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Helen Binkley, PhD, ATC, CSCS*D, NSCA-CPT*D
Column Editor
INTRODUCTION
How often do you have an athlete come to you complaining of pain in the lower portion of the front of the leg? The athlete probably tells you that the pain increases with activity. You know immediately that this is probably shin splints. But what can you do to help the athlete who is suffering from shin splints other than telling them to rest? The purpose of this column is to give strength and conditioning professionals the knowledge to treat and prevent shin splints.
Medial tibial stress syndrome (MTSS), often referred to as shin splints, is an overuse injury of the lower leg that affects a large majority of the athletic population. Athletes will often report a region of tenderness along the posteromedial edge of the tibia. Athletes will complain of exercise-induced pain along the middle to distal third of the posteromedial border of the tibia (10). The injury presents itself with diffuse palpable pain that is often described as a dull ache following exercise. This pain is often alleviated with rest (2). However, with continued training, the pain will become more consistent and severe (10). Originally, the tibialis posterior muscle was thought to be the anatomic site involved, but it has been found that the irritation is consistent with the origin of the medial soleus muscle and its deep fascial insertion, termed the “soleus bridge” (14).
When examining an athlete for potential MTSS, several factors should be examined. A thorough history and physical examination should be conducted by an athletic trainer or physician to rule out other possible injuries whose signs and symptoms mimic MTSS. These injuries include a stress fracture, exercise-induced compartment syndrome, and popliteal artery entrapment.
On occasion, diagnostic procedures, such as x-rays and magnetic resonance imaging, will be used to diagnose the injury. As part of the physical examination, the athletic trainer or physician will evaluate the flexibility and foot type of the athlete (6). Hamstring and heel cord tightness have been shown to be a significant predictor of sustaining a MTSS injury (4). In addition, those athletes with either high arches or low arches had twice the incidence of injury as compared with subjects with average arch height (5).
Several studies have shown female athletes to be more predisposed to MTSS than male athletes (1,6-8,11). Other causes of MTSS are training surfaces, improper training techniques, progressing to higher intensity levels too quickly, muscle imbalances, a more pronated foot type, change in training footwear or worn-out footwear (running shoes should be replaced after about 350 miles), or footwear with little padding (9,14).
Engaging in a static stretching program will help rehabilitate athletes who have MTSS and prevent the occurrence in athletes who do not have MTSS. The muscles that should be focused on are the hamstrings, gastrocnemius, and soleus. Static stretching has been shown to cause a plastic response, which will result in a permanent tissue elongation (12). Performing these stretches as part of a strength and conditioning program will help in the rehabilitation of athletes suffering from MTSS and work as a preventive exercise for others.
Consulting with an athletic trainer to include strengthening exercises (dorsiflexion, plantar flexion, inversion, eversion, and combinations of these movements) with lightweight tubing would be beneficial. Additionally, ice can be used to help with the pain and discomfort associated with MTSS.
WARM-UP
The warm-up enhances the blood flow to the working muscles and enhances conduction of nerve impulses. Before stretching, athletes should always warm-up for 5-10 minutes. The warm-up should consist of exercises that involve large muscle groups. Because the focus is increasing the flexibility in the lower extremity, warm-up exercises should be performed with the muscles of the lower extremity in mind. Jogging is one exercise that will increase the blood flow to the area. With athletes who are already experiencing pain due to MTSS, jogging may not be the best exercise to perform. Instead, have the athlete ride a stationary bike during the warm-up. This will eliminate the ground reaction forces that may cause an increase in pain.
HAMSTRING STRETCHING
Introducing a hamstring stretching regimen can significantly increase flexibility and decrease the incidence of injury. Muscle tightness in the hamstrings or any other muscle in the lower extremity can affect the biomechanics of the entire closed kinetic chain during athletic activity, which can lead to injury (7). Tightness of the hamstrings will cause a compensatory dorsiflexion of the ankle, increasing the stresses on the lower leg during gait cycles (13).
Because of the relationship of the muscles in this closed kinetic chain, it is important to stretch the hamstrings as part of a MTSS prevention and treatment program. Hamstring stretching can be performed many different ways. Two of the most often used techniques are the standing hamstring stretch and the supine hamstring stretch. Although the stretches are performed differently, both are shown to significantly increase hamstring flexibility (3).
The standing hamstring stretch is performed when the individual stands on one leg while placing the stretching leg forward on a raised surface and simultaneously bending forward at the waist. It is important to note that while performing this stretch, the spine should not be flexed. The supine hamstring stretch can be performed in 1 of 2 ways. The first has the athlete lying supine in a doorway and placing the stretching leg on the wall while the other leg rests flat on the floor (Figure 1).
Figure 1: Supine hamstring stretch with door.
The second method is performed as a partner stretch. The athlete being stretched lies supine. The partner will flex the leg to be stretched keeping the opposite leg flat on the floor. Both stretches should be performed until a comfortable stretching sensation is felt in the hamstrings. The stretch should be held for 30 seconds. The stretch should be performed 3 times with a 15-second break between stretches.
GASTROCNEMIUS STRETCHING
Like the hamstring, the gastrocnemius can be stretched multiple ways. The first method is called the heel drop and is performed on a step. The athlete stands in an upright position on the leg to be stretched, with the body weight on the forefoot and the ankle in plantar flexion (Figure 2).
Figure 2: Heel drop for gastrocnemius.
The second method requires the athlete stand several feet away from a wall. The athlete has a staggered stance, with the leg to be stretched placed in the rear, keeping the heel firmly on the ground. The athlete leans forward, placing the palms of the hands against the wall causing the ankle to go into dorsiflexion, while maintaining full knee extension. The foot should be kept straight and angled 90° from the wall (Figure 3). During the final method, the athlete sits with his or her legs in front. The athlete puts a towel or a rope around the forefoot of the leg to be stretched and pulls the ankle into dorsiflexion. All 3 stretches should be performed until a comfortable stretching sensation is felt in the hamstrings. The stretch should be held for 30 seconds. The stretch should be performed 3 times with a 15-second break between stretches.
Figure 3: Gastrocnemius wall stretch.
SOLEUS STRETCHING
The soleus is the muscle that athletes often forget to stretch. The soleus is stretched in the same way as the gastrocnemius but with one major difference. To properly stretch the soleus, the knee must be in slight flexion. This slight flexion allows the gastrocnemius to be shortened while the stretch is performed. This shortening of the gastrocnemius better isolates the soleus.
The athlete should be positioned close to a wall with the legs staggered, the back straight, and palm of the hands against the wall. To start, the athlete should be in a position that allows the legs to be bent and the buttocks dropped. Have the athlete lean into the wall until he or she feels a comfortable stretch in the lower calf. The stretch should be held for 30 seconds. The stretch should be performed 3 times with a 15-second break between stretches (Figure 4).
Figure 4: Soleus stretch.
ICE MASSAGE
Ice massage is a convenient way for athletes to ice the painful areas caused by MTSS. To make an ice cup, simply fill a paper cup with water and allow to freeze. Remove the top two-thirds of the cup leaving at least 1 inch on the bottom of the cup to act as a handle. Apply the ice massage to the painful area using overlapping circular or longitudinal strokes. The ice massage should be continued until the skin is numb to fine touch. The numbness usually occurs between 7 and 10 minutes. The ice massage can be repeated several times a day.
CONCLUSIONS
MTSS is an injury that affects a large portion of athletes. Often, the only option given is to rest and wait for the MTSS to go away. By introducing a stretching program that incorporates the stretches shown in this article, the strength and conditioning professional can reduce the occurrence of MTSS among athletes and help rehabilitate athletes who are already suffering from MTSS.
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