Medial Tibial Stress Syndrome Part 3 - Treatment and Rehabilitation

So we have made it to this point. You have been rolling, stretching, warming up before your runs, but your nagging shin splint pain will not go away. Maybe it has improved 50%, but as you continue to train for your upcoming event, the pain has plateaued. Sound familiar?

I know it has for me. As we discuss treatment options here in part three of our Medial Tibial Stress Syndrome series, a few of the techniques we show that are commonly used here in the office were used to help me overcome my battle with shin splints when I was working toward my first marathon.

Just with any other injury, if you are truly doing everything you can (allowing ample time to warm-up before exercise, training within your limits and not hanging too long in the upper limits as you progress, you are stretching, rolling, and giving constant attention to recovery and rest) and you can not shake the pain after 10-14 days, YOU NEED HELP! Our goal with this series is to give you options, ideas, and a direct path of the things you should be doing, but if they don’t get you to where you need to be, or out of pain…that is why we are here!

Below are a few of the treatment options we typically utilize when caring for medial tibial stress syndrome, as well as a basic return to running rehab protocol that not only provides strength in needed areas but is aimed at preventing future injuries.

NOTE: The care we provide is adapted to each individual person and their presenting condition. What works for one athlete may not work for another. This is where the exam and functional analysis come in. If any of these exercises cause pain, STOP, and seek care from licensed professionals. (Like Us!)

---

SHIN SPLINTS: IN OFFICE TREATMENT

MYOFASCIAL RELEASE

IASTM - Instrument Assisted Soft Tissue Mobilization

DYNAMIC CUPPING THERAPY

DRY NEEDLING THERAPY

KINESIO TAPING

---

SHIN SPLINT REHABILITATION PROTOCOLS

Medial Tibial Stress Syndrome - Rehabilitation Exercises - Phase 1

Medial Tibial Stress Syndrome - Rehabilitation Exercises - Phase 2

---

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Resolve Low Back Issues Part 4: Most Common Myths Of Low Back Pain

Low Back Pain Myths

Few musculoskeletal conditions have a cult-like following of myths as Low Back Pain, many of which have been said by various healthcare providers across all specialties. To help clear the air, let's take a look at the 5 most common misunderstandings and myths that we encounter in our chiropractic clinic that could actually make your low back pain worse.

Before we get started…

These myths and misunderstandings are not aimed at making low back pain seem 'made-up,’ it is a very real and challenging condition. These myths are just folklore passed down from old, unsubstantiated in the research, ways of thinking. Our truth is that, if you believe one thing and that makes you feel that your low back is wrecked for life, a long road of pain is what you are in store for. We call this fear-avoidance and catastrophizing, the medicalization of a condition. We will touch more on this when we cover imaging next week. But a big part of recovering from low back pain is believing that you can get better. It may sound silly, but no more ridiculous than believing these myths below!

NUMBER 1: Your back pain is from a misalignment, bone out of place, or a ‘subluxation.’

We don’t practice this way any longer, stop using explanations from this era.

These are common descriptions patients and doctors alike will give when describing their back pain.  The most common being...you threw your back out, and it is now misaligned...commonly spoken by chiropractors of a generation ago or current doctors, chiropractors, and physical therapists that have not caught up with current research.  The truth to this is that your spine is a dynamic structure designed to move, what we ACTUALLY find is that the pain you are feeling is often associated with immobility, or areas of the spine that should be moving, but due to tight muscles and previous injury, may not be moving well or correctly anymore.  Spinal manipulation or an ‘adjustment’ is designed to restore normal motion to these restricted areas.

A bone did not shift out of place and therefore needs to be put back in! That’s not how it works.

NUMBER 2: Arthritis is the root of all evil!

Arthritis is like wrinkles on your face…lets just keep it nice and say they are signs of wisdom. Truthfully, if you live and play hard and long enough, we will all experience some degree of degeneration.  However, and please understand this, it is a natural process and does not necessarily equate to pain! When conditions present that are more challenging, using arthritis as the ‘fall guy’ is the easy way out for a provider and an often acceptable answer for the patient.

NUMBER 3: “But…I have scoliosis and a short leg” that is the cause of my back pain.

Just like arthritis, scoliosis and an actual short leg (1cm or shorter than the other) are comfortable areas to place blame when someone presents with back pain.  Both can absolutely lead to dysfunction, and if unaddressed, pain and discomfort. To a certain degree, uneven leg lengths and spinal rotation/curvature are normal variants, meaning most people have these at a mild level and are unlikely to be a pain generator. For most (not all) look to place the blame elsewhere.

NUMBER 4: Rest is what I need to recover, right?

The days of ‘take 2 of these, rest, and call me in the morning’ are long gone. You likely have a relative who spent a good amount of their life with back pain that limited some or all of their activity. When you see a case like this or someone who is much too young to be experiencing recurrent back pain, it may seem like the right thing to do is rest up for a while. Fortunately, we now have stacks of research that supports the fact that bed rest is the worst (top 3 at least) idea when it comes to low back pain. The new adage is ‘Movement is Medicine.’ When someone presents to our office, we are not only just trying to relieve pain, but to relieve pain SO THEY CAN GET OUT AND MOVE. Even walking, WALKING, has been shown to reduce low back discomfort and be a great tool to prevent future occurrences.

NUMBER 5: Slap a brace on it & it will be fine.

Brace low back pain long term & you should join the circus with that thinking.

This is excellent advice if you are looking to weaken your core muscles completely. Did you know that powerlifters use the belt to their advantage to complete amazing feats of strength not to brace their low back, but to give their stomach something to press in to, creating intraabdominal pressure (think bracing your stomach if someone was to punch you) that stabilizes the spine from the inside? Our bodies are amazing, it has its own ‘weight belt’ built-in. Using straps, belts, or any other contraption like this for extended periods of time tells your body that you do not need it to do its job anymore. This core weakness and inability to naturally brace yourself through muscle control —> LEADS TO CHRONIC LOW BACK PAIN.

In summary, things change. Our treatment methods and your outlook on your condition must change. Every single one of these five myths is still spouted today in an office somewhere near you. Knowing the validity of that is often more important than the care you receive. While in certain circumstances, these can be valid reasons for low back pain. For most, especially those who come through our Cottonwood Heights, Utah Chiropractic and Rehabilitation clinic, we want a better answer. One that helps address and correct the dysfunction. One that promotes confidence and encourages the patient to try harder, that they can feel better and live a life they enjoy.

Next week, in part 5 of our Fix Your Low Back Series, we are going to discuss red flags, when you need imagining, and why you shouldn’t always rest your diagnosis and pain on those images.

---

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Runner's Knee Part 3: Training Modification & Self-Care

Over the last two weeks, we have discussed the ins and outs of Runner’s Knee - Patellofemoral Pain Syndrome, the anatomy involved, how adjacent joints (hip and ankle) can contribute to maltracking, and why runners are particularly susceptible to this common overuse injury.  You can read Part 1 & Part 2 here.  

Now it’s time to talk about self-treatment and training modification.  Our goal is to maintain training (load) if possible when you find Runner’s Knee settling in, but more often than not, rest and self-care are needed while also modifying our training volume and intensity until symptoms recede.

TRAINING MODIFICATION FOR RUNNER'S KNEE

Let's get the big one out of the way first!  One of the reasons many runners try to avoid visits to a doctor’s office about one pain or another is the fear that the physician will tell them to stop running.   Depending on the injury, how long it has been ongoing, current severity, and other factors, some runners are able to continue training during treatment and rehab, albeit in modified form.  

Without getting too technical, we first need to understand the concept of 'load' and how it changes when we are injured.  As runners, we have a specific language, so I am going to explain it in those terms. When our training is on and we are injury-free and fit, long runs, speed work, tempo runs, and intervals go well and help us improve.  The load on the knee (and other joints) is well managed, and there is ample time to recover. Now, let's say you decide to sign up for a race that is in 6 weeks, and your training base is less than optimal. In hopes of having a good race, you ramp up quickly, doing hard days back-to-back, pushing it to your goal race pace for a good portion of your long run, etc., and now...BOOM, knee pain!  What has happened here is that you exceeded the load threshold your body can handle and recover from.

For an interesting read, look into Scott Dyes work. This is what is commonly referred to the ‘envelope of function’ in the coaching and physician world.

Jumping back in...now that we are injured, our load threshold is lower.  This is why a 5-mile run is painful halfway through when just 2 weeks ago, you were cruising through 10 miles with a few pickups.  If you continue down this path, patellofemoral pain can become so severe that just getting out of bed and navigating stairs is difficult.  When we encounter a runner in this position, we need to sit down and talk about a training plan, race expectations, and our long-term goals.

While it is never our goal to shut a runner down in the middle of a training cycle, the athlete's long-term health and ability are top of mind.  Because of this, when discussing training, we tend to cover three things.

Can we gradually ramp up training while continuing to respond to treatment?

When we begin treatment, we have to start with a baseline. That may be 2 miles, 5 miles, or No miles before the pain sets in. That is our starting spot. As we follow-through with the suggested treatment plan, this load threshold must also go up. Rarely does pain go from 100 to 0, meaning, the pain goes from beginning at mile 2, then mile 4, then we find ourselves back up to 8-10 miles with no pain. This is the progress we look for.

Initial volume should decrease by 50% for the first 2 weeks.

If you are coming to us for knee pain, make a conscious effort to dial it back for a few weeks. This allows you to keep training, but also a little more rest than normal while we get through the first few treatment session.

Intensity, or pain-provoking runs, need to take a full break until volume can increase without pain.

With runner’s knee, we find that the harder, hillier efforts cause the most problems. While we want to maintain load on the knee while we treat, easy runs are the plan for the first few weeks. Looking at what we just talked about with gradually ramping up, we need to make sure you can handle a good distance without pain before we start pounding out the speed-work and hill repeats. And this goes for downhill too!

SELF TREATMENT OPTIONS FOR RUNNER'S KNEE

Now that we have discussed training modification, what can you start doing at home to help with Runner’s Knee?  Honestly, you should be doing all of this already, but pain is a much better reminder to break out the foam roller than a good run.  Your relationship with your foam roller needs to be strong. Your diet needs to be on point. Your bedtime needs to be early. Lastly, you need to realize that weight training is your friend.

Let's discuss a few of the easiest and most common self-treatment options.

Foam Rolling:

I don’t need to further detail my love for foam rolling over stretch or the benefits that regular foam rolling can provide for a runner. As we address runner’s knee, rolling needs to be frequent, short bursts throughout the day. Meaning, roll the quadriceps, hamstrings, and posterior hip muscles 3-5 times per day. Again, these are short 2-3 minute sessions. 10-15 rolls up and down over each area. Check the video!

Hip Mobility Drills:

As runner’s, our knee functions is highly influenced and controlled by what is happening at the hip. If your hip range of motion is limited, this will eventually show up at the knee. Check the video!

Ankle Mobility Exercises:

As a practitioner, I’m typically a ‘ground-up’ person when it comes to runners. While the hip controls the show, if the ankle does not move properly, it can not react properly or efficiently when the foot hits the ground causing problems up the chain. Studies show that just a few degrees difference between ankles is a good indicator of future injury. Work on your ankle mobility - Check the video!

Kinesio Taping:

This is a bit controversial. As you will hear me say in the demonstration below, the effect of taping is hard to prove. Don’t get me wrong, I love taping, in the short-term. It is by no means a long term fix for any injury! With that, you can also find 500 runners at the upcoming Big Cottonwood Marathon or the St. George Marathon that have their knees, shins, hips, and ankles taped that will absolutely swear by it. With all of that, I just don’t have solid evidence that proves any of that...but placebo is a powerful tool and I do appreciate taping as a means to help someone recovery and cue good movement patterns. If anything, the tape is a visible reminder to roll, stretch, and rest more. Check the video!

Body-Mass Index:

BMI has to be briefly discussed her because whatever weight we are carrying around affects our knees! Remember from the part of this series we mentioned that during running, the knee takes on 5-6 x’s your body weight during each step. While many people us running for weight loss, and other avoid it due to weight, the fact is, those with knee pain will benefit from weight loss if they are in the higher BMI category. I am not a dietician, we do not push weight-loss in our office, and I can’t tell you how many ‘Clydesdales’ category runners that can kick my tail in a race. Health is more than just pounds, but Runner’s Knee can be helped by a better BMI.

Psychosocial Influences:

Lastly, psychosocial factors. Runner’s are among the worst when it comes to injuries and the doom and gloom that comes with it. Some are severe enough that I have referred out to a professional for guidance. This is not something to be ashamed of and can actually help your recovery and performance. We now understand pain a bit better than we did 20 years ago, we still have a long way to go, but we know one thing to be true, if you do not think you will get better, you won’t. You have to buy into the plan, think positive, take the little wins, and know that this will not last forever. Any injury will last longer than we want it to, but you have to realize that by pure running statistics, you will get hurt at some time if you are training consistently, but it will also pass.

Hopefully, this article cleared up a few things regarding your training and the ability to continue through treatment, as well as a few ways to care for Runner’s Knee yourself.  Ideally, you can manage this yourself, learn from it, and prevent it from recurring. As runners, we are prone to injury; that is just the way it is. But, we want to make sure you have the necessary knowledge and tools to help yourself before you give up, stop running, and then drag yourself into a sports physician's office.  

LET'S REVIEW TODAY’S INFORMATION

• When faced with Runner's Knee, training modifications are a must.  We typically cut the training volume by 50% and avoid intense workouts (intervals, hills, tempo) for the first 2 weeks.

• Self-care is a must.  It not only helps speed your recovery over your treatment plan, but it can also help prevent future injury.  

• Self-care can be as simple as foam rolling a few times per day or running specific mobility, stability, and strength exercises.  

Stay tuned for part 4 of our runner’s knee series, where we will discuss when to seek treatment and how we treat Runner’s Knee in our office, as well as a few examples of our suggested rehabilitation exercises.  

Train smart, recover well, race great!  

---

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Murray, Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

The Best Running Warm-Up To Help Prevent Injury

SHOULD YOU WARM-UP BEFORE RUNNING?

If you are like SOME runners, you prepare for your run by completing two quick stretches. First, you bend over and touch your toes. Next, you stand up, grab your foot from behind, and pull it toward your butt.

If you are like MOST runners, you don't even do that!  In place of a long-winded stance on why you should be doing this and how research shows that warming-up before exercise not only prevents injury but improves performance. We are going to cover the bases of a great running warm-up through our Bands, Balance, & Bounce Running Warm-Up Routine.

---

Running Warm-Up Part 1: BANDS

CLICK HERE TO WATCH THE VIDEO

• Clamshell

• Glute Bridge

• Band Walks

• Low Row

---

Running Warm-Up Part 2: BALANCE

CLICK HERE TO WATCH VIDEO

• Plank

• Dead Bug

• Bird Dog

• Single-Leg Stance

• Leg Swing

---

Running Warm-Up Part 3: BOUNCE

CLICK HERE TO WATCH THE VIDEO

• Iron Cross

• Scorpion

• Mountain Climbers

• Plank Twists

• Butt Kickers

• High Knees

• A-Skips

• Side Shuffle

• Carioca

• Reverse Shuffle Butt Kicker

Dr. Reheisse is a Board-Certified Chiropractic Sports Physician practicing in Murray, Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

(1) Fradkin, Zazryn, Smoliga. Effects of Warming-Up on Physical Performance: A Systematic Review With Meta-analysis. The Journal of Strength & Conditioning Research. January 2010.

How 'The Big 3' Can Decrease Low Back Pain and Make You Stronger & Faster

If you are among the estimated 50% of all athletes who experience recurrent low back pain, don’t stress, there are exercises that can help…and a couple you should probably avoid.

Our ‘core’ is the link between our upper and lower bodies, and mastery of control here is the secret to improved strength, running efficiency, faster speed, and overall health and athleticism. In regards to back pain, our core needs to be solid to not only support a stable spine but provide for proper biomechanics when running, throwing, squatting, swimming, and even just walking.

From an anatomical perspective, our core is made up of the rectus abdominis, transversus abdominis, internal and external obliques, quadratus lumborum, glutes, and internally, the diaphragm and pelvic floor muscle. The goal of these muscles is not only to be strong but to provide a stable platform for our spine through any and all movements. Stability here has a dramatic impact on injury risk and should be a focal point in any sport and health training plan.

Lets use the example of a runner as the majority of our patient population are runners and almost every sport requires it. A strong core, one with ample endurance, allows for proper movement through our hips, legs, and upper body without excess expenditure of energy. If we are weak here, the late stages of a long run or race become challenging injury risk increase. As the core fatigues, the hips begin to dip, causing extension through the low back, excessive strain on the hamstrings, inward rotation of the femur causing excessive rotation of the tibia that can lead to excessive strain of the ligaments of the knee. This can travel down the chain and lead to poor pronation control causing shin splints, Achilles strains and plantar foot pain…you see where we are going here. Simply put, the core needs to function properly, or the whole system fails.

Most people understand parts of this and that core strength is important, but we still find people who lie on the floor, knock out 100 crunches, call it a day and then wonder why their low back hurts the next day. For this reason, I do not recommend sit-ups or crunches. These two exercises cause undue strain on the low back through repetitive flexion that stresses the discs, joints, and muscles of the lumbar spine.

While many finds these exercises easy to perform, and a staple in their routine, I want to introduce you to a more effective core routine. One that focuses on proper back support and overall functionality as an athlete, regardless of sport. These 3 exercises, termed ‘The Big 3’ were developed by Prof. Stuart McGill, rigorously studied, and proven to protect your back and improve core endurance.

The big 3 are made up of the Modified Curl-Up, Bird Dog, and Side Bridge.

1. Modified Curl-Up

McGill Curl - Up. Low Back Pain Relief Utah.

Lying on your back, place one leg flat on the floor with the other bent. This position allows for a neutral pelvis during the movement and puts your core muscles in control of the movement without undue strain on the low back. Place your hands under the small of your low back to ensure a normal arch is maintained during the movement. Begin by bearing down to brace your abdomen, continue a normal breathing pattern throughout. If you have difficulty maintaining the brace while breathing, this is where you start. Now, pretend your neck, upper back, and low back are locked together and cannot move independent of one another (straight line from head to pelvis), slowly, lift your shoulders blades off the floor and return to the floor in a smooth pattern, only coming off the ground a couple inches. Take note of your posture, did your chin stick out, did your shoulders round forward from memories of doing endless crunches? Work through 2–3 sets of 10–15, slow and controlled.

2. Bird Dog

Bird Dog Ex. for Low Back Pain

Begin in a quadruped position with hands under shoulders and knees under hips, both about shoulder-width apart. Brace your abdominals while maintaining a neutral (straight) spine. While maintaining this posture, breath in and out, squeeze your glutes and begin moving your right arm up to a point position while also bringing your left leg to a straight position. Our goal here is to avoid rotation through the spine, maintain our posture and keeping the hips in line. Slowly return to the starting position and then perform with the opposite arm and leg. That is one repetition, perform 3 sets 10–15.

3. Side Bridge

Side Bridge - Core Stability

Lying on your side, prop yourself up on your elbow, hinge at the hips, and stack your knees on top of each other with a 90 degree bend. Maintaining a solid shoulder directly over the elbow on the ground, lift your hips up and push them forward, bringing your spine to a neutral position. Hold for a 5 count and then slowly return to the starting position. Be aware of head posture and hip extension, maintain a straight line from the head to the pelvis. Perform 3 sets of 10–15 on each side, holding each for a 5 count at the top.

Obviously, there are numerous other exercises that provide stability for the spine while strengthening the core, this is just a starting point. Focus and repetition will bring proficiency, and proficiency will bring improved performance! If you have any questions, please ask, I’m happy to answer what I can.

Until next time, train hard, train smart, and recover well.

---

Source: McGill, S. (2002). Low Back Disorders: Evidence Based Prevention and Rehabilitation. (2nd Ed).

Dr. Reheisse is a Board-Certified Chiropractic Sports Physician practicing in Murray, Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Hamstring: Proximal Strain & Tendinopathy

As the weather cools down, a thought of last year comes to mind.  During this time I was beginning my sports residency in St. Louis under one of the best conservative care sports physicians I have had the pleasure to work with.  Of all the cases we encountered, one injury (many actually) sticks out as a very common occurrence this time of the year….Proximal Hamstring Strain & Tendinopathy.  

Hamstring injuries can be a beast; they drag you down mentally and physically as treatment tends to draw out and disrupt your training plans and goals.  They present with pain and tenderness near the gluteal fold and over the posterior thigh, making it sometimes difficult to run, ride, walk and even sit.  What I would like to do here today is briefly (as a longer post is to come later) give you some basic suggestions based on research findings, what patients have responded positively to, as well as what to do about your training and overall fitness.

There are many misconceptions out there about hamstring tightness and what can be done about it.  What we do know is that stretching, and stretching, and stretching the hamstrings some more, trying your hardest to touch the floor is not very effective, even counterproductive (1).  It may lengthen the muscle for a short period of time but the stress it places on the enthesis and the myotendinous junction could set you up for further injury if care is not taken.  

In the acute or reactive phase of a hamstring tendinopathy, there are a few key thoughts to consider that can aid in recovery.  At REVIVE Sport & Spine we focus on treating our athletes while keeping them active in sport but sometimes a decrease in activity is needed while a select few may need to shut down for a few weeks.  When working with tendinopathy issues, offloading the tendon from compressive and tensile loads is key (2).  Compressive loads are just what they sound like, anything that can compress the muscle or tendon such as sitting.  Tensile loads on the other hand are more dynamic in nature including activities like running and jumping.  Our goal in maintaining activity during treatment is to decrease both compressive and tensile loads while completely eliminating movements that combine the two such as hill running, static stretching and over striding (common with treadmill running, one reason I dislike this winter running option and also what I believe causes so many proximal hamstring issues in the winter months).  What can you do for activity during treatment?  Running on flat, soft surfaces at a decreased intensity and lower volume is one option.  Begin strengthen the hamstrings, gently with slow progression, utilizing isometric and eccentric type exercises (3) while also decreasing the time spent compressing the tendon in activities like sitting and static stretching.  Besides, too much sitting is just not good for your health in general!

While this is just the tip of the iceberg, we will dive deeper into hamstring issues in the near future focusing more on possible causes and some ideas as to what you can do to speed up your progress.  We will look at glute strength, hamstring exercise progression, the effect of tight hip flexors and weak abdominals as well as anterior pelvic tilt and poor lumbopelvic stability.  

As always, be sure to consult your personal physician before taking on any exercise or self prevention plan, self diagnosis and treatment is never a good option.  If you feel you are developing a hamstring issues and want to get ahead of it quickly, the team at REVIVE Sport & Spine is ready to help you build and get the most out of your winter training.  Happy Holidays and Happy Movement!

Resources:

1. Sole G, Milosavlijevic S, Nicholson H, Sullivan J.  Selective Strength Loss and Decreased Muscle Activity in Hamstring Injury.  J Orthop Sports Phys Ther 2011;41(5):354–363, Epub2 February 2011. doi:10.2519/jospt.2011.3268

2. Cook JL, Purdam C.  Is Compressive Load a factor in the Development of Tendinopathy?  Br J Sports Med.  2012 Mar;46(3):163-8. doi: 10.1136/bjsports-2011-090414.

3. Jayaseelan DJ, Moats N, Ricardo CR.  Rehabilitation of Proximal Hamstring Tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling.  Journal of Orthopaedic and Sports Physical Therapy.  2014 Mar;44(3):198-205. doi: 10.2519/jospt.2014.4905. Epub 2013 Nov 21.