shin splints?????

[Netty]

Hi,

Patient is complaining of pain over the shin about half way down between the knee and ankle and it is tender over an area of about 1 inch in diameter and with a slight depression.

They also have under the skin lumps and bumps that can be felt. Could this possibly be shin splints? The person is a runner and only gets the pain whilst running.

I am sorry I cannot give more details as I have only spoken to this patient over the telephone so far. I was wondering mostly if lumps and bumps are common with shin splints? or any other ideas???


Thanks alot

Netty

[Aisha_kb]

Hey Netty, as your history is quiet vague we will not be able to help you out much in this case... A good history and assessment is very important for a physio to better understand what to do next.

Anyway, the humps & lumps that you are talking about are very normal and not necessary related to shin splint... I am sure if you palpate your own shin you would find them.

Was the patient dormant for a while and then started running all at once? OR is there any change in his running norms, like did he change his shoes? or place in which he ran? or intenstity of it?

[Netty]

Hi Aisha,

Thanks for your reply.

Yes I do understand that I need to give a more detailed history however I have only spoken to the patient on the phone. I will be seeing them tomorrow when I will be able to give a fuller history. However I just wanted to know what the lumps and bumps under the shin that the patient told me about over the phone could be, whether it was possible shin splints or compartment syndrome.

Thanks anyway and I will post fuller history once I have seen patient tomorrow!

Netty

[GAR42]

I am a PT patient. I have been diagnosed with MTSS/ Periostitis/Shin splints. I have been non responsive to any therapies for 1 and 1/2 years. I have a very involved history, but in summary, I started with bilateral calf pain in March '06. Calf pain mostly resolved, but medial shin pain persists. I had an ultrasound on Tuesday, September 4. The tech showed me my tibia where it lines up with healthy tissue around my knee. As she moved the wand south, the area surrounding the tibia all turned black, because there was no signal response. The tissue had all seperated from the tibia. She said she had never seen periostits this bad. She went and summoned the Dr. who gave me the number for a surgeon.

I have been off my activities for a year and a half. I used to play indoor baseketball 2-3x/week. Now, I do no impact exercises of any kind. I am in the middle of my 5th course of therapy. I have had two pairs of orthotics. I am not overweight (6'2"/185#) and I use heat, ice and HEP with no relief. What can I do? I had ASTYM which seemed to work in the short term for the fibrosis (or whatever was going on) but did not help with the inflammation or the attachment of the muscle sheath to the tibia. What modalities are there that can help this? Is there anything else short of surgery? Do you have experience with post surgical patients and, if so, what is the course of recovery.

I appreciate your help.

[ginger]

"shin splints " hey, yeah sure. referred pain from L3/4 more likely. What is it that keeps you allowing repeats of methods that don't work , five series of treatments to your legs with no results, you must get very frustrated. I can't give you the name of the physio who will fix your referred pain problem . I would feel like I had ignored your pleas for help however if I allowed you to continue to get inappropriate treatments for a simple low back nerve irritation and went on to have , god forbid , surgery. That would merely add further insullt to your compounded woes.
Find a physio who is willing and able to mobilise L3 and L4 in your low back . The best method is known as Continuous Mobilisation. Applied with skill and persistance , passive movements to these facet joints will release protective responses there that have lead to an inflammatory event (s) of nerve roots . It is the effects then of altered nerve physiology that has created an altered sensation picture which is interpreted as pain . It is common in these cases to also have local redness and perhaps swelling to the painfull region . This presents a quandary for the young players or inexperienced therapist . Untill or unless your lower lumbar spine has been returned to an unprotected mobile state , your medial leg referred pain will persist.
Either find a more experienced physio who will treat your back or convince your current therapist not to follow the course that has been thoroughly and convincingly demonstrated to be ineffective and incorrect.
Cheers

[alophysio]

Hi Ginger and GAR42,

I agree with you Ginger that a lot of pain is referred from the lumbar spine.

However,
1. Continuous mobilisation is not the only way to treat this. That is a very one-dimensional approach from what i can gather from your posts about CM.
2. I don't think referred pain from the lumbar spine results in physical separation of the periosteum from the bone.
3. GAR42's problem sounds like a serious problem.
4. Why won't you answer any questions about continuous mobilisations?? Should i PM you?

GAR 42,

I understand this is a problem. From what you say, you have had your feet looked at, which is a logical starting point. However have your biomechanics been looked at from the back/pelvis/hip region?

Netty, whatever happened to your patient? The lumps and bumps occur from small sections of the periosteum pulling off the bone. The resultant inflammation and sweliing eventually scar up. Yes lumps and bumps are common but they don't have to be normal - there is a big difference!

In my experience, shin splints are a symptom of poor biomechanics somewhere along the kinetic chain - i have even treated people's thoracic spine which helped their shin splints (by changing the way the thoracolumbar muscles affected the lumbo-pelvic hip position).

Thanks!

P.S. Ginger, the treatment that you describe as "thoroughly and convincingly demonstrated to be ineffective and incorrect." - is this GAR42's previous treatment or the treatment of shin splints in general?? If it is the latter (in general), then can you please provide references to how this has been proven so?

[rockin ronnie]

ginger, can u explain correction of excessive pronation and calf/soleus stretching improving "shin splints"? Surely that would be the first line of treatment, then consider lumbar spine if there is failure to improve. That's how i would manage it. Would you go straight for the lumbar spine?

RR

ps love your work

[GAR42]

Alophysio has it right. It would not be accurate to say I am only experiencing referred lumbar pain. My shin symptoms are bilateral, whereas my LS MRI was only positive with impingement to the left. I do have referred lumbar pain and my PT has focused on my low back, pretty much exclusively since the ASTYM reached its maximum benefit. I have had a variety of strengthening, stretching and ROM for my LS. I can tell the difference between my referred LBP, which manifests as glute, hamstring and calf tightness, and my periostitis, which is a medial tib burning sensation. I am under the care of an ortho, a physical med specialist and a podiatrist, and they all think that these are two separate conditions. The overriding question is what to do when every conservative method to address the MTSS has been tried.

Alophysio, I really like your suggestion to have a look at my overall biomechanics. I am also going to look at different orthotics. I have been referred for a surgical consult, too.

Thank you

GAR42

[GAR42]

That is exactly the course I have followed for the last year and a half. Shins were acute and calves in spasm when I first started PT. That resolves, but the residual soreness has never gone away. LBP also resolved, but glute, ham, calf tightness remains.

I have had excellent Drs. and PT's. I wouldn't be posting if we all weren't scratching our heads.

GAR42

[ginger]

Gar42,
When neural irritating events take place , leading to altered sensations, it is your brain that feels the pain and other sensations, exactly the same as when a local event takes place, where it is nerves that produce information interpreted by your brain. It will not be possible to interpret the difference between these on the basis of subjective analysis of the sensations alone.
You sound so wonderfully confident about your current treatment regime even though the balance of your likely referred events are still present ( hams , gluts, calves ). while your therapist deals with the lumbar spine with exercise stretch and , as you say ROM . It may take you a long time to realise the kind of effect that ten minutes of Continuous Mobilisation will produce. These kinds of referred events are routinely turned off in my own practice , by either myself or any of my experienced students , in ten to fifteen minutes.
It is not unusual to have L3 and L4 referred events to include burning sensations , along with twitching, itching, cold , heavy, tight etc etc etc , that is why they are called altered sensations. Pain not responding to local treatments are the most obvious among other signals of the common thread of somatic referred events of which I speak. No rocket science or further investigations required , just a shift of emphasis and a willingness to see your issue as a temporary nerve irritation , rather than a mysterious local ailment . Unfortunately it does appear that your therapist is not skilled in local passsive facet joint movement therapies. Find one ,they are out there .

[alophysio]

Ginger,

GAR42's periosteum is coming off the bone. I don't think there is any referred pain. There is an anatomical deficiency. I can appreciate your position but trashing his physios (whom you probably don't know) isn't exactly professional behaviour.

I appreciate you have a certain opinion about matters and more than happy to hear them - i would much rather someone tried your CMs than just stick someone on electrotherapy (but that is only MY opinion).

I do feel however that you are avoiding my questions about CM...

[ginger]

ronnie,
Some 'shin splints' are found to be hyper activity of Tib post , at the effect of over pronated feet giving stretch relflexive impetus to recruitment of this anti pronation muscle. In these cases orthotics work a treat.
The above mentioned galaxy of pain however , clearly indicates referred pain and patterns of recruitment happening , with some of it L5 ( calves hams gluts ) and some of it L3/4 ( medial shin burning ). Unfortunately , the closer one looks at a referred pain event, the more likely it will be that , with the advantage of science and a host of instuments keenly dedicated to the proposal that pain and pathology go together, the more interesting features will come into view. It is also likely that in the absence of someone to turn off these referred events , that these "pathologies " will take centre stage , in the minds of both doctor and patient . It is regrettable , but doctors of medicine miss the boat a lot of the time when it comes to interpreting MSK problems. In most cases , certainly in my own long experience , it will be dysfunction and referred events driving pain etc , rather than things like this that or the other "itis ".
Takes a solid leap sometimes to leap out of that paradigm . I encourage you to consider it however as the way forward with seemingly perplexing problems that do not respond to treatment. Over time I have become more and more alert to neuralgic cause and find my treatment success very much better , than in the bad old days when I , like many on these pages , were convinced that local 'disease' was the common thread to be analysed .
I wish you well.

[ginger]

Alophysio, hey there mister, I'm trying to work my way through as many direct questions as I have time and the inclination for . Having read my pieces in RE on CM, you will now be somewhat aquainted with this as a means to restore normal facet/nerve behaviour. It was formulated over time out of the basis provided by the venerable Geoffrey Maitland. I found his approach somewhat mechanistic and not sensitive enough and went on to discover that facet behaviour changed ( for the better ) the more passive movements were given. I won't reiterate any of the material available to go over in my early posts on RE. Most of your questions have already been addressed at infinitum within the body of RE. Forgive me , I do get a bit fed up sometimes , no disrespect to you intended , repeating the same story in different threads. Still, that is my wish , to allow the therapeutic community to realise the benefits of my clinical studies and conclusions. I am not a researcher, don't have the time or the resources. I am a working physio who has a usefull method and explanations to offer. I would rather address your queries on the forum , it achieves much more than private messages.

[alophysio]

Thank you Ginger,

I look forward to reading your responses.

Have you submitted case studies to journals?

[GAR42]

Remember that I am patient, not a trained PT. My knowledge is based on my experiences, questions and independent research, so I may come across as a layman, which I am. That said, I reject the notion that I don't know my own history, body or symptoms well enough to discern the difference between my aching back on the left, and my swollen, burning shin on the right. Ginger, you sound incredibly knowledgeable and experienced. I hope you have not gotten to the stage, like so many in the medical field, that you have developed your own opinions and methods to the point that the patient's views are unimportant. The critical tone of your posts would make me think so.

My 1st PT was the head athletic trainer at our local university, which is one of the top 5 in the country. My Dr. is the former team Dr. for a MLB team, and is currently a Doc for the US Olympic team. My current PT was recommended to me by my former PT, as well as many others, because he is certified in ASTYM and because of his other credentials. My podiatrist was just voted best in the City by a survey of patients and peers. I cannot imagine that, with all of these qualified people involved in my care, that we are all just blindly following a pointless "paradigm."

In my current regimen my therapist does what he has been calling manual traction. He wraps a large belt around my waist and the other around his and then he leans back. 10 minute sessions (I think). Is that "CM?" If not, then by all means I am willing to try it. I will do some more research and discuss it with my PT.

[ginger]

GAR42
I am not able to generate the warmth of the interest I would take in your problem when only the written word is provided. I have a no nonsense approach that seems to serve me and my patient well. Added to my incredible physical beauty and fabulous charm I am able to , by and large , put my own patients at ease within the exclusive confines of my office. Here however, you just get the staright talking guy. No need to sugar coat the truth my son , it serves well enough on its own.
I won't repeat my assertions , you will either accept them and move on , or you won't.
I wish you well.