Medial Tibial Stress Syndrome & Achilles Tendinopathy (PDF)

COMMON INJURY CONDITIONS Medial Tibial Stress Syndrome Medial tibial stress syndrome, also known as shin splints, is often the result of multiple factors that lead to the development of progressive medial shin pain. Typically, the primary culprits are being female, having less running experience, b...

COMMON INJURY CONDITIONS Medial Tibial Stress Syndrome Medial tibial stress syndrome, also known as shin splints, is often the result of multiple factors that lead to the development of progressive medial shin pain. Typically, the primary culprits are being female, having less running experience, being overweight, possessing an increased navicular drop (Newman et al. 2013), and having more dynamic pronation (Dowling et al. 2015) through the stance phase of gait. Lack of dynamic hip control may also play a role (Dowling et al. 2015). Prolonged pronation paired with a lack of hip and knee stability and control during gait may place an increased eccentric demand on the medial shin musculature causing the production of somatic dysfunction. Common Signs and Symptoms • Pain with walking and stance phase loading during gait that typically increases with use • Posteromedial tibial point tenderness, particularly over the medial soft tissues • Pain that subsides with inactivity Common Differential Diagnoses • Stress fracture • Exertional compartment syndrome • Sciatica • Muscle strain • Popliteal artery entrapment • Deep vein thrombosis (DVT) • Tumor • Infection • Tibial periostitis Clinician Therapeutic Interventions • Determine the root of the patient’s condition (e.g., faulty biomechanics, training errors, leg length discrepancy, weak hip musculature, surface or shoe alteration). • Consider requesting an MRI or bone scan to rule out stress fracture if tenderness is localized over the bone. • Address any insulting factors or conditions, such as increased tibial internal rotation. • Scan and treat the structures in the order presented in the Treatment Points and 88 Treatment Points and Sequencing 1. Tibialis posterior and flexor digitorum longus 2. Tibialis anterior 3. Medial gastrocnemius 4. Soleus 5. Popliteus 6. Flexor hallucis brevis 7. Pes anserine 8. Iliotibial band 9. Adductors of the thigh 10. Sacroiliac joint 11. Gluteus medius 12. Psoas • • • • • • • Sequencing box. However, base your treatment sequencing off the most dominant (tender) points first. Follow PRT with thermal ultrasound or laser, PNF stretching of the medial and posterior pretibial musculature, and myofascial massage. For some patients, KT Tape or shin taping reduces pain during the initial stage of therapy. Apply instrumented soft-tissue mobilization (ISTM) if recalcitrant tissue adhesions are present. Consider performing a biomechanical evaluation of gait if a training, movement, or biomechanical error is suspected. Implement open- and closed-chain strengthening for the intrinsic foot, pretibial and hip, and core muscles to address weaknesses or compensations identified in the gait analysis, with a particular focus on eccentric control of tibial internal rotation. Have the patient use temporary or custom orthotics to unload the medial soft tissues during the initial phase of rehabilitation. If a walker boot is utilized, address any alteration in gait mechanics it may cause with a temporary lift or orthotic in the non-involved shoe to prevent abnormal joint loading at the non-involved limb, hip, and pelvis. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. COMMON INJURY CONDITIONS • Slowly progress the patient to dynamic physical activity through aquatic therapy or with an antigravity assisted running device. Patient Self-Treatment Interventions • A continuous low-intensity pulsed ultrasound unit may help. • Perform self-release of the tibialis posterior on a daily basis or when irritated. • Perform PNF stretching of the medial pretibial muscles and gastrocnemius soleus com- plex after exercise on a daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions. • Perform self-massage for five to eight minutes daily after stretching. • Ice-massage the medial shin when reirritation occurs. Typically, patients with chronic symptoms respond best to heat (e.g., warm whirlpool or Jacuzzi). (Note: Consult with the clinician about where you are in the healing process, which will determine whether to apply heat or ice.) T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 89 COMMON INJURY CONDITIONS Achilles Tendinopathy (Noninsertional) Noninsertional Achilles tendon injury, or tendinopathy, is common in athletic and recreational athletes (Peters et al. 2015). According to Murphy, Curry, and Matzkin (2013), runners transitioning from a running shoe to barefoot running may be at more risk for injury than others. Additionally, runners attempting to change their running gait from a heel to midfoot strike pattern may also be susceptible to Achilles tendinopathy. When patients move from a heel to midfoot strike position either through alteration in shoe type or intentionally through gait modification, additional eccentric loading is placed on the Achilles tendon as the heel lowers to the ground (Giandolini et al. 2013). The tendon may simply become irritated when the load placed on it exceeds its extensibility limits or its ability to adapt to the load, which typically occurs from training error (Nielson et al. 2012), pathological biomechanical alterations during the gait cycle, or a sudden shoe or surface change. Although initial insult to the tendon can result in an inflammatory condition known as tendinitis, chronic inflammation of the tendon, or tendinosis, is more often the case. If left untreated, the condition may progress to degeneration of the tendon at its insertion or within the tendon without the classic signs of inflammation that may eventually lead to rupture. Common Signs and Symptoms • Pain with walking and toe-off during gait • Diffuse swelling on the sides of the tendon behind the malleoli • Point tenderness at the calcaneal insertion site or within the tendon itself Common Differential Diagnoses • Calcaneal fracture • Retrocalcaneal bursitis • Achilles tendon tear • Soleus strain • Haglund’s deformity Clinician Therapeutic Interventions • Determine the root of the patient’s condition (e.g., faulty biomechanics, training errors, leg length discrepancy, surface or shoe alteration). • Consider requesting a radiograph to rule out Haglund’s deformity and calcaneal fracture 90 Treatment Points and Sequencing 1. 2. 3. 4. 5. 6. 7. 8. 9. • • • • • • • • • • • Achilles tendon Tibialis posterior Medial gastrocnemius Lateral gastrocnemius Soleus Popliteus Flexor hallucis brevis Plantar interossei and lumbricals Dorsal interossei if the pain is located at the heel and has been chronic. Address any insulting factors or conditions such as excessive heel pressure from tight shoes. Scan and treat the structures in the order presented in the Treatment Points and Sequencing box. However, base your treatment sequencing off the most dominant (tender) points first. Follow PRT with thermal ultrasound or laser, PNF stretching, and myofascial massage of the Achilles tendon. For some patients, the use of KT Tape during the initial stage of rehabilitation reduces pain. Consider having the patient use a low-intensity pulsed ultrasound self-adhesive device daily. Apply ISTM if recalcitrant tissue adhesions are present. Implement an eccentric strengthening protocol as tolerated. Consider performing a biomechanical evaluation of gait if a training, movement, or biomechanical error is suspected. Implement open- and closed-chain strengthening for the intrinsic foot, pretibial and hip, and core muscles to address weaknesses or compensations identified in the gait analysis. Have the patient use temporary or custom orthotics to unload the Achilles tendon if a gait analysis warrants. If a walker boot is utilized, address any alteration in gait mechanics it may cause with a temporary lift or orthotic in the non-involved T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. COMMON INJURY CONDITIONS shoe to prevent abnormal joint loading at the non-involved limb, hip, and pelvis. • Slowly progress the patient to dynamic physical activity through aquatic therapy or antigravity-assisted running devices. Patient Self-Treatment Interventions • Perform self-release on a daily basis or when irritated. • Perform PNF stretching of the Achilles tendon and gastrocnemius soleus complex after exercise on a daily basis. Do not stretch if it produces pain because doing so may result in additional tissue lesions. • Perform self-massage for five to eight minutes daily after stretching. • Ice-massage the Achilles tendon or insertion site on a stretch when reirritation occurs. Typically, patients with chronic symptoms respond best to heat (e.g., warm whirlpool or Jacuzzi). (Note: Consult with the clinician about where you are in the healing process, which will determine whether to apply heat or ice.) T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 91