Shin Splint Pain:
The Runner's Nemesis
A myofascial treatment protocol is used to alleviate this common condition
By Dimitrios Kostopoulos, MA, PT, FAAPM, Konstantine Rizopoulos, PT, FABS, and Arnita Brown, MS, PT
Shin splint pain can affect not only runners, but also individuals who engage in any kind of activity involving the lower extremities. In addition, shin splints have been estimated to make up approximately 15 percent of all running injuries.1 The approach to treatment of shin splints due to tibialis posterior dysfunction has evolved through the years since the introduction of myofascial trigger point therapy. Research has improved understanding of the deep posterior compartment syndrome and the proper use of fasciotomy vs. conservative care. The current literature has begun to focus on alternative treatment approaches that may alleviate shin splint pain due to overexertion of the tibialis posterior muscle.
The term "shin splints" has been defined specifically in the literature as pain and tenderness along the inner distal two-thirds of the tibial shaft. The treatment differs depending on the cause of the shin splints. However, controversy in the literature continues to be related to the pathology of shin splints. One theory supports that shin splints refer to mechanical injury due to "overuse syndrome" that develops in poorly conditioned athletes or in novice runners running on hard surfaces.1, 2
A second theory supports that shin splint pain is the result of a chronic compartment syndrome characterized by vascular compromise leading to ischemia secondary to increased compartment pressure.3, 4-7 Travell's theory suggests that the tibialis posterior muscle, also referred to as the "runner's nemesis," is a major contributor to shin splint pain caused by myofascial trigger points.2
Myofascial Trigger Points
Travell has postulated that myofascial trigger points located in the tibialis posterior could cause shin splint pain on exertion without producing a true compartment syndrome.2 She suggests the use of myofascial treatment techniques to alleviate shin splint pain. The senior author of this article successfully uses myofascial trigger point therapy of the tibialis posterior muscle in runners as well as in individuals with excessive pronation of the foot with shin splint pain.
The tibialis posterior is the most deeply located muscle in the calf. Weakness of the muscle results in decreased ability to supinate the foot and plantar flex the ankle joint. This results in pronation of the foot and decreased support of the longitudinal arch. Weakness interferes with the ability to rise on the toes.2, 8 The function of the tibialis posterior muscle is to prevent hyperpronation of the foot during midstance of the walking cycle, to prevent excessive weight bearing on the medial side of the foot, and to distribute body weight among the heads of the metatarsals.2
Myofascial Trigger Point Examination
The myofascial trigger point examination includes palpation of the tibialis posterior muscle for trigger points (TrPs), establishing the referred pain pattern (RPP),2 range of motion (ROM), muscle strength (MS) and functional limitations.
Palpation. The trigger point is a hypersensitive, hyperirritable spot in the muscle that causes referred pain and discomfort and inhibits muscle flexibility.2, 9 On palpation of the tibialis posterior muscle, touch the area to feel for warmth, swelling or any other inflammatory sign. Activation of the trigger point with deep pressure may elicit a local twitch response or "jump sign."2, 10 The trigger points in the tibialis posterior can be palpated along the origin and insertion of the muscle.
The pain of shin splints due to mechanical injury of the tibialis posterior is generally palpable in the posteromedial aspect of the leg. The patient describes tenderness and soreness in the muscle reinforcing the diagnosis of shin splint due to trigger points.2
Referred Pain. The referred pain pattern of tibialis posterior trigger point concentrates in the postreromedial aspect of the leg extending to the achilles tendon. It spreads from the proximal aspect of the calf to the heel distally with spillover into the sole of the foot and toes.2 In other cases the referred pain pattern may extend to the shaft of the anterior tibia.9
Other Tests. Range of motion as well as manual muscle testing may reveal deficiencies of the tibialis posterior muscle.
Ischemic Compression. Ischemic compression applies sustained pressure to the trigger point with sufficient force (20 pounds to 30 pounds of pressure) for 30 to 45 seconds to inactivate it.9 Travell uses the term "ischemic compression" because on release of the pressure, the skin is at first blanched, and then shows reactive hyperemia.2 If a trigger point is moderately active, it may not be completely inactivated on the first attempt. For chronic, very hyperirritable trigger points, ischemic compression progressively eliminates the TrP in a succession of small steps that may take a few days. If TrP's persist, the physical therapist can repeat the procedure preferably after a hot pack and active ROM (AROM).6, 9
Ischemic compression must be followed by myofascial stretching exercises. The tibialis posterior is stretched to eversion, abduction and dorsiflexion. The toes are extended to eliminate the tension of the flexor hallucis longus and the flexor digitorum longus muscles. The patient is asked to exhale with each stretch for further relaxation. After each period of ischemic compression, myofascial stretch is performed and the patient is asked what he feels.
As a home stretch exercise, the therapist may assign a stretch from the standing position for the tibialis posterior. The patient will also be instructed on a passive self-stretch for home.9 Travell suggests the use of spray and stretch as an alternative myofascial technique.
As an alternative to the myofascial stretch that is a passive kind of stretch, we can use post-isometric relaxation techniques to increase ROM. This technique was proposed by Lewitt to increase ROM. He places the tibialis posterior muscle initially in its tolerated lengthened position. The patient is asked to perform an isometric contraction of the tibialis posterior at 10 percent to 25 percent maximum voluntary contraction holding for three to 10 seconds. The patient is instructed to relax while the therapist passively moves the foot into the increased ROM length.
This new length of the tibialis posterior is maintained and subsequent cycles of isometric contractions are performed until no further increase of ROM occurs. At this time the patient can actively evert and dorsiflex.6
1. Ultrasound does reach the muscle and can be used in conjunction with ischemic compression and myofascial stretch to inactivate the trigger point activity.
Moist heat is recommended to rewarm the skin and further release muscle tension as the patient relaxes.
3. AROM is emphasized concentrically and eccentrically performed slowly and smoothly to maintain ROM once trigger points are inactivated.
4. Contract/relax (Voss), which is the opposite of post-isometric relaxation, employs maximal isometric contraction of the antagonist (evertors) to permit shortening of the tibialis posterior.5
This article presents a very effective technique in the treatment of shin splint pain. We have been treating patients who experience posteromedial leg pain diagnosed as shin splints with myofascial trigger point therapy with success. We believe that eliminating the trigger points in the tibialis posterior is significant to alleviating the pain and full recovery of function. It is important to be aware of another strategy in the treatment of shin splints.
The reference list is available online after October 25 at www.physical-therapy.advanceweb.com, under "Resources," or by request via e-mail: email@example.com or fax (610) 278-1425 Attn: Mike Le Postollec.
* For more information, contact the authors at 888-842-6376; (718) 626-2699; e-mail: dimipt @aol.com; or Web site www.HANDS-ON-PT.com
* Dimitrios Kostopoulos and Konstantine Rizopoulos are the founders of Hands-on Physical Therapy, New York. They use research and teach a comprehensive therapeutic approach that integrates myofascial, neurofascial and proprioceptive therapy techniques. Arnita Brown is a physical therapist graduate from the physical therapy program at Mercy College, New York.