  These exercises work to reduce tension on the affected muscles, by mobilizing and utilizing other ones.  Once inflammation control is achieved, a slow gradual return to activity from low stress, i.e., short job to high stress, i.e., hopping, jumping.

Of course, prevention is the key for “shin splints”.  It is important for beginner runners to follow a structured workout plan, conceived by a knowledgeable running coach.  Running on softer surfaces is also recommended, in addition to flatter surfaces.

As always, if you have any questions, please contact me.

Health and happiness!

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March 10, 2014 Posted by | Fascia, Foot and ankle injuries, Overuse injuries, Running, Sportsmedicine | , , , , , | 1 Comment

Interview with Dr. Robert Schleip

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I had the opportunity to interview the preeminent researcher in the fascinating world of FASCIA, Dr. Robert Schleip from Germany.  He has singlehandedly changed the way I,and many others should treat patients with soft tissue injuries, particularly plantar fasciitis (heel pain).  Fascia is a continuous web of tissue that surrounds the bones, ligaments, tendons and muscles of the ENTIRE body!  Its all-encompassing nature, highlights the fact that it has a major impact on injuries and prevention and also the interconnection of the entire body.  Below is the e-mail interview:

(Me) I have been fascinated by your work.  What type of response have you been getting here in the U.S.?

(RS) There has been an avalanche of interest from the US, yet also Canada.  Not only in our work but in the new field of fascia research in general.  Most interest comes from manual therapists, yet also from sports medicine people, yoga instructors, manual art specialists, and others.

(Me) Tell my audience about your background.  I believe it is important that the scientific and medical community works hand and hand

(RS) I have been a bodyworker since three decades.  Mainly as a practitioner and instructor of the Rolfing method, yet also as a Feldenkrais teacher.  Based on my frustration with a pseudo-scientific foundation of my work, I began to enter the field of academic science myself, first as an avid reader and participant of conferences, and then 6 yrs ago I became an active laboratory scientist myself.  Together with a small team of colleagues at the University of Ulm in Germany, and in combination with my PhD dissertation, I could show that normal fasciae, i.e., the dense muscular connective tissues, have active contractile properties.  This was awarded with Vladimir Janda Award in 2006 and has stimulated several further studies since then.  I was also involved in organizing the first International Fascia Research Congress, at Harvard Medical School in Boston in 2007, which was a hugh success.  It was booked out months in advance and received an enthusiastic coverage in the scientific media; and soon we’ll be having the 2nd such congress in Amsterdam.

And you are right: I strongly agree that scientists and health care practitioners should work closer together.  Yet this is exactly what is currently happening in the field of fascia research.  The current excitement that everybody feels in this field is not only because the cinderella effect, in which the tissue which was most neglected in orthopedic research in the last few decades is achieving an almost superstar position since that first Harvard congress.  Moreover, that excitement, which has some qualities of  a gold digger’s rush, is largely colored by the interdisciplinary mixture of the people entering this field and the mutual cooperation of clinicians, researchers, movement therapists, nutritionists, and many others.

(Me) Tell us the results of your studies in regards to contractile cells in fascia (myofibroblasts).

(RS) Pathological fascia such as Frozen Shoulder or hypertrophic scars contain so-called myofibroblasts, which are connective tissue cells with smooth muscle like contractile properties.  These tend to densify and to contract the fascial matrix.  What we did is look for the presence of such cell in normal human fasciae.  Basically we found such contractile cells in all fascial tissues that we looked at, although at different cellular densities.  Additionally we suspended pieces of fascia in an organ bath environment and stimulated them wth specific cytokines or with mechanostimulation.  Here we could show, that many of the fascial pieces could actively contract and relax in a smooth muscle like manner.  This finding may have implications of understanding many conditions and therapies which involve hypo-trophic or hypertrophic fasciae. Possibly manual therapies, yet also stretching or yoga or Pilates practices, may be targeting the active ability of fascial tissues to regulate their tonicity independently of the muscular tone.

(Me) Tell me the results of your studies of fascia in regards to water content.

(RS) We repeated and extended some earlier experiments from a group in Montreal, which showed that when a ligament or other fascial tissue is being stretched isometrically, that is yields and looses some of its original stiffness by the well-known feature of creep or viscoelastic relaxation.  We could show that this yielding or temporary softening is due to a loss of tissue water from the ground substance; i.e. that some water is squeezed out of the tissue, like in squeezing a wet towel or sponge.  When one then gives the tissue a sufficiently long resting period, it sucks up again with water and regains its original stiffness.  Yet quite surprisingly, if the previous stretch was strong enough and the resting period long enough, then the tissues in our experiments filled up to a state of supercompensation, where they filled with more water than they had lost during the stretch and in which they ganied the state of “strain hardening”.  This means that they ended up being stiffer than before, for about 1 or 2 hours after the original stretch.

It seems like the stiffness and elasticity of fascial tissues depends to a very large degree on the regulations of their water content.  Water makes up about two thirds of the volume of fascial tissues.  And most of that biological water seems to be in a bound state, in which the water molecules are arranged in an organized fashion similar to a liquid crystal, or like the surface tension that allows a spider to move on top of a water pond.  Aging tends to go along with a loss of hydration in tendons, and degradation of the normal water molecule coating around the elastin fibers.  It seems like the dynamic changes of the various water content and water binding properties of fascial tissues have a very profound effect on our bodies; and that many practices like massage, sports activities, or stretching are influencing those properties.  We now have the technology, e.g. with modern magnetic resonance imaging, to study those changes in water molecules, and I can’t wait to see the results of some of those studies in relation to specific preconditioning practices in sports, or in manual therapies. 

(Me) As a podiatrist, I am interested in this information in regards to plantar fasciitis or more precisely, plantar fasciosis.  Do you think stretching should be a first-line treatment for this condition?

(RS) Yes, in my Rolfing practice, which I still maintain two days a week I find that the plantar fascia in those people is not only thicker, but is seems to be also much drier and less elastic.  One can often palpate some rope-like or ribbon-like dry strands in the sole.  These feel similar to the rat fascia in our lab after they have been exposed to air for several minutes.  So I think stretching is most likely a very good treatment.  However, the stretching should not be done with the intention of stretch the collagen fibers inside, but to squeeze out the fluid contents of the tissue similar like in squeezing a sponge or a wet towel, such that it will soak up with new water molecules immediately afterwards.  If done slowly and repeatedly one will find that dense tissues like the plantar fascia can regain their original youthful juiciness and elasticity. 

(Me) I have used massage therapy (myofascial release) for stubborn cases of plantar fasciosis.  Do you think this would be a good first-line treatment? 

(RS) Yes, absolutely.  But is takes several months of fascial tissues to change their morphology, muscles can do that much faster.  So it may take some patience to yield a complete healing response from the plantar fascia. 

(Me) Any exciting new research results you can share with us?

(RS) Yes, we found strong indications that acute back pain is generated in a large proportion of the cases by microinjuries in the lumbar fasciae.  In many cases, the discs are not the causal factor for the pain, yet the lumbar fascia shows signs of injuries, inflammation, scarring and adhesions.  And this fascia is densely innervated not only with mechanoreceptors which are important for proprioception, but also with free nerve endings which can drive the central nervous system mad and lead to chronic long term pain syndrome.

(Me) Thank you for your time and I hope to meet you in the near future

(RS) It’s been a pleasure, hope to see you maybe at the next fascia congress in Amsterdam this October.

I know it a little technical, but I feel Dr. Schleip’s work is so important, because it  gives a legitimacy to massage therapy and similar manual therapies.  Feel free to send a line for clarification or for any questions you may have.

Happiness and good health!

July 5, 2009 Posted by | Fascia, Robert Schleip, Stretching | , , , | Leave a comment