History and Presenting Symptoms
An 18-year-old baseball player presents with aching pain and tightness in his left lower leg. He describes a collision injury during a game four days earlier, which resulted in pain and bruising in the front of his leg after sliding into second base. Despite repeated icing, the area still feels swollen. He describes this as “shin splints.”
Vitals. This very fit young athlete weighs 150 lbs, which, at 5’10’’, results in a BMI of 23—he is not overweight. He is a non-smoker, and his blood pressure and pulse rate are both at the lower end of normal range.
Posture and gait. Standing postural evaluation finds generally good alignment throughout his spine and pelvis, with normal spinal curves and no lateral curvature or listing. The knees and ankles are also well aligned, with no knee varus or valgus, and no calcaneal eversion or foot flare. Both medial arches are somewhat high, and gait evaluation finds excessive supination, with insufficient pronation.
Chiropractic evaluation. Motion palpation and joint play analysis identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of end range mobility at the left of L4/L5.
Primary complaint. Examination of the left lower leg finds moderate tenderness and tightness along the anterior tibialis musculature. There is loss of sharp sensation discrimination in the lateral aspect of the foot, but no numbness or paresthesia. The left foot intrinsic muscles demonstrate no weakness, and he has no difficulty performing toe extension. All ankle ranges of motion are full and pain-free, except inversion is limited by the tightness of the anterior tibialis muscle. The left cuboid is tender to palpation and demonstrates a lateral subluxation.
Imaging. No X-rays or other forms of musculoskeletal imaging were requested.
Anterior compartment syndrome in the left lower leg, associated with mild neurological compression.
Adjustments. Specific, corrective adjustments for the lumbar spine and left cuboid were provided as needed.
Support. Custom-made, stabilizing orthotics were supplied to support the high arches and decrease the shock stress on the legs and spine from excessive supination.
Rehabilitation. Initially, frequent Proprioceptive Neuromuscular Facilitation (PNF) stretching followed by icing treatments was performed to lengthen and relax the anterior tibialis musculature. As improvement was noted, isotonic resistance exercising in inversion activated and strengthened the antagonists of the anterior tibialis muscle. Finally, a comprehensive strengthening program using exercise tubing prepared him for a return to full athletic capability.
Response to Care
The stretches and adjustments were well tolerated, and he reported a decrease in symptoms within the first 24 hours. After two weeks of care, he was able to return to practice, including light running. He responded well to the orthotics, and was released from care after a total of eight treatment sessions over six weeks.
The commonly used term “shin splints” is a non-specific description of pain in the lower leg. Several conditions can produce pain in this area, and must be differentiated for effective treatment. High arches and excessive pronation may predispose athletes to the development of shin splints. While most causes of shin splints are easily treated with conservative means, anterior compartment syndrome that causes neurological impairment may need to be surgically decompressed.
Persistent pain in the lower leg following sports activities may indicate an increase in intramuscular pressure in one of the osteofascial compartments. Acute trauma can cause the internal pressure of a muscle to elevate excessively during exercise and stay high for a prolonged period post-exercise. While there are five fascial compartments, the anterior compartment is most frequently involved, making the pain area similar to shin splints. Sensory changes are often evident distally; paresthesias may involve the first web space, the instep, or the lateral aspect of the foot. If elevated intracompartmental pressures persist, permanent damage to muscle tissue and nerves can develop, making early surgical decompression of the involved compartment mandatory.
Prompt, conservative care allowed this relatively mild case to be treated without surgery. The custom-made, stabilizing orthotics provided support and shock absorption during future athletic activities, and no recurrences were reported.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at [email protected].