‘Shin splints’ are a real problem out there – common, painful, activity limiting and often treatment resistant. A bit of research on ‘shin splints’ (or the more recent, awkward, and I am not sure helpful term, ‘medial tibial stress syndrome’) in the medical databases, won’t provide much clarity in aetiology or agreement in treatment and you will find there are probably many different kinds of shin splints. If you Google ‘shin splints’, in-line with the growing trend, you’ll get lots of diagrams with multiple strips of brightly coloured tape applied in complex patterns.
Sometimes you need to be aware of the science, and move on. Move on to what you see in front of you – clinical scientists are often years in front of desk scientists.
Here is a clinical pattern I have seen many times over the last 30 years.
I recently caught up with an old friend while teaching a course in Brisbane, Australia. She is a keen golfer, mid 40s, and had a left tibial fracture 3 years ago – it healed well and she was back to good quality golf within months. Six months ago she began to experience medial tibial pain radiating to the posterior medial malleolus in her left leg during and after golf . She had a medical check up – there was nothing sinister and no complications from the fracture. She also saw a number of therapists who proposed muscle imbalances in the leg, ‘switched off glutes’, trigger points and biomechanical issues in her feet – she had been told that both her feet were ‘flat’. Various therapies had been diligently applied and adhered to, including strengthening, stretching, suctioning, needling – even a bit of ‘core stability’ (perhaps this last one was thrown in as a ‘just in case’).
The end result for my friend was that she was avoiding golf and if she did play, used a cart to minimise the amount of walking. Especially, as she had been warned, on uneven ground.
I checked her out. There was nothing exceptional in the leg at the time of examination – nothing surprising at all for a 40 year old, active woman who had been fully functional for a number of years post fracture.
However, there was a clear neurodynamic finding which had not been examined in the past. In the slump position, with left ankle dorsiflexion/eversion and knee extension, the tibial area pain was recreated. Releasing knee extension released the tibial symptoms, as did releasing neck flexion. The same test on the right side revealed hamstring tugging and a better range of knee extension. I reasoned these to be relevant findings.
Post examination thoughts
I thought that there were two critical elements in the clinical presentation of the person in front of me. Firstly, and most importantly, an avoidance behaviour based on the (erroneous) fear that playing golf or exercising and experiencing any pain meant that there was further damage occurring and things were getting worse. One comment from my friend went something like ‘If I keep playing golf with my muscles all out of balance, the trigger points will come back and I’ll just make it worse’. Secondly, there was the relevant neurodynamic finding. If I was trying to be a bit smart, I might suggest that a third clinical element was a positive feedback loop between these first two, with the fear-based ‘though viruses’ helping to drive a sensitive nervous system which in turn provided erroneous evidence for the thought viruses to be maintained.
We treated it. First I suggested not calling it ‘shin splints’ – this metaphorical diagnosis suggests that the problem needs support or outside help – aching shin, even just sore shin is better.
Secondly we moved her nervous system around a bit with the idea of restoring its sliding and gliding function and maybe flossing and flushing out some areas that had been a bit ‘sticky’ for some time.
Thirdly, we chatted. I suggested that there may be a bit of an increased ache for a day or so post stretching as this sometimes happens but not to worry about it ‘It’s your body adjusting to the treatment’. I suggested that the problem now was a ‘bit of nerve and soft tissue irritation, it sometimes happens, even a few years after an injury as the brain holds memories of serious injuries and can react over time* – almost trying to heal it again so it puts a bit of useful swelling there which can irritate things. It gets a bit compounded when treatments don’t work or make sense and you start to worry – worry can make things more sensitive too. But this is all good – it will go. Go back to golf – there’s nothing that can be damaged – play 18 holes – a few aches and pains are fine and normal, continue the post game gin and tonic ‘
She played 18 holes of golf 2 days later – no problems. It’s now 3 weeks later, and with much golf and regular stretching there are no reported problems.
Not all ‘shin splints’ are the same of course – some acute presentations may be serious medical emergencies** and should be treated as such. But my example is a common and repeated scenario and I believe that this problem is not often treated in this way.
This is not intended to be some crowing about a ‘miracle’ – there was no miracle cure, no quick-fix, no tricks, no secret technique performed by magical hands. There was just some basic clinical reasoning powered up by a modern, neuroimmune understanding of how pain works – or at least the best understanding available to us right now.
The kind of pattern reported above is common and will usually ease with the simple principles . If I had to have a go at the pathology, I would suggest some tibial nerve irritation, perhaps even a minor compartment syndrome in the posterior compartment which houses the tibial nerve. How simple it would be to suggest that the nerve and its connective tissue sheath were sticky, perhaps with limited oxygenation, some local immune inspired inflammation perhaps also related to slightly altered anatomy post fracture. But more than that – I suggest that the person’s perception of the problem has also added to the sensitivity both locally and in neuroimmune territory representing the meaning and the function of the leg.
I rang my friend today and asked how she was going – ‘I am doing fine. Golf is no problem at all. It’s good to know I couldn’t hurt this paying golf and its good to have some stretches that I know are getting at it’.
Sometimes our game can be deceptively simple?
David Butler, Noigroup
*We are talking here about a temporal brain glial response – microglia and astrocytes have a danger surveillance function which may last for many years. If activated they may encourage responses in other systems such as the endocrine and sympathetic systems leading to swelling and increased local sensitivity.
**If you ever see or experience lower leg pain that commences suddenly, is associated with rapid and significant swelling of the lower leg, changes in blood flow, tingling and or loss of sensation don’t hesitate, seek appropriate medical assistance immediately.