Helping Amy Find Amy Again

March 03, 2011 Posted by Dr.Chang

This week we had the pleasure of meeting with Amy (you may know her as Suzy from SuzySaid) about some problems she is having with shin splints as she adds running to her current exercise routine.

For the past 9 months or so Amy has been focusing on finding herself again through exercise and a healthy lifestyle.  To keep herself motivated, she is documenting her journey on her blog, Finding Amy Again.

The things that she is experiencing are very similar to the plight of many of our patients.  They are well intentioned thirty and forty something’s who have lost their youthful athletic prowess and are now returning to the sports arena only to get injured in the process.  We have partnered with her to keep her feet and ankles healthy and we will document her progress on our blog in hopes that it will inspire other people who are in the same ‘shoes’ as Amy.

Our meeting began with a conversation about her exercise routines.  Amy trains at Clay Fitness and has more recently started added running to her routine.  She shared with us that she really wants to train for a local race (she has already done a 4 miler!) but her shins are making it very difficult to complete more than 2-3 miles without a lot of pain. She exercises in shoes fitted to her by local running shoes experts at the Ragged Mountain Running Shop.  Her running shoes are neutral positioning shoes and are not worn.

The pain that she experiences is inside and outside on her anterior shin bone (tibia) and comes with high intensity activity.  It shows up when doing her Clay Fitness circuit training after about 20-30 minutes or when running at about 3 miles or so.  The condition resolves slowly after stopping activity.  The recovery day that follows bring about substantial soreness in the same areas.

We did a quick evaluation of Amy’s foot structure and stance.  She has an upright rectus Cavus foot structure.   We must emphatically note that the cavus foot is a poor shock absorber and rather unforgiving foot. It does not accommodate the ground or uneven surfaces very well.  We immediately suspected this may be a root of the cause of her problem. You can find more information on cavus foot here .

Our conclusion: Amy has classic signs of shin splints (listed below).  This is a fairly common condition for an individual who is beginning a new exercise regimen and has an existing foot structure prone to it’s development.

So what are shin splints exactly?
The term shin splints is a name use often to describe any pain in the front and lower leg.  However, the “true” shin splint is reserved for pain, arising from a number of causes, at the front inside edge of the shin bone (tibia).  The most common cause is inflammation of the periosteum (sheath of tissue surrounding all bones) of the tibia.  This inflammation is a result of repetitive traction forces of the muscles of the lower legs that arise at these locations on the bones.  The tern Medial Tibial Periostitis is often used for shin splints.

Amy has some of the classic signs for shin splints:
1.    Pain over the lower half of the shin bone
2.    Pain at the beginning of exercise which settles as the session continues, but returns when fatigue levels are reached.
3.    Pain returning after activity and may worsen next day
4.    Swelling
5.    Focal “lumpy/bumpy” tissue on inside of the shin bone
6.    Pain on range of motion toe and feet in downwards position.
7.    Redness on inside of shin bone, usually present with swelling if occurs.

Causes of shin splints are centered around abnormal biomechanics (patterns of movement) and errors in training.  Some common causes are:
1.    Over pronating (flattening)  feet
2.    Over supinating (arching) feet
3.    Inadequate and unsupportive shoes
4.    Increasing training too soon
5.    Running on uneven surfaces
6.    Inappropriate warm-up/cool-down and stretching

Treatment Strategies
The most important element in long term management of shin splints is to control the abnormal mechanical issue.  The most immediate problem to address is the acute inflammation at the muscle bone interface.

Acute inflammation is resolved with R.I.C.E. principles (Rest ice compression and elevation.  ) and anti-inflammatory medication.

Biomechanical problems are addressed with taping, appropriate shoes, and well designed  shoe orthotics.

When shin splints are active.  Cease the causative exercises and start cross training to rest the injured area.

For Runners, avoid hard pavements and uneven surfaces.  Tarmac, grass and trail runs can reduce shock to the legs and feet.

As a rule of thumb with running, distances should not increase by more than 10% per week.  This help to prevent over use injuries.

Shin splints can be caused by tight posterior lower leg calf muscles (gastroc, soleus, and posterior tibialis).  Regular regimented stretching daily and deep muscle massage can improve flexibility

So what did we do for Amy?
1)    Prescribed over the counter inflammatory medication e.g. ibruprofen
2)    Performed analysis of foot in stance.  We will evaluate her gait next visit.
3)    Applied a plantar rest strapping (tape) to her feet and instructed on how to accomplish this on her own at home.  She should wear while exercising and when in next day recovery when she is sore.
4)    Advised patient to do deep tissue massage on the the posterior leg muscles, avoid inflamed areas of pain.  Do calf muscle stretching daily and pre/post exercise.

We will see how our initial treatment plan for Amy helps to resolve her symptoms over the next two weeks.   We expect the results to be good.  If plantar rest strapping (tape) helps, this is an excellent signal to us that orthotic therapy will help.  We will then proceed with manufacturing some custom orthotics for her.  The goals of orthotics therapy will be cavus foot shock absorption and subtalar joint stabilization and control.  Keep checking back to see how it’s going! We hope we can help Amy find Amy again.

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