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Portland Chiropractor - Shin Splints

Brad Farra - Monday, June 07, 2010

What are shin splints and how did I get them?

As a sports chiropractor in Portland I see a lot of running injuries.  Shin splints is one of the most common running injuries.  Shin Splints is an entirely too vague of a term describing exercise induced lower leg pain.  The term shin splints is used by runners to describe their symptoms or by a doctor as a diagnosis.  Shin splints is essentially the strain of a muscle and its attachment to the tibia.  A more specific term would be tenoperiostitis or traction periostitis.  There are two types of shin splints, posterior and anterior.  Posterior shin splints are on the inside (medial) side of the shin and it's also called postero-medial shin splints or medial tibial stress syndrome.  Posterior shin splints involve the tibialis posterior, flexor digitorum longus, and the flexor hallicus longus muscles.  Anterior shin splints, also called antero-lateral shin splints, involves the tibialis anterior muscle. 

Shin splints is a repetitive/overuse type of injury.  The primary factor in both anterior and posterior shin splints are weak muscles/tendons.  This weakness leads to damage/degeneration of the soft (connective) tissues that connect the tendon to the periostium of the bone; hence the term tenoperiostitis.  When repetitive muscle contraction, of one or more of the above mentioned muscles, is too forceful this painful condition results. 

Repetitive impact is the most common cause of shin splints.  Shin splints is not limited to running, but you can bet there is probably running involved in the sport if shin splints is an issue.  Several factors play a role to increase the likely hood you will have problems with shin splints:  long distances, hills, hard/uneven surfaces, training errors (too far, too fast, too soon), changes in routine, new activity, inappropriate shoes, poor conditioning, inadequate warm-up, over pronation/under controlled pronation, and over training.


How can I prevent shin splints?

Prevention questions are among the most important questions I answer as a Portland Chiropractor.  I work with a lot of athletes in a preventative manner.  The most important thing you can do to prevent shin splints is to not make any training errors.  Don't run too much, too fast, too soon.  The most common training errors are when you increase your mileage or speed too quickly.  This also includes avoiding over training. 

There are specific exercises that can be done to help prevent shin splints.  It's simple:  Strengthen the muscles listed above as the culprits in shin splints.  Running on softer surfaces lessens the impact on the leg and in turn decreases your vulnerability to shin splints.  If you run on uneven surfaces, as in trail running, make sure you build mileage slowly so your body has time to adapt to this type of stress.  Always be sure you get an adequate warm-up before your running event, especially if your sport involves sprinting.  Have a coach look at your technique and consider using a technique that can help decrease the impact stresses on your leg/shin.

Treatment of shin splints:

The treatment of shin splints usually involves temporarily limiting or stopping the offensive activity.  The most effective therapy for shin splints involves the use of Graston Technique, ice, rehab exercises,stretching, and kinesio-taping.  Proper evaluation of the entire kinetic chain should be performed by a qualified practitioner.  Manipulation of the low back, SI, knee, ankle, and foot joints can also be helpful.  The athlete can also use a compression sock or have the shin taped for running.  A change in shoes may be helpful.

There are many other factors that should also be addressed with shin splints; these issues include foot positioning at foot strike (foot flair), hip position (externally rotated hip), stride length (too long of a stride), and leg length inequality.  Weak quads, hamstrings, hip abductors, or hip flexors can also be a factor with an athlete suffering from shin splints.

How long will my shin splints last?

When you start feeling the pain of shin splints the condition has more than likely been going on for a significant amount of time.  If you seek treatment immediately after you start feeling the pain the condition should significantly improve in 1-2 weeks.  If the condition is chronic it could take months to resolve.  Treatment should continue after the resolution of pain to reduce scar tissue/adhesions.  If you are being treated for shin splints and are not seeing improvement consider one of the other possible causes for shin pain listed below.  Be sure that all of the factors listed above have been addressed.

All shin pain is not shin splints!

Other shin pain that is NOT shin splints:

-Tibial Stress fracture

-Compartment syndrome

-Intermittent claudication

-deep vein thrombosis


If you have any questions about shin splints or other running/sports injuries feel free to comment on this blog.  If you live in the Portland area and need treatment for a sports injury or have any questions please visit my website:  www.drbradfarra.com

Winter Running

Brad Farra - Tuesday, January 05, 2010

Wintertime running can be safe and enjoyable provided you make a few adjustments.

You may wonder what a Southerner could possibly teach you about cold-weather running. Well, I may live in Atlanta, but I travel enough to have logged plenty of miles in the ice and snow. I admit that when I first began visiting places like Minneapolis, Winnipeg and Boston in the dead of winter, I was tempted to limit myself to indoor exercise. But after seeing a steady stream of runners head out to face the elements, I eventually followed them.

What a pleasant surprise to discover that, with a few adjustments, I could enjoy a run in 20-degree temperatures as much as a 70-degree run! Through trial and error I learned how to adapt traditional running advice to the vagaries of cold weather. Here's what I found.

Form and stride: A long stride is perilous on ice and snow, where footing can be dicey. A shorter stride is more stable because it keeps your feet more directly underneath your body. Another way to add stability is to decrease your "bounce." By keeping your feet close to the ground and taking some of the spring out of your step, you'll gain more control.

Warming up and cooling down: Because cold reduces the flexibility of muscles and tendons, a thorough warm-up is crucial. Here's one that works particularly well on cold days: Start by walking, then walk and jog for a few minutes, then jog slowly for a few more minutes before easing into your normal running pace.

If you'd rather hit the ground running, warm up indoors. Jog in place or spin easily on a stationary bike for a few minutes until you break a sweat. Then suit up and head out the door.

The very idea of "cooling down" may seem ridiculous when you're sprouting icicles, but a gradual transition from outdoors to indoors is smart. (Going straight from arctic temperatures into a hot shower can tax the heart.) Cool down by reversing the warm-up process: Ease your running pace into a slow jog, then walk and jog for a few minutes, and end with a few minutes of walking.

Hydration and nutrition: Believe it or not, winter running can dehydrate you. So don't neglect to drink. No matter what the weather, drink plenty of water throughout the day. If you're running long enough to require energy bars or gels, stash them close to your body to keep them from freezing.

Intensity: Even on a clear running surface, going all-out in very cold weather has some risks. I've seen many well-trained runners suffer pulled muscles when weather conditions changed during a workout. It's possible-after a good warm-up-to do some gradual accelerations during an outdoor run without much injury risk, but intense speed sessions are best done on a treadmill or indoor track during the winter.

Four Cold-Weather Myths

Don't know what to believe when it comes to winter running? Here are the cold facts:

Myth: You'll freeze your lungs.
Fact: There's no evidence that exercising in cold weather, even in extreme cold, will hurt your lungs. If the cold air hurts your throat, breathe through a bandanna or a polypropylene face mask.

Myth: You'll burn more calories when you run in the cold.
Fact: When you run continuously, you burn roughly 100 to 120 calories per mile. The air temperature doesn't significantly change this.

Myth: You don't have to drink as much when it's cold.
Fact: Most people sweat about as much during winter runs as they do during summer runs, but many runners don't recognize dehydration as easily during the winter. When in doubt, drink.

Myth: We're meant to hibernate during cold weather, not run.
Fact: Just take a trip to the Twin Cities in February and see how many people are running outside, enjoying the subzero temperatures. With the right clothing and a positive attitude, you can adapt to just about any type of weather.

Reprint: Runner's World, January 2000, p. 30

Running is NOT Bad for Your Knees!

Brad Farra - Tuesday, October 13, 2009

It's never my running patients that wonder if running is bad for their knees, it's the non-running folks that tell me running is bad for their knees. Running is not bad for your knees. It's been proven time and again with solid research that running can actually be good for your knees. This doesn't mean it's good for everyone or that there aren't reasons you shouldn't run. If you have specific questions about whether you should run or not, then speak with a Chiropractic sports physician or another physician that treats sports and extremity injuries. Below is a link to an article from the New York Times that references some current research highlighting the positive influence of running on your body. I think the most important thing for runners to keep in mind is that you must prepare your body for running and if you don't run regularly you must ease into the sport. Specific stretching and strengthening should be done before and after running to reduce the chance of injury.


Knee Injuries and Recovery

Brad Farra - Friday, October 09, 2009

This is a good follow up from my last blog. I read this from Wikipedia and I thought I might pass it along.

The knee is a core tool for an athlete; it allows football and basketball players to run, cut, and jump. Baseball players use their knees to push off when they throw. The flexibility and rotational ability of a knee is what helps make some tennis players superstars. It’s difficult to return to competitive athletics after any serious injury, but knee injuries takes a lot longer to get over and often end a career. While having a good physical rehab process is very important, the athlete’s ability to overcome the mental hurdles that are created with a knee injury will determine whether or not he will be the same player that he was before the injury.

The words “it’s an ACL” strike fear in the heart of an athlete. The immediate mental translation is will I ever play again and if I do play will I ever be as good? Why do knee injuries cause so much fear in competitive athletes? According to the Brown University Biology and Medicine Web site, athletes in contact sports are 10 times more likely to have a serious knee injury than in non-contact sports, with knee injuries accounting for approximately a quarter of the injuries and generally taking two to three times longer to recovery than injuries to other parts of the body[2][3]. Knee injuries are also increasing, “over the last 15 years, ankle sprains have decreased by 86% and tibia fractures by 88%, but knee ligament injuries have increased by 172%”

What cause knee injuries and what is the prognosis for total rehabilitation? Leg bones are connected to the kneecap by four strong ligaments: Anterior Cruciate Ligament (ACL), Lateral Collateral Ligament (LCL), Medial Collateral Ligament (MCL), and Posterior Cruciate Ligament (PCL). The ACL provides stability and controls stress across the kneecap and keeps the knee from rotating too much or moving too far forward. Around 60% of ligament tears are ACL, most occurring in basketball, skiing, football and soccer. When an ACL tears it unravels like a rope and will not heal on its own. For competitive athletes treatment is almost always surgery. It normally takes 6 to 9 months to recovery from an ACL reconstruction surgery, at which point most athletes had returned to between 80% and 100% of their full level of previous play with about 90% returning to competition [4]. After the first ACL injury, there is a 5 to 15% risk of repeated injury [5]. MCL and LCL ligament tears are less frequent then ACL injuries accounting for about 25% with LCL injury being much less frequent than MCL injuries [6]. MCL injuries are normally caused when a significant force is applied to the side of the knee while the lower leg is held in a fixed position. The MCL is the only ligament that has enough of a blood supply to heal partial tears without surgery [7] PCL injuries account for between 3% and 20% of all tears [8]. Most often the cause is a blow to a bent leg. Because of the type of blow, PCL tears are often accompanied by ACL tears. While conservative treatment is still controversial in some sports for both PCL and MCL tears, it has proven to be as effective in returning an athlete back to his playing condition as has surgery [9]

Why or why not surgery? If an athlete wants to play competitively ACL tears require reconstructive surgery. During surgery the old ACL is removed, a graft from the patellar tendon or the hamstring is prepared, holes are drilled in the tibia and femur and the graft is attached with screws to the bones. Now the tough part begins, surgery is followed by 6 to 9 months of rehabilitation. This rehabilitation is crucial to strengthen the areas surrounding the graft so that it does not fail. Athletes may accept that injuries are part of their lives and may know how to deal with physical rehabilitation, but few are prepared for the emotional pain, fear and anger that also result from injury. Athletes are used to being part of a team. When they are injured they are suddenly on their own. Their teammates will continue on but they now have a new job, physical and emotional rehabilitation of their bodies and much of the work will have to be accomplished on their own. In Sidelines, Psyched Up or Psyched Out? David Doermann describes a University of Utah pamphlet that is given to all student athletes to help them understand what to expect if they are injured. It describes the emotional process that happens when someone is injured as similar to the five stages of grief [10] The first stage is denial. Athletes by their very nature believe that they are superior physically and therefore do not accept the fact they can be injured. When an athlete realizes an injury is real his reaction may be to isolate and blame himself. Denial is followed by anger, particularly at himself for allowing the injury to occur. During the third stage the athlete tries to make bargains with coaches, trainers or God, such as if I spend 2 hours walking every day I can play again in 2 months.

Very often these bargains are unreasonable dreams. The competitive athlete will now move to a period of depression, feeling sorry for themselves, withdrawing or simply giving up. This stage particularly can put an athlete’s rehab off track. To be successful an athlete must finally get to the acceptance stage when he realizes that the only way to handle the injury is to focus on his physical rehab which could result in returning to competition. The factors that contribute the most to helping an athlete reach psychological acceptance and recovery are education, social support, psychological skill training and goal setting; traits that many athletes use in their pre-injury training [11]

Understanding an injury and their reaction to it helps athletes cope with the problems that naturally arrive along with the injury. Support and understanding of team mates, family and friends can also be a critical factor in recovery. Knowing and understanding how others have coped gives athletes mechanisms for starting to construct their own recoveries. While having social support that listens and appreciates the seriousness of an injury is necessary, too much sympathy from family or friends can impair the athlete’s acceptance level which can slow or derail the recovery process. A study done by the Aristotle University of Thessaloniki, Greece concludes that “psychological intervention techniques can aid significantly to the rehabilitation process. In particular, the goal setting process seems to have positive clout in the athletic injury recovery, in the attitude of the injured athlete, in the successful confrontation of the injury, in the recovery of confidence and in the adherence to the rehabilitation program” [12]

[edit] References

  1. ^ Soligard T, Myklebust G, Steffen K, et al. (2008). "Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial". BMJ 337: a2469. doi:10.1136/bmj.a2469. PMID 19066253.
  2. ^ (Lysaght)
  3. ^ (Lysaght)
  4. ^ (Lysaght)
  5. ^ (Lysaght)
  6. ^ (Lysaght)
  7. ^ (Selesnick)
  8. ^ (Lysaght)
  9. ^ (Cluett)
  10. ^ (Doermann)
  11. ^ (Armatas)
  12. ^ (Armatas)

Armatas, V.1, Chondrou, E., Yiannakos, A., Galazoulas, Ch., Velkopoulos, C. Physical Training 2007. January 2007. 21 March 2009 <http://ejmas.com/pt/2007pt/ptart_galazoulas_0707.html>. Cluett, Jonathan M.D. Medial Collateral Ligament Treatment. 29 May 2006. 16 April 2009 <http://orthopedics.about.com/cs/kneeinjuries/a/mclinjury_2.htm>. Doermann, David. Continuum, The Magazine of the University of Utah. Spring 1998. 19 March 2009 <http://www.alumni.utah.edu/continuum/spring98/ sidelines.html>. Lysaght, Michael J. Knee Injuries and Therapies in Competitive Athletes. 20 March 2009 <http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group06/Group6project/ Homepage.htm>. Selesnick, Dr. Harlan. Sports Injuries ESPN. 4 October 2007.

Iliotibial band (ITB) Syndrome

Brad Farra - Thursday, October 08, 2009

I had a patient tell me today that because of me he is back running again and is signed up for an Ironman triathlon next season. Before being treated by me he had other doctors tell him that there is nothing that can be done about his knee and that he should just not run. Iliotibial band (ITB) syndrome should be nothing that keeps you away from running. ITB syndrome can be treated quite successfully.

ITB syndrome is an irritation of a large band of connective tissue that runs from the hip and the tensor fascia lattae and gluteus maximus muscles across the lateral knee to attach below the lateral condyle of the tibia. The pain associated with this can be anywhere along the course of the ITB, but it's usually lateral knee pain. With flexion of the knee the ITB slides over the the lateral distal femur (lateral femoral condyle) and this can cause pain if the ITB is irritated or inflamed due to tension throughout the ITB.

ITB syndrome is very common in distance runners, but can also occur in cyclists. The causes can include but are not limited to: Over training, over pronation and even under pronation due to increased lateral stress on the knee, worn out shoes, hill training, hard surface running, uneven surface running, leg length asymmetry, anterior cruciate ligament laxity, improper use of orthotics, and even weak gluteal muscles.

If you have pain in your knee or hip it is important to have it looked at by a qualified sports physician. Due to the possible contributing factors it's important to consider the entire biomechanical chain when assessing any type of knee pain. This evaluation would include an exam of the low back, hips, knees, and ankles/feet.

Treatment usually includes some type of soft tissue manipulation to the ITB. I use Graston technique (www.grastontechnique.com), but other methods can also be effective. Other treatment would include correction of any biomechanical faults such as over pronation.

Don't let your pain stop you from doing what you want to do!!