Shin Splints 501
I just read a series of short articles on Active.com entitled Shin Splints 101 which contained some conventional thinking on this common running injury. I just wanted to contrast and compare ideas for evaluation, treatment and exercise based on our findings at the MIHP Think Tank. Are you ready for an advanced course on shin splints? Here we go:
Our work in muscle injury revolves around two basic physiologic principles:
1. Sherrington's concept of reciprocal innervation: If one muscle is short and tight (or over facilitated), then it's antagonist will neurologically become long/weak (inhibited)
2. Synergistic dominance: If one muscle become over facilitated, then it's synergist may become inhibited
Another premise uphold when looking at muscle injury is this: The muscles that come in crying out in pain are not usually the short/tight ones, but the ones that are long and weak. The underfacilitated. The overused.
What is a shin splint? It is an injury resulting from overload to the anterior compartment muscles of the lower leg (primarily tibialis anterior and tibialis posterior). These muscles are responsible for decelerating dorsiflexion (tibialis posterior), plantar flexion (tibialis anterior) and pronation (both of them).
Who are their antagonists? The gastrocnemius is the antagonist to tibialis anterior. That is, if the gastrocnemius (calf muscle) is short/tight, then the tibialis anterior becomes long and weak, and thereby prone to injury.
Who are their synergists? The gastrocnemius is the synergist to posterior tibialis (i.e. they both decelerate dorsiflexion). If the gastrocnemius become short and tight, then the posterior tibialis may become inhibited.
Pronation v. supination: Because both the TA and TP are located on the medial side of the ankle, they are prone to injury in someone who over pronates. Remember, pronation should only occur for 25% of the stance phase. Any more time spent pronating will result in overload to the tendons and ligament on the medial side of the ankle and lower leg.
The two most common causes of over pronation: Believe it or not, it isn't a lack of an orthotic in your shoe! Before you slip an orthotic in your shoe or invest in motion control running shoes, consider that the two most common causes of over pronation are a weak gluteus medius (hip abductor) and a lack of ankle dorsiflexion (tight calf muscles).
Conventional wisdom says: Strengthen the gastrocnemius (calf muscles) by doing heel raises and the tibialis anterior by doing toe raises. Stop over pronation by purchasing supportive shoes.
ReBUTTal on conventional wisdom: The tibialis anterior didn't get hurt because it was too weak. It got hurt because it was inhibited and/or overworked. Don't work an already overworked muscle. Instead stretch the gastrocnemius (calf muscles) with the toes pointed straight ahead AND strengthen your gluteus medius and maximus (your butt muscles).
For you clinicians out there:
1. Check pelvic alignment. An anteriorly rotated innominate or inflare can create a functionally longer leg, creating an over pronation scenario.
2. Check for trigger points in the iliopsoas and piriformis as these will externally rotate the leg (creating over pronation forces) and inhibit the gluteal muscles. Counterstrain them.
3. Check for trigger points in quadratus lumborum. The quadratus lumborum and gluteus medius are functionally antagonistic in the frontal plane. If QL is short/tight, then GM becomes long and weak. Counterstrain it and then teach QL to work long and GM to work short.
4. Normalize ankle dorsiflexion. If this is just due to tight gastrocnemius, the gravity drop or downward dog exercise are excellent. If the restriction is felt in the anterior ankle then a posterior talar glide will be necessary to normalize dorsiflexion.
Enough said. Now, go and chase those runners down and help get rid of their pain!
Until next time...
Iliotibial Band Friction Syndrome
Iliotibial band friction syndrome is often described as an overuse injury that produces pain on the lateral knee. In fact, it is listed among the Big Five of running injuries, along with Achilles tendonitis, chondromalacia, plantar fasciitis and shin splints.
Unfortunately, it is also often misunderstood.
For instance, the quick fix for this injury (and many of the others in the list) is simply to stop running for awhile. Just rest the area and let it recover. The premise is that running, in and of itself, created the problem.
But the question that really needs to be asked is, how come the other knee isn't hurting if both legs ran the same mileage? Is it simply a cause of overuse?
Yes and no. Running isn't bad for you. Bad running is bad for you.
The most common scenario that causes ITBFS is a limb that won't pronate. Under pronation. You won't see that too much in the literature.
The normal gait pattern is such that heel strike is designed to occur on the lateral (outside) of your heel with pronation occurring for 25% of the stance phase. This act of pronation not only acts as a shock absorbing mechanism, but also transfers the force to the thicker and larger structures of the medial knee.
Someone so spends more than 25% of stance phase in supination is going to make the ITB very angry. After all, it isn't designed to have to cushion the blow of force dissipation for such a long time.
Some common causes of a limb not pronating?
• Tight gluteus medius (lateral hip muscle) - See the photo? Can you do this move equally on both sides?
• A leg that feels too short (pelvic malalignment, quadratus lumborum or iliopsoas trigger points)
• A subtalar joint that won't evert (Is there a history of ankle sprains in the past?)
• A tight lateral hamstring (Does the revolving triangle in yoga class make you fall over?!?)
• And... a shoe that offers too much support (Check to see if there is a gray bar on the medial side of your shoe last!) We are fans of neutral shoes for these folks.
The good news is... it's fixable! And it doesn't require tons of time away from running.
Oh, and by the way... if you understood what I just said, then you will realize that the ITB is overworked and overstretched in this scenario. Why on earth would you want to stretch an already over stretched muscle?
If you have this problem, or know of someone who does... do them a favor and look up at the hip and down at the subtalar joint. Fix that stuff and then send them back out on the road.
Until next time...
The origins of anterior/lateral meniscal pain
I've seen this three times in the last week, so I'm taking that as a sign that I am supposed to write about it.
Have you ever had a knee patient who complains of anterior knee pain with end range knee extension? They will either describe a pain at the anterior knee joint line or deep inside the knee. This is common, especially in post-surgical knee patients, and will delay healing time or possibly be the reason for a lack of terminal knee extension.
There are two primary scenarios that will create a pinch in the anterior/lateral knee with end range extension:
1. A femur that is internally rotated (check for t.p. in the anterior fibers of gluteus medius and TFL and/or in the medial gastrocnemius)
2. A tibia that is externally rotated (check for t.p. in the bicep femoris tendon and check for a posteriorly displaced fibular head)
The trigger points may be treated with counterstrain and/or deep trigger point massage. The posteriorly displaced fibular head may be treated with MET. All of these aforementioned techniques take less than two minutes!
Make sure you re-check end range extension after you treat the trigger points you find. Normal extension end-feel should yield a stretching sensation in the BACK of the knee.
Then make sure you address the offending tender point with exercises in the gym:
1. Gluteus medius - try medial reach with contralateral arm at waist level, heel-toe walking or carioca walking
2. Medial gastrocnemius - try gravity drop, downward dog, long strides in the ladder (make sure the toes stay pointed straight ahead) and balance board or foam roll rockers.
3. Bicep femoris - try the revolving triangle, anterior cone touch with the opposite hand or an anterior pulley low row with the opposite hand as the stance leg.
It sounds like a lot to get knee extension, but I assure you, it is the fast track to achieving a normal gait pattern and normal functioning of the lower extremity.
Until next time...
Adhesive Capsulitis (and a weak shoulder)
For anyone that has ever had a "weak" shoulder, this case might really help you out.
For the lay person, here is the major point: Weakness with lifting your arm up may be due to your shoulders not being the same level (check this in the mirror!) and a trigger point on your infraspinatus muscle (lower angle of your shoulder blade), which you would only notice if someone poked it. The good news is, it's fixable! But it takes some corrections in places nowhere near your shoulder... like your hips and your thoracic spine and maybe even your ankles.
For the clinician: I had the opportunity to evaluate a Marine who had sustained a gunshot wound that pierced his left 6th intercostal space and exited through his right external oblique. After 15 months of multiple surgeries and rehab, he is now complaining of left shoulder weakness and limited range of motion. He had a soft tissue endfeel at approximately 140 degrees of elevation.
Visual observation reveals his R shoulder significantly higher than his L. He stands with his L foot slightly externally rotated. (This is a classic Leaning Tower R scenario, for all of you Missing Link alumni) - R leg more supinated, L leg more pronated.
His range of motion is limited to about 140 degrees of elevation by a soft tissue restriction. Isometric MMT revealed 4 flexion and 4 abduction strength with mild pain noted in the posterior shoulder region with resistance.
Trigger points were palpated in the R upper trapezius, L iliopsoas, L piriformis and L quadratus lumborum.
Here is the assessment of his three key rotational spots:
Hips: Tight hamstrings bilaterally (90/90 test approx. -40 degrees); (+) R FABERs test (hip won't externally rotate); Normal piriformis test bilaterally.
Thoracic spine: 50% rotation bilaterally. R limited primarily due to hip and thoracic spine limitations (restored with piriformis inhibition, ITB release, thoracic NAGs and posterior rib mobilization). L limited primarily due to hip restrictions (restored with piriformis inhibition, ITB release and lateral hip mobilization).
Ankles: L>R tightness on the gravity drop; Severe hypomobility of the L>R subtalar joints into eversion. Incidentally, prior to his injury he had a history of L ITB friction syndrome and has used Brooks Beast shoes (their most stable motion control shoe) for years.
He presented with R SI joint dysfunction. I corrected an inflare and a posterior rotation, L on R sacral torsion.
Following correction of all of the above, his shoulder height was symmetrical. He still had mild pain/weakness with resisted shoulder abduction (4 MMT).
I palpated a significant trigger point on the L infraspinatus (inferior angle of the scapula). After counterstraining that tender point, his MMT was 5/5 and pain-free.
How did that happen?
Well, if you look at a picture of the infraspinatus, you will find that a trigger point in the inferior angle would have to be caused by one or m0re of the following:
1. An upwardly rotated scapula which would put the supraspinatus and deltoid in a long/weak position
2. An abducted scapula (which would put the rhomboid in a weak position
3. Or an elevated scapula (which was not the case here).
Normalization of shoulder strength after counterstrain to the infraspinatus would lead us to believe that the first scenario was the case. The deltoid/supraspinatus were weak because the infraspinatus trigger point was creating upward rotation of the scapula, placing them in a long/weak position.
The manual therapy fixes were mentioned above, primarily to normalize his posture and rotational movement patterns and inhibit the infraspinatus.
The exercise fix:
1. Strengthen the rhomboid in the short position. By they way, this gets compromised with abnormal rotation of the opposite hip.
2. Lower the opposite shoulder by encouraging thoracic rotation: backstroke, prone alternating arm lifts, plyoball throws, prone sky reaches, STEMs, etc.
3. Get that L hip to work! Shoulder flexion drives off of the L hip, which in this case was shown to be a major cause of his postural asymmetry (remember the trigger points in the iliopsoas, quadratus lumborum and piriformis?). Those trigger points will all inhibit the gluteus maximus.
Try some anterior cone reaches, pulley low rows (hip dominant), wall airplanes, the yoga warrior series to wake up that L hip.
4. Normalize ankle dorsiflexion with the gravity drop, downward dog, BOSU or foam roll rockers, Warrior I.
5. THEN put the shoulder to work with all the ways you normally do that.
Well, that's a lot of stuff to work on, so I'll let you get to it.
Have a great day.
FAI and Hip Labral Tears
I frequent a running site where I get to hear about injuries that plague this group of athletes. There has been a recent increase in people complaining of hip pain, femoroacetabular impingement and labral tears. Some have had success with surgery, while many remain frustrated and have not been able to return to running.
The question that has to be asked is how did this happen to begin with? If the hip is sitting funny in the socket, then that is what ultimately causes a labral tear or wearing away of the femoral head.
For you people suffering with hip pain, know that there is a fix and it doesn't necessarily include a knife. We have had people contact us via email, receive a few exercises based on their answers to a few questions and they have become significantly pain-free in 1-2 weeks. It started out as my little pilot study and has yielded some really great results.
For you clinicians out there, there is a biomechanical fix.
Here are the things you want to check first:
1. Pelvic alignment - innominate inflares/outflares or anterior/posterior rotations will cause the hip to bind or pinch with IR/ER.
2. 90/90 hamstring test - if this is tight, check to see if they have a posteriorly displaced fibular head. You can fix that with a muscle energy technique or mobilization and it should improve hamstring length.
3. FABER's test - if this is (+) or limited on one side, the things to check are - latissimus dorsi flexibility (do the lat squeeze for those of you familiar with our techniques), correct inflare/outflares and mobilize the hip (this should be done last). If that doesn't work, check the opposite iliopsoas for a trigger point and if you find one, counterstrain it. Your goal is to normalize this motion as activating the glute is more difficult if this is restricted.
4. Piriformis test- If the patient gets a pinch in the groin with passive internal rotation, this also will impair the ability of the gluteal muscles to be activated during weight bearing activities. Common causes for this are inflares/outflares, a sacral torsion, trigger points in the iliopsoas or piriformis. Check these out on these patients and "fix what you find".
Remember, it's almost always about the butt... FAI and labral tears occur in hips where the gluteus medius and maximus were not functioning properly and more times than not it is due to a muscle imbalance or pelvic malalignment.
As for exercise intervention, once you determine why the glute muscles have taken a vacation, there are very specific ways to wake it back up. Stay tuned for more on this part.
Until next time...
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