How to Treat Anterior Shin Splints

Ask a runner about shin splints, and they've likely heard of or suffered from them. Ask a physiotherapist or podiatrist (clinicians), and it's a rabbit hole to dive deep into.


While the term shin splints is primarily referred to as medial tibial stress syndrome (MTSS) in clinics and the literature, a large number of clinicians are starting to include a variety of other conditions under the umbrella term. All of which have the common trait: pain somewhere along or near the shin.


As a team focused on MTSS, we often receive questions and comments from clinicians and patients regarding the other kind of shin splints. Namely, anterior shin splints.


Great news: I have been given feedback that the Solushin has helped patients treat anterior shin splints under the guidance of a physiotherapist or podiatrist! While true, it is not the most reliable statement, hey?


That's because the unfortunate thing about the diagnosis of shin splints is that it genuinely isn't a thorough diagnosis. In the case of anterior shin splints, there are inherent risks associated with misdiagnosing the cause of your patient's pain. For example, the potential risks associated with acute exertional compartment syndrome. So, it is crucial to distinguish between the four injuries commonly associated with anterior shin splints: anterior tibial stress syndrome, tibialis anterior tendinopathy, anterior tibial stress fractures and chronic exertional compartment syndrome.


I have written this article as a reflection of my current understanding based on my interactions with 100s of clinics, reviewing literature and monitoring the use of the Solushin in the Australian athletic populations. The purpose is to encourage further research and discussion regarding the use of the Solushin for injuries associated with the tibialis anterior.

The Tibialis Anterior

The tibialis anterior (TA) is one of the muscles responsible for dorsiflexion - the action of pulling your toes up towards your knee. It originates along the upper two-thirds of the lateral surface of the tibia and inserts into the medial cuneiform and first metatarsal bones of the foot.


Along with the other dorsiflexor's, the extensor hallucis longus (EHL), and the extensor digitorum longus (EDL), your TA helps you clear your foot of the ground while walking/running and helps maintain control during plantar flexion. Simply put, if you have a friend who drags their feet everywhere, yell at them to engage their TA!

Anterior Tibial Stress Syndrome

Like MTSS, ATSS is resultant of poor loading with pain resulting from excessive (traction) of soft tissue structures and bony loading along the tibia often resulting in periostitis along the anterior border. And, like MTSS, ATSS is often attributed to overuse and overtraining.


As a syndrome, it is essential to understand that the causes and symptoms are likely to be multi-factorial. To get a clearer understanding of the severity of the injury and the resulting treatment, ATSS is often broken down into four stages:


Stage 1 – discomfort that appears during warm-up. Early intervention to avoid further deterioration is advised.


Stage 2 – discomfort that may disappear during warm-up but reappears at the end of the activity. A load management protocol is advised to avoid further progression of the injury.


Stage 3 - discomfort that gets worse during the activity. It is essential to confirm the condition may have progressed to a stress fracture. Immediate rest is recommended before undertaking a load management protocol.


Stage 4 – pain or discomfort all the time. All activity must immediately cease. Professional guidance is essential to exclude stress fractures or more significant tibia fractures.

Anterior Tibial Stress Fracture

As highlighted above, anterior tibial stress fractures are often implicated in stage 3 and 4 ATSS (increased likelihood in the former). A stress fracture is the result of an imbalance between bone formation and bone reabsorption during excessive, repetitive, dynamic cyclic loading [1].


Anterior tibial stress fractures are less common than posteromedial tibial stress fractures (often associated with stage 3,4 MTSS), making up approximately 2.7 to 4.6% of stress fractures [2]. However, like posteromedial tibial stress fractures, soleus muscle tightness and weakness are often implicated in the injury as reduced dorsiflexion from tight calves can increase loading of the tibia when walking and running [1].


Conservative treatment is generally pursued as seen in stage 4 ATSS with rest and activity modification under professional guidance often pursued. When the conservative treatment of the stress fractures fails, surgical intervention is usually recommended [1].

Tibialis Anterior Tendinopathy (Tendonitis)

Tibialis anterior tendinopathy is an overuse injury presenting with pain and stiffness predominantly at the front of the ankle and this is explained by a long term degenerative and inflammatory process that occurs when the tendon is repetitively used. Despite the location of pain mostly presented at the front of the ankle, this injury is often included in response to my question: which anterior shin splints are we talking about? As such, I thought it was worth adding in this article.


Whenever the tibialis anterior muscle contracts or is stretched during walking or running, tension is placed through the tibialis anterior tendon. Tibialis anterior tendonitis typically occurs due to activities placing excessive amounts of stress through the tibialis anterior muscle. These activities may include fast walking or running (especially up or downhill or on hard or uneven surfaces) or sporting activity (such as running or kicking sports). Soleus muscle tightness and weakness is again often implicated in the injury.


Conservative management consisting of rest, activity modification, stretching, orthotics, and physical therapy are often pursued when treating tibialis anterior tendinopathy.

Chronic Exertional Compartment Syndrome

Exertional compartment syndrome occurs when the tissue pressure within the compartment exceeds the arterial perfusion pressure resulting reduced blood flow to the muscle and ischemia to the muscle and respective nerves. 


Most patients with this condition will describe pain with use – that is, with powerful muscular contraction they experience dull aching pain in the lower leg. It usually resolves upon ceasing activity. Although poorly understood, it is thought to occur as a result of muscle swelling during periods of increased metabolic demand and forceful contraction. 


It must also be noted that this does not include acute compartment syndrome (ACS). This is a limb threatening emergencies which usually occur with significant trauma (e.g. a broken leg). On the other hand, chronic exertional compartment syndrome (CECS) is a problem that occurs over time and does not threaten the blood supply to the leg. 

Regarding the tibialis anterior compartment, this condition is often due to overuse and usually affects young athletes, particularly runners. While the prevalence is unknown, several observational studies have demonstrated varying rates. One retrospective study of 4100 military personnel found an incidence of 0.49 per 1000 persons [3].


Conservative management consists of rest, activity modification, stretching, orthotics, and physical therapy. These measures are effective for most people, however, in some rare cases a surgery to release the pressure in the affected compartment is required [4].


When to use the Solushin

As the inventor of an orthosis that treats medial tibial stress syndrome (MTSS) and reduces tension in the soleus (21% improvement on knee-to-walls in an hour), I am often hit with the question: can I use this for anterior shin splints?


Highlighted above, we've seen four completely different injuries that fall under that umbrella term. So, it is important to distinguish when you can and cannot use the Solushin medical device.


The Solushin applies counter traction to the three origin sites of the soleus muscle: posterior to head of the fibula, mid-diaphysis and at the musculotendinous junction with the Achilles tendon. In addition, counter traction is also applied to the posteromedial tibial border.


While initially designed for MTSS, we have seen some great results for relief of anterior tibial stress syndrome (ATSS), undiagnosed tibialis anterior pain and tibialis anterior tendinopathy. Antagonistic to the soleus muscle, there are no surprises there; by reducing tension in the soleus, the overall exertion on the tibialis anterior is reduced. It is early days, and this evidence relies solely on the feedback from clinics where the Solushin was used as an adjunct.


Anterior stress fractures? Do not use the Solushin in the short-term to avoid any impediments to healing. As a result, when assessing ATSS, it is also essential to rule out a stress fracture, particularly in stage 3 or 4 of the progression of the syndrome. However, in the medium to long-term, it is worth considering the Solushin to help manage the loading of the tibialis anterior.


When can you use it for exertional compartment syndrome? The mode of action of the Solushin - the counter traction - applies focal compression on different areas of the lower limb. As a result, I would not recommend its use for exertional compartment syndrome. By applying compression to a high-pressure environment, you are inevitably going to increase the overall pressure. And, while the focal compression is not specific to the tibialis anterior, the strapping and sleeve are worthy of caution. That said, some NRL and AFL teams who used the Solushin for the treatment of CECS in the tibialis anterior compartment have had great results when the device was used under thorough observation. 

Conclusion

"Anterior shin splints" is a broad term that loosely encompasses a variety of injuries—namely, anterior tibial stress syndrome, tibialis anterior tendinopathy, anterior tibia stress fractures and chronic exertional compartment syndrome.

 

While initially designed for medial tibial stress syndrome, the Solushin has demonstrated promising results in clinics for the treatment of anterior tibial stress syndrome and tibialis anterior tendinopathy. In addition, while not recommended due to safety concerns, we have seen NRL, and AFL teams successfully use the Solushin to alleviate pain associated with chronic exertional compartment syndrome of the anterior compartment while under close observation.


About the author:

Ben Lindsay is the Managing Director and engineer behind the Solushin medical device. A former national medalist swimmer, Ben aspires to learn from physicians, physiotherapists and podiatrists so he can develop tools to improve the quality of care for their patients.

References

  1. Tsakotos, G., Tokis, A., & Paganias, C. (2018). Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report. Journal Of Medical Case Reports, 12(1). doi: 10.1186/s13256-018-1718-8
  2. Blank, S. (1987). Transverse tibial stress fractures. The American Journal Of Sports Medicine, 15(6), 597-602. doi: 10.1177/036354658701500613
  3. Waterman, B., Liu, J., Newcomb, R., Schoenfeld, A., Orr, J., & Belmont, P. (2013). Risk Factors for Chronic Exertional Compartment Syndrome in a Physically Active Military Population. The American Journal Of Sports Medicine, 41(11), 2545-2549. doi: 10.1177/0363546513497922
  4. Gill, C., Halstead, M., & Matava, M. (2010). Chronic Exertional Compartment Syndrome of the Leg in Athletes: Evaluation and Management. The Physician And Sportsmedicine, 38(2), 126-132. doi: 10.3810/psm.2010.06.1791


1 comment

  • Andrew

    Fascinating read Ben

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