Medial Tibial Periostitis
What are Shin Splints?
Shin splints are a common term for pain along the medial border of the tibia which develops or worsens with exercise, there may also be some tenderness in surrounding the tissues and/or swelling. This condition is also called: Medial Tibial Periostitis or Medial Tibial Stress Syndrome [MTSS]
Causes of shin pain?
Change in:
- Training ie increase of intensity, speed, uphill runs
- Ground surface: soft to hard or uneven
- Improper shoe ware: old or lacking motion control of the midfoot arch
- Poor conditioning level for the sport played
- Biomechanical insufficiency
- Leaning forward while running
- Hitting heel hard on ground, slapping foot down
- Hips externally rotated (tight gluteal muscles)
- Excessive pronation of the mid and rear foot
What happens?
An inflammatory reaction occurs due to pulling on the periosteum (outer part of the bone) of the tibia, from either muscles or the fascia which protects and connects the body.
There are various stages:
- Mild: Pain is initially only felt after intense work out and is diffusely tender
- Moderate: Pain felt in normal daily activities such as walking. Morning pain and stiffness often noted.
- Severe: Progression on to changes to the inside of the bone and possibly progress to a Stress Fracture of the tibia.
Biomechanics of running:
The action of running is complex involving multiple joints of the leg.
The phases are:
• Heel strike – into pronation [contact]
• Mid stance – out of pronation
• Toe off – [propulsion]
• Swing
Excessive pronation of the foot has been implicated as a contributing factor in medial tibial pain pathologies.
Rehabilitation
Rehabilitation is paramount for returning to sport.
The following are guidelines for a rehabilitation program:
- Rest the limb
- Address any inflammation
- Maintain current cardiovascular fitness
- Find the cause
- Environmental – surface
- Biomechanical ie pronation
- Incorrect shoe ware
- Orthotics if needed
- Address any biomechanical dysfunction
- Re-train the muscles correctly
- Regain function to go back into sport
Hop Test
A criteria for returning to sport:
- No pain along the tibial border
- Cause of pronation addressed
- Extending ankle (up) to >10°
- Flexible of calf muscles
- Hop test ( See picture) = no pain
- Successful completion of running program & sport specific activities without pain.
Days 0 – 7 (or until no inflammation)
- No running or jumping
- Cardiovascular fitness by:
- Pool work outs with inflatable devices ie deep water running
- Upper body ergonometer
- Stretching of calf muscles – be able to have 10° of dorsi flexion (ankle extension)
- Ice massage
- Non Steroidal Anti Inflammatory Drugs [NSAIDs] IF prescribed by your GP
- Taping considered:
- Mid foot support
- Medial tibial border
Mid foot support
Medial tibial border
Treatment:
- Your therapist may use massage techniques, joint mobilization and/or electrotherapeutics. Consultation by a Podiatrist to assess your foot’s biomechanics should be considered
- Days 8 -15 usually:
- Once inflammation subsides and the shin is relatively pain free to touch:
- Progression is only upon pain free walking.
Strengthening the muscles
- Plantar flexion [toes toward ground]
- Dorsi flexion [toes to nose]
- Inversion [raise inside of foot]
- Eversion [inside of foot to ground]
Functional Exercises:
Single leg heel lowers
- Toe walking and heel walking
- Two legged heel raise
- Single leg heel raise
Eccentric Muscle Contraction:
- Two legged heel lowers
- Single leg heel lowers
Single leg stance
Proprioception/Balance Exercises:
- Writing alphabet with foot
- Two leg stance eyes open
- Two leg stance eyes closed
- Single leg stance eyes open
- Single leg stance eyes closed
- Two leg stance on stability disc
- Single leg stance on stability disc
Next progression:
- Light running program on soft surface may commence if it is pain free, with good running shoes & as long as any pronation issues have been addressed.
- Straight line @ 60% pace moving to 100% as able and pain free
- Running in figure 8s starting wide and slow then progressing to be short and tight
- Introduction of lunges, squats, side running, jumping, skipping, box jumps as able pain free
Final progression:
- Sport drills to replicate game activities safely
- Full activities of sport and training sessions, need to be able to do 100% and not limited by pain.
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