shin splints?????

[Netty]

Hi,

Patient is complaining of pain over the shin about half way down between the knee and ankle and it is tender over an area of about 1 inch in diameter and with a slight depression.

They also have under the skin lumps and bumps that can be felt. Could this possibly be shin splints? The person is a runner and only gets the pain whilst running.

I am sorry I cannot give more details as I have only spoken to this patient over the telephone so far. I was wondering mostly if lumps and bumps are common with shin splints? or any other ideas???


Thanks alot

Netty

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[Aisha_kb]

Hey Netty, as your history is quiet vague we will not be able to help you out much in this case... A good history and assessment is very important for a physio to better understand what to do next.

Anyway, the humps & lumps that you are talking about are very normal and not necessary related to shin splint... I am sure if you palpate your own shin you would find them.

Was the patient dormant for a while and then started running all at once? OR is there any change in his running norms, like did he change his shoes? or place in which he ran? or intenstity of it?

[Netty]

Hi Aisha,

Thanks for your reply.

Yes I do understand that I need to give a more detailed history however I have only spoken to the patient on the phone. I will be seeing them tomorrow when I will be able to give a fuller history. However I just wanted to know what the lumps and bumps under the shin that the patient told me about over the phone could be, whether it was possible shin splints or compartment syndrome.

Thanks anyway and I will post fuller history once I have seen patient tomorrow!

Netty

[GAR42]

I am a PT patient. I have been diagnosed with MTSS/ Periostitis/Shin splints. I have been non responsive to any therapies for 1 and 1/2 years. I have a very involved history, but in summary, I started with bilateral calf pain in March '06. Calf pain mostly resolved, but medial shin pain persists. I had an ultrasound on Tuesday, September 4. The tech showed me my tibia where it lines up with healthy tissue around my knee. As she moved the wand south, the area surrounding the tibia all turned black, because there was no signal response. The tissue had all seperated from the tibia. She said she had never seen periostits this bad. She went and summoned the Dr. who gave me the number for a surgeon.

I have been off my activities for a year and a half. I used to play indoor baseketball 2-3x/week. Now, I do no impact exercises of any kind. I am in the middle of my 5th course of therapy. I have had two pairs of orthotics. I am not overweight (6'2"/185#) and I use heat, ice and HEP with no relief. What can I do? I had ASTYM which seemed to work in the short term for the fibrosis (or whatever was going on) but did not help with the inflammation or the attachment of the muscle sheath to the tibia. What modalities are there that can help this? Is there anything else short of surgery? Do you have experience with post surgical patients and, if so, what is the course of recovery.

I appreciate your help.

[ginger]

"shin splints " hey, yeah sure. referred pain from L3/4 more likely. What is it that keeps you allowing repeats of methods that don't work , five series of treatments to your legs with no results, you must get very frustrated. I can't give you the name of the physio who will fix your referred pain problem . I would feel like I had ignored your pleas for help however if I allowed you to continue to get inappropriate treatments for a simple low back nerve irritation and went on to have , god forbid , surgery. That would merely add further insullt to your compounded woes.
Find a physio who is willing and able to mobilise L3 and L4 in your low back . The best method is known as Continuous Mobilisation. Applied with skill and persistance , passive movements to these facet joints will release protective responses there that have lead to an inflammatory event (s) of nerve roots . It is the effects then of altered nerve physiology that has created an altered sensation picture which is interpreted as pain . It is common in these cases to also have local redness and perhaps swelling to the painfull region . This presents a quandary for the young players or inexperienced therapist . Untill or unless your lower lumbar spine has been returned to an unprotected mobile state , your medial leg referred pain will persist.
Either find a more experienced physio who will treat your back or convince your current therapist not to follow the course that has been thoroughly and convincingly demonstrated to be ineffective and incorrect.
Cheers

[alophysio]

Hi Ginger and GAR42,

I agree with you Ginger that a lot of pain is referred from the lumbar spine.

However,
1. Continuous mobilisation is not the only way to treat this. That is a very one-dimensional approach from what i can gather from your posts about CM.
2. I don't think referred pain from the lumbar spine results in physical separation of the periosteum from the bone.
3. GAR42's problem sounds like a serious problem.
4. Why won't you answer any questions about continuous mobilisations?? Should i PM you?

GAR 42,

I understand this is a problem. From what you say, you have had your feet looked at, which is a logical starting point. However have your biomechanics been looked at from the back/pelvis/hip region?

Netty, whatever happened to your patient? The lumps and bumps occur from small sections of the periosteum pulling off the bone. The resultant inflammation and sweliing eventually scar up. Yes lumps and bumps are common but they don't have to be normal - there is a big difference!

In my experience, shin splints are a symptom of poor biomechanics somewhere along the kinetic chain - i have even treated people's thoracic spine which helped their shin splints (by changing the way the thoracolumbar muscles affected the lumbo-pelvic hip position).

Thanks!

P.S. Ginger, the treatment that you describe as "thoroughly and convincingly demonstrated to be ineffective and incorrect." - is this GAR42's previous treatment or the treatment of shin splints in general?? If it is the latter (in general), then can you please provide references to how this has been proven so?

[rockin ronnie]

ginger, can u explain correction of excessive pronation and calf/soleus stretching improving "shin splints"? Surely that would be the first line of treatment, then consider lumbar spine if there is failure to improve. That's how i would manage it. Would you go straight for the lumbar spine?

RR

ps love your work

[GAR42]

Alophysio has it right. It would not be accurate to say I am only experiencing referred lumbar pain. My shin symptoms are bilateral, whereas my LS MRI was only positive with impingement to the left. I do have referred lumbar pain and my PT has focused on my low back, pretty much exclusively since the ASTYM reached its maximum benefit. I have had a variety of strengthening, stretching and ROM for my LS. I can tell the difference between my referred LBP, which manifests as glute, hamstring and calf tightness, and my periostitis, which is a medial tib burning sensation. I am under the care of an ortho, a physical med specialist and a podiatrist, and they all think that these are two separate conditions. The overriding question is what to do when every conservative method to address the MTSS has been tried.

Alophysio, I really like your suggestion to have a look at my overall biomechanics. I am also going to look at different orthotics. I have been referred for a surgical consult, too.

Thank you

GAR42

[GAR42]

That is exactly the course I have followed for the last year and a half. Shins were acute and calves in spasm when I first started PT. That resolves, but the residual soreness has never gone away. LBP also resolved, but glute, ham, calf tightness remains.

I have had excellent Drs. and PT's. I wouldn't be posting if we all weren't scratching our heads.

GAR42

[ginger]

Gar42,
When neural irritating events take place , leading to altered sensations, it is your brain that feels the pain and other sensations, exactly the same as when a local event takes place, where it is nerves that produce information interpreted by your brain. It will not be possible to interpret the difference between these on the basis of subjective analysis of the sensations alone.
You sound so wonderfully confident about your current treatment regime even though the balance of your likely referred events are still present ( hams , gluts, calves ). while your therapist deals with the lumbar spine with exercise stretch and , as you say ROM . It may take you a long time to realise the kind of effect that ten minutes of Continuous Mobilisation will produce. These kinds of referred events are routinely turned off in my own practice , by either myself or any of my experienced students , in ten to fifteen minutes.
It is not unusual to have L3 and L4 referred events to include burning sensations , along with twitching, itching, cold , heavy, tight etc etc etc , that is why they are called altered sensations. Pain not responding to local treatments are the most obvious among other signals of the common thread of somatic referred events of which I speak. No rocket science or further investigations required , just a shift of emphasis and a willingness to see your issue as a temporary nerve irritation , rather than a mysterious local ailment . Unfortunately it does appear that your therapist is not skilled in local passsive facet joint movement therapies. Find one ,they are out there .

[alophysio]

Ginger,

GAR42's periosteum is coming off the bone. I don't think there is any referred pain. There is an anatomical deficiency. I can appreciate your position but trashing his physios (whom you probably don't know) isn't exactly professional behaviour.

I appreciate you have a certain opinion about matters and more than happy to hear them - i would much rather someone tried your CMs than just stick someone on electrotherapy (but that is only MY opinion).

I do feel however that you are avoiding my questions about CM...

[ginger]

ronnie,
Some 'shin splints' are found to be hyper activity of Tib post , at the effect of over pronated feet giving stretch relflexive impetus to recruitment of this anti pronation muscle. In these cases orthotics work a treat.
The above mentioned galaxy of pain however , clearly indicates referred pain and patterns of recruitment happening , with some of it L5 ( calves hams gluts ) and some of it L3/4 ( medial shin burning ). Unfortunately , the closer one looks at a referred pain event, the more likely it will be that , with the advantage of science and a host of instuments keenly dedicated to the proposal that pain and pathology go together, the more interesting features will come into view. It is also likely that in the absence of someone to turn off these referred events , that these "pathologies " will take centre stage , in the minds of both doctor and patient . It is regrettable , but doctors of medicine miss the boat a lot of the time when it comes to interpreting MSK problems. In most cases , certainly in my own long experience , it will be dysfunction and referred events driving pain etc , rather than things like this that or the other "itis ".
Takes a solid leap sometimes to leap out of that paradigm . I encourage you to consider it however as the way forward with seemingly perplexing problems that do not respond to treatment. Over time I have become more and more alert to neuralgic cause and find my treatment success very much better , than in the bad old days when I , like many on these pages , were convinced that local 'disease' was the common thread to be analysed .
I wish you well.

[ginger]

Alophysio, hey there mister, I'm trying to work my way through as many direct questions as I have time and the inclination for . Having read my pieces in RE on CM, you will now be somewhat aquainted with this as a means to restore normal facet/nerve behaviour. It was formulated over time out of the basis provided by the venerable Geoffrey Maitland. I found his approach somewhat mechanistic and not sensitive enough and went on to discover that facet behaviour changed ( for the better ) the more passive movements were given. I won't reiterate any of the material available to go over in my early posts on RE. Most of your questions have already been addressed at infinitum within the body of RE. Forgive me , I do get a bit fed up sometimes , no disrespect to you intended , repeating the same story in different threads. Still, that is my wish , to allow the therapeutic community to realise the benefits of my clinical studies and conclusions. I am not a researcher, don't have the time or the resources. I am a working physio who has a usefull method and explanations to offer. I would rather address your queries on the forum , it achieves much more than private messages.

[alophysio]

Thank you Ginger,

I look forward to reading your responses.

Have you submitted case studies to journals?

[GAR42]

Remember that I am patient, not a trained PT. My knowledge is based on my experiences, questions and independent research, so I may come across as a layman, which I am. That said, I reject the notion that I don't know my own history, body or symptoms well enough to discern the difference between my aching back on the left, and my swollen, burning shin on the right. Ginger, you sound incredibly knowledgeable and experienced. I hope you have not gotten to the stage, like so many in the medical field, that you have developed your own opinions and methods to the point that the patient's views are unimportant. The critical tone of your posts would make me think so.

My 1st PT was the head athletic trainer at our local university, which is one of the top 5 in the country. My Dr. is the former team Dr. for a MLB team, and is currently a Doc for the US Olympic team. My current PT was recommended to me by my former PT, as well as many others, because he is certified in ASTYM and because of his other credentials. My podiatrist was just voted best in the City by a survey of patients and peers. I cannot imagine that, with all of these qualified people involved in my care, that we are all just blindly following a pointless "paradigm."

In my current regimen my therapist does what he has been calling manual traction. He wraps a large belt around my waist and the other around his and then he leans back. 10 minute sessions (I think). Is that "CM?" If not, then by all means I am willing to try it. I will do some more research and discuss it with my PT.

[ginger]

GAR42
I am not able to generate the warmth of the interest I would take in your problem when only the written word is provided. I have a no nonsense approach that seems to serve me and my patient well. Added to my incredible physical beauty and fabulous charm I am able to , by and large , put my own patients at ease within the exclusive confines of my office. Here however, you just get the staright talking guy. No need to sugar coat the truth my son , it serves well enough on its own.
I won't repeat my assertions , you will either accept them and move on , or you won't.
I wish you well.

[Yarok]

hi

from my point of view tibialis anterior works excesively to balance hyperactivity of gastrocnemius which are tight/hyperactive cos L/C dysfunction.

thanks

[alophysio]

Hi Yaro,

i agree that Tib Ant does do that as well. I just reread the thread - there does seem to be 2 separate issues here but i think the L/S was the main problem...but the MTSS is the worst pain.

How are you GAR42?

Your current PT is indeed using manual traction. With respect to your PT's and their qualifications, i am sure they are very experienced at what they do. However (and please remember that i don't know them!) are any of them back specialists? From my limited experience, i have found sports physios good at sports injuries but fairly average when it comes to spinal problems whereas us spinal physios just get excited when an ankle sprain comes in the door because it is something different to treat! I guess what i am saying is that spinal physios should have a lot more "tricks in the bag" than just traction. e.g.
1. Mobilisations and Manipulations - I know in the US you can't do manipulations in certain states but ok in others i think - chiros holding on tight there! These mobes and manips can be...
a. Maitland
b. Mulligan
c. Paris (St Augustine Uni in Florida - pretty good i hear)
d. Nordic
e. Muscle Energy
f. CMs ala Ginger
g. any other name you want to give rhythmic attempts at moving a joint
BTW traction comes under this point at well. There are also compressive, opening, transverse, rotations, accessory, physiological etc etc directions to take with these.

2. Soft tissue techniques - obviously trigger points, massage and any thing to try manipulate the soft tissues

3. Electrotherapy - good for breaking pain cycles if they can't tolerate meds. I am cynical about these but a lot of people will swear they get better with them. I would mainly use U/S if i had to.

4. Motor Control - this is my speciality. Very few people know how to do this properly in my experience. Needs a good eye and a good understanding of what is "normal" and what is aberent motion.

5. Exercises and Stretches - standard physio/exercise physiology stuff.

I would say most PTs are trained in the first 3 but not so good at point 5 and probably suck at point 4. Maybe i am cynical...

However, Shirley Sahrmann from the US is damned good at motor control / movement patterns - maybe get a hold of her book or find someone that SHE recommends you see in your city.

I know you probably know the above because you are a PT student. I also know the list above is limited and i have probably missed things i do so...i'm sorry!

Let us know what is going on!

[GAR42]

Hi Alo,

Thank you for continuing to follow up. You mentioned that I am a "PT Student." Actually, I am just a patient, but I have a good sense of what you were describing. It sounds like my PT's have been fairly well versed in spine issues, because I have pretty much had all the things you listed. I have not had much in the way of manipulations, but lo and behold, I started seeing a chiro today. I will give it a few visits and see. I am a little sceptical of chiros that try to sell their service as a life style, but he did not do that at all. I am definitely willing to try a limited course. To your point, he used a table that articulated in the middle, and moved me up and down at the waste ("rhytmic attempts at moving a joint?”) I actually went to him because he is certified in both cold laser and graston techniques. The latest theory according to my podiatrist and my orhtho is that even after deep tissue massage and ASTYM I still have scar tissues affecting the tibial tendon. I did some research and the cold laser may have some benefit for the periostitis, and the graston technique can help break up any residual scar tissue. My podiatrist and first PT both recommended cold laser, so I felt that it's worth a shot. I can definitely feel the benefit of the graston after just one treatement. I hope it sustains (the ASTYM helped for about 2 weeks, but then it got worse). These are covered by my insurance and my next option is surgery, so I have nothing to lose except a copay.

Thank you.

GAR

[Nick Martin]

Hi, I am a newly qualified physio but have just been trained up by, who I believe, is the best outpatients physio in the country. (This is based on the fact that after 2 surgeries and seeing 23 medical people he is the only person that could fix my shoulder). Obviously without seeing you it is difficult to say, but it doesn't sound as though you have had a lot of the treatment route I would go down. Firstly, do your feet overpronate? If they do this is often tibialis posterior insufficiency. There are many exercise you can do trying to build up this muscle to hold up your medial arch. It is also likely that your flexor hallucis longus has got tight in an attempt to hold up the arch and this will need to be stretched out. More proximally it is often the case that posterior glut med/anterior glut max are weak and tensor fascia lata/glut min overactive causing the knee to internally rotate. This imbalance would need to be sorted out with strenghtening post glut med and deep manual work on ITB/TFL. And also exceptionally deep tissue work would need to be done on the inflamed area next to the tibia. Obviously all of this is conjecture without seeing you, and to be honest if it has completely disattached from the tibia you will prob need surgery and then address all these biomechanical issues afterwards, as this is probably the reason the problem occurred in the first place. Hope this helps, Nick

[alophysio]

GAR42, sorry about calling you a student - don't know how i got that mixed up with 'patient'!

Good luck with the chiro...and laser.

Are your PTs well trained in Motor Control?? Even PTs here is Australia aren't that flash when it comes to the practical application of motor control...

Nick, you make good points - which country did you study in??

[GAR42]

Nick,

Your points are very helpful. I would love to get to feeling better and get back to my lifestyle. I am very concerned that the acute injury may get better but that I may not know the biomechanics of what caused this. It's not enough to say it was a result of my weekly basketball league. I've done that my whole life with no problems. I think your theories are pretty viable and I will pursue them with my ortho.

Thanks

GAR

[GAR42]

That's O.K. I take "student" as a compliment. After all this time, I feel like a student. Thanks for your ongoing interest. The chiro actually has a sports/PT approach and I am impressed. Graston technique really helps the MTSS. If I can get the LBP under control, then I'll be on to something.

GAR

[Nick Martin]

Alophysio.
I trained in birmingham, england which was a completely useless degree, but as I say I am currently being trained by an awesome Olympic physio. Regards, Nick

[denver07]

Hi all. I've become desperate here! I have had the same symptoms described by GAR42 for over 2 years. Pain after I run, large palpable bumps along the medial tibia, have flat feet. I stretch and strengthen gastroc and soleus the best I can, use ice massage, and wrap the area with bandage when at the gym. Need help. Thanks.