This was article published for the AAMT Australian Association of Massage Therapists March 2006 Journal.
One of the more perplexing areas of the body for a manual therapist to address is the lower leg, ankle and foot. With enormous potential for stress and dysfunction through the body’s handling of weight bearing and exertional activities, the lower leg compartment is often difficult to treat.
Shin pain is an extremely common complaint among any individuals who are active and athletic. Overuse injuries that cause shin pain such as tibial stress fracture, inflammatory shin splints, or compartment syndromes create clinical situations where you have to determine an accurate differential diagnosis, so that your assessment and the treatment choices are critical to your success. Often these overuse conditions co-exist, making diagnosis difficult.
Shin pain can present itself several ways in your practice. Three common varieties we may encounter for treatment are shin splints or medial tibial stress syndrome, tibial stress fracture and compartment syndrome.
“The pathophysiology of overuse injuries is local inflammatory response to stress. The cause are intrinsic (malalignment syndromes-muscle imbalance) or extrinsic (training error)”1 Management of Common Musculoskeletal Disorders 3rd Ed Hertling & Kessler p 419
From a clinical perspective, shin pain involves one or more of three pathological processes; bone stress, inflammation and raised intracompartmental pressure. 2 Clinical Sports Medicine, Bruker & Khan 2nd ed 2001 Chp 26 Shin Pain p508
1. Bone stress is a continuum of increased bone damage due to strain, stress reaction or fracture.
2. Inflammation develops at insertions of muscles, particularly tibialis posterior and soleus and the fascia to the medial border of the tibia.
3. The lower leg has a number of muscle compartments, each enveloped by a thick inelastic fascia. As a result of overuse and/or inflammation, these compartments may become swollen and painful..
Shin splints are a vague term widely used with a variety of definitions. Tibial Stress Syndrome (Shin Splints) is a common lower leg injury that affects many people involved in running sports. It is synonymous with anterior or medial tibial stress syndromes, tendoperiostitis, tibial periostitis, and tibialis tendinitis, all which denote varying degrees of soft tissue and osseous changes1.
It is an over-use injury and inflammatory condition of the tibia or fibula in which micro tears develop in the muscle’s myotendinous origin located along the bone shaft. The repetitive action of dorsiflexion/plantar flexion pulls the muscle away from its attachment on the bone causing periostitis2.
Shin splints are the name given to pain at the front of the lower leg. The most common cause is inflammation of the periostium of the tibia (sheath surrounding the bone). The injury is an overuse injury and can be caused by running on hard surfaces, running on tiptoes and sports where a lot of jumping is involved. If you over pronate then you are also more susceptible to this injury.
Signs and Symptoms for Shin Splint Pain include:
- Tenderness over the inside of the shin
- Lower leg pain
- Occasional edema or swelling.
- Lumps and bumps over the bone.
- Pain when the toes or foot are bent downwards in plantarflexion, and redness over the inside of the shin
- A gradual onset of pain on the inner lower third of the leg, with increased pain with weight bearing activities (running, jumping, etc.).
- Pain with activity that is usually alleviated with rest
- A “dull ache” that may disappear after a warm-up.
Anterolateral shin pain may occur secondary to heel contact on hard surfaces, or to wearing a shoe with a hard heel, or biomechanical abnormalities such as forefoot varus.
Posteromedial shin splints cause symptoms along the posteromedial border of the middle and lower tibia over the posterior compartment, which is appreciated during toe-off. Research has shown a strong positive correlation between excessive pronation and posterolateral shin splints.
Types of tibial stress syndrome
Medial Tibial Stress Syndrome involves the tibialis posterior muscle and often occurs in individuals who are moderately to severely pronated (collapsed medial arch or flat feet), thus placing tension on this posterior muscle and tendon.
Anterior Tibial Stress Syndrome involves the tibialis anterior muscle. This muscle is responsible for 80% of foot dorsi-flexion and acts as a strong decelerator for plantar flexion. Frequently, anterior shin splints arise in runners over-training on hills since both uphill and downhill running requires repetitive firing of the tibialis anterior muscle.
Symptoms are usually worse while running downhill as the tibialis anterior is responsible for slowing down the forefoot after heel strike (eccentric contraction)5. Consequently, a tight Achilles tendon may be found in this syndrome, resisting proper range for the tibialis anterior to function and leading to friction and inflammation.
It is synonymous with anterior or medial tibial stress syndromes, tendoperiostitis, tibial periostitis, and tibialis tendinitis, all of which denote varying degrees of soft tissue and osseous changes1. It is an over-use injury and inflammatory condition of the tibia or fibula in which micro tears develop in the muscle’s myotendinous origin located along the bone shaft. The repetitive action of dorsiflexion/plantar flexion pulls the muscle away from its attachment on the bone causing periostitis.
MTSS or tibial periositis (shin bone) presents exercise-induced pain localized to the distal posteromedial border of the tibia. Clinical distinction with shin splints is hazy, but MTSS is focal and painful. Pathophysiology is controversial, but is most likely periosteal inflammation at the origin of tibialis posterior or soleus
Medial Tibial Stress Syndrome MTSS is an irritation of the tibia (shin bone) at points where the Soleus and Tibialis Posterior muscles attach to it. It is caused by over-use in runners, with those who run on hard surfaces being particularly affected. However, there are a number of factors, such as altered foot, knee and hip posture, which can predispose a person to the syndrome.
Compartment syndrome is a serious, possible life threatening condition whereby trauma or hemorrhage causes swelling within a muscle compartment. It is defined as ‘an elevation of the interstitial pressure in a closed osseofascial compartment that results in micro vascular compromise’ (Mubarak and Hargens 1983).
The most common site of compartment syndrome is the lower leg (Abramowitz and Schepsis 1994), with the anterior compartment being the most frequently affected, followed by the lateral compartment and the deep posterior compartment.
Compartment syndromes arise when a muscle becomes too big for the sheath that surrounds it causing pain. The large superficial muscle on the outside of the shin is called the tibialis anterior and is surrounded by a sheath. This is called the anterior compartment of the lower leg. Compartment syndromes can be acute or chronic.
Acute anterior compartment syndrome can occur as result of an impact which causes bleeding within the compartment and therefore swelling.
A muscle tear which also causes bleeding or an over use injury which also causes swelling.
• Sharp pain in the muscle on the outside of the lower leg, usually the result of a direct blow.
• Weakness when trying to pull the foot upwards against resistance (dorsiflexing).
• Swelling and tenderness over the tibialis anterior muscle and pain when the foot and toes are bent downwards
Tibial Stress Fractures
Stress fractures of the lower limbs account for more than 95% of all stress fractures in athletes. One half occurs in the tibia & fibula and is the result in fatigue failure within the bone, although surrounding muscle may fatigue first.
Increased or differing activity result in altered relationship of bone growth & repair. Wolff’s Law.
Factors that influence the development of stress fractures include:
• Repetitiveness of activities
• Muscle forces acting across the bone. Muscle force or torque may stress the bone if imbalances between antagonistic muscles exist.
• Gradual Onset 2-3 weeks
• Patient c/o Pain initially with activity
• Relieves with rest
• Next stage pain continues for hours, perhaps thru the night or worse at night suggests bone pain
Clinical exam reveals localized tenderness with or without swelling usually over the site of the fracture
Commonly known as ‘crescendo pain’
Stress fracture pain tends to build up gradually during the act of running, beginning as an annoying irritation and becoming a throbbing torment as an athlete continues to run(1).
There is usually little of the numbness, weakness, and swelling associated with compartment syndrome, and pain is usually not present to a significant degree when the athlete is at rest.
Sometimes, there is a specific point of tenderness in the lower leg, which is often felt on the inside of the calf when deep pressure is applied with the fingers.
Often, the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site.
Clinical Heath History and Presenting Symptoms.
It is important to differentiate between symptoms that are presented to make an accurate assessment.
• If the patient reports the pain improves after warming up and with continued exercise, then periosteal problems are most likely.
• If the pain worsens with exercise and is accompanied by a feeling of tightness, then compartment syndrome may be present. A pain that disappears relatively quickly with rest, and the presence of associated symptoms such as numbness, a ‘dead’ feeling in the leg or pins and needles in the foot indicates compartment syndrome
• If jumping activities increases the pain, or if there is pain at rest or night ache, a stress fracture must be considered.
Treatment and Techniques:
Traditional Treatment for Anterior Shin Splints
With space available for this article we will address treatment of anterior shin splints. The most common treatment for shin splints is at least one week of rest. Ice packs or a light elastic bandage may also help minimize the pain, along with over-the-counter anti-inflammatory pain pills or creams. Shin splints eventually heal, but returning to a stressful activity too soon can cause them to flare up again quickly. This is why many doctors and coaches suggest a two to four week restriction on running after recovering from shin splints. Low impact cross training on bicycles or treadmills may be allowed, however.
Pain from anterior or medial tibial stress syndrome usually comes about with a delayed onset, often 24 hours after the primary bout of physical activity that initiated the problem. If the offending activities can be avoid, this may often be enough to alleviate the problem. 3(Orthopedic Massage, Theory & Technique, Whitney Lowe, Mosby 2003 p82)
With muscular overuse of this nature, massage and direct myofascial release often are modalities of choice. Anterior compartment tightness, the focus is upon tibialis anterior, (TA) which is a long fusiform shaped muscle, covered by strong fascia. It gains it’s upper attachment from the deep surface of this strong fascia, and the upper two thirds of the lateral tibial surface and adjoining interosseous membrane and inserts through both the superior & inferior extensor retinacula to the medial side of the medial cuneiform bone and the base of the first metatarsal, the insertion reaching under both bones to blend with that of the peroneus longus. (Anatomy & Human Movement: Structure & Function, Palastanga, Field & Soames, Butterworth-Heinemann, 2000, p352)
Traditional massage approaches utilize longitudinal stripping with awareness of how attachment sites affect musculature tension. The amount of depth, force and pressure to be used is within patient tolerance levels. Often a deep tissue approach is ineffective, either due to pain, over or underpressure or myofascial resting tension that does not allow the tibialis anterior to relax. This is usually when the practitioner changes technique to use active engagement of the patient’s dorsiflexion/plantarflexion as the practitioner longitudinal strips the TA from insertion to origin. This tends to be more effective, but again often does not always lower the existing tension of the muscle.
This is when switching modalities using myofascial release is effective. Because the investment of fascia is three-dimensional running superficial to deep, treating the fascial anchoring sites are quite important. For the TA this includes all the superficial crural fascia and awareness of anterior crural intermuscular septum. The crural fascia anchors along the anteromedial tibia and the entire medial border of the fibula from fibular head to fibular malleolus.
Treatment for the superficial crural fascia can be quite straightforward. Many practitioners use direct myofascial release- MFR.
Michael Stansborough, Direct Release Myofascial Technique, p. 52 uses what he calls an Anterior Compartment Interosseous Membrame technique. 5
Patient: Sidelying with upper hip and knee flexed, support with pillow.
Therapist: Stands at foot of the table.
Contact: Use of an elbow with 90º flexion, begin at fibular malleolus. Glide proximally 2-3 inches at a time between tibia & fibula. Superficial fascia can be treated more quickly-the interosseous membrame will respond to slow steady contact. Encourage the client verbally to fully allow the weight of the leg into the table.
John Smith, Structural Bodywork, Elsevier Ltd., 2005, p.156 has a MFR Shin technique. 6
Patient: Supine, no bolster
Therapist: Use of a hand with fingers spread, octopus grip, for broad contact superiorly upper to mid anterior crural fascia. You can work on the flat of the tibia, with fingertips on the margins. Inferior hand anchors reticulum.
Contact & Action: Ask for slow flexion-extension of the ankle
Treatment and Techniques: An Alternative Approach
Steven Goldstein’s Technique. 16
Borrowing from excellent structural integration practitioners such as Peter Schwind, Thomas Myers, Michael Stansborough & John Smith for direct MFR, I attempt to integrate indirect osteopathic technique such as positional release techniques from Lawrence Jones’ strain-counterstrain, joint play techniques from Andrew Noble, indirect two pointing from Michael Mann.
The key is to engage fascial receptor tonus by first stimulating the sensory receptors in the fascia. You achieve this by superficial (very light contact, minimal pressure) contact of the targeted soft-tissue you wish to change.
Patient: Supine with or without bolster
Therapist: Two pointing (Mann 1989) consists of wrapping both hands in a form-oriented approach. (Schwind 2006). Encircle the joint to relax receptor tonus then proceed with more direct MFR. Photos courtesy of Steven Goldstein Integrative Fascial Release Manual 2006
Contact & Action: Usually encasing the joint with both hands for 1-2 minutes with emphasis on static pressure at the hamstring insertions and gastrocnemius origins will also facilitate a golgi tendon organ response.
Apply to ankle joint in the same manner. Relax indirectly the retinaculum with specific focus on the talus bone.
Contact & Action: As tissue soften, engage the superficial fascia around the ankle and employ a superior shear lightly. Sustain with slight crowding of the talus into the tibia.
Because of the strong investment of fascia at the anterior talocrural joint it is important to assess joint play of the talus bone.
Joint Play for the Mortise. 15
The mortise is made up of the lower tibial condyle, tibial and fibular malleolus, which constitutes the superior aspect of the talus.
The joint play movement we are going to assess and treat is anteroposterior glide
Patient lies with hip, knee and ankle at 90º
Therapist: grasps the patient’s lower leg around the ankle just above the malleoli with left hand, whilst with right hand grasp the dorsum of the foot, this being the stabilizing hand.
Contact & Action: The mobilizing left hand then pulls forward and pushes back alternatively
The Subtalar 15
The joint play movement for this is called the rock of the talus on the calcaneus
Patient: sitting on the table with legs hanging over the edge.
Therapist: lateral to foot in crouched position. When applying this kind of joint play the ankle must be in long axis extension.
Contact & Action: Left hand pulls and pushes upwards and downwards while the calcaneus is stabilized producing posterior rock of the talus on the calcaneus.
Joint play as Technique
If you can reproduce this assessment then you can crowd or compress the joints into a closed-pack position, sustain light to moderate compression for 30 to 60 seconds, and usually a softening or release of the fibrous capsular tissue will occur. Mobilize as you crowd the joint and usually you will feel as ‘give’ to the hold and a breaking of adhesion. Reassess proximally and usually there is a considerable softening of the crural fascial sleeve.
1. Hertling & Kessler , Management of Common Musculoskeletal Disorders 3rd Ed p 419
2. Bruker & Khan, Clinical Sports Medicine, 2nd ed 2001 Chap. 26 Shin Pain p508
3. Whitney Lowe, Orthopedic Massage, Theory & Technique, Mosby 2003 p82)
4. Palastanga, Field & Soames, Anatomy & Human Movement: Structure & Function, Butterworth-Heinemann, 2000, p352)
5. Michael Stansborough, Direct Release Myofascial Technique, p 52
6. John Smith Structural Bodywork, Elsevier Ltd., 2005, p156 has a MFR Shin technique.
7. Powerpoint: Foot & Ankle: Researched and Written by Elizabeth Windham and Chris Watts. 2001
8. Powerpoint: Greg Loomis ‘Compartment Syndrome’ 2003
9. Powerpoint : Robin Ploeger, Ankle & Lower Leg Anatomy & Injuries, 1998
10. PDF Download: Sharon Edwards Acute Compartment Syndrome, Emergency Nurse; 12:3, June 2004
11. PDF Download: Matt Callison , Abstract: Journal of Chinese Medicine #70 October 2002, Article: Acupuncture & Tibial Stress Syndrome, pp54-57
12. PDF Download: Richard Baxter, Medial Tibial Stress Syndrome: Shin Splints, 2006
13. Peter Schwind, Fascial & Membrane Technique, Churchill-Livingstone, English Translation 2006
14. Leon Chaitow & Judith Walker DeLany, Clinical Application of Neuromuscular Technique, Volume 2,The Lower Body, Chp 14, The Leg & Foot, pp501-507
15. Andrew Noble: Joint Play: A Course in Synovial Joint Mobilization, Version 2.1, 1991
16. Steven Goldstein: Integrative Fascial Release Course Manual, 2006