One of the reasons that this is a syndrome is due to the same tendon/muscle complex can cause pain in so many places. These include:
- Arch area
- Navicular Tuberosity
- Medial Foot and Ankle
- Medial Shin
- Posterior Tibia
This study has linked the pain in the medial tibia to hyperpronation.
This study has linked the pain in the medial shin to arch collapse via the navicular drop test.
This article ties the improvement in pain with the use of orthotic devices.
This article ties the improvement in pain with improvement in knee valgus.
It was back in the 1980s when rotatory stress and resultant abnormal muscle pull was finally added to the list of causes of stress fractures. Non-weight bearing bones like the pelvis (ischial tuberosities) and chest (ribs) were breaking and blamed on excessive or abnormal muscle pull. The sports medicine world was so excited that stress fractures could be unrelated to poor shock absorption. Of course, it could be both at times, and one of those areas concerns medial shin splints. 10% of cross country runners that do not clear their early season shin splints should be worked up for tibial stress fractures.
>> Anatomy, Bony Pelvis and Lower Limb: Tibialis Posterior Muscle
The fibula also is a bone that develops stress fractures with abnormal peroneal muscle firing and has no relationship to weight bearing.
Why am I bringing this up? Patients who present with medial shin splints, typically along the posterior medial border of the tibia, are typically blamed on the posterior tibial tendon and/or poor shock absorption. The treatment can be centered on pronation control with orthotic devices and stable shoes, or better shock absorption from orthotic devices and neutral shoes. Podiatrists tend to think more pronation caused, and other sports medicine disciplines more shock absorption caused. Both the rotatory forces of abnormal pronation called pronatory moments, or the excessive vertical forces of GRF (components from each of the 3 planes involved), can cause shin splints or occult stress fractures. Therefore the muscle pull for pronatory deceleration, the muscle pull for bone protection, or the GRF and tibial compression forces can cause the classic periostitis, muscle myositis, or tibial stress reactions/fractures. Your gait evaluation of their running gait in their present shoes will probably teach you the most for discernment as to the appropriate treatment direction.
When you first see these patients, it is important to check for over pronation, and/or shock absorption problems. It is also important to rule out Vitamin D deficiency and other bone health concerns (like inadequate caloric intake). Talk to them about how they train as it may be obvious that they run too many downhills, or too many days in a row, or that they are increasing their weekly mileage too fast. Some runners overstride and therefore slam their heels too hard. Some runners are too stable and hard of a shoe, or a shoe that is too unstable for them. The list goes on, but if you can help a little in multiple areas, like having them run every other day, not running downhill at the end of their runs, you can dramatically help them.
Stress fractures of the tibia are common, but typically present with pain in the same area. The tibial compression test is a great help identifying these patients, along with x-rays. The compression test will be from anterior to posterior with your forearm behind the leg and your other palm pushing downward from anterior to posterior. The palm pressure should be 3-4 inches above the point of maximal tenderness described or pointed to by the patient. A negative tibial compression test is pretty conclusive for no stress fracture, a fracture you may never see on x-rays.
Next week I will talk some about accessory navicular pain, another version of posterior tibial pain syndrome.
