History and Presenting Symptoms
:dropcap_open:T:dropcap_close:he patient, a 27-year-old female, is a media designer who has been running regularly for the past eight years. She reports the recent onset and gradual worsening of pain in the front of her left lower leg, which is now limiting her regular physical activities. The leg pain is described as an “aching soreness” that has been getting progressively worse. She recalls no specific injury, and has no obvious swelling or discoloration. Her left leg pain becomes particularly noticeable when she runs downhill or tries to increase her mileage. There is also now a mild persistent aching in her left buttock region. She is planning on running her first 10k race in four months.
Exam Findings
Vitals. This active young woman weighs 122 lbs, which at 5’4’’ results in a BMI of 20.9 – she is at normal weight. She doesn’t drink alcohol or smoke, and her 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 her spine, although she shows evidence of a left posterior ileum. She has mild calcaneal eversion, with a lower left arch. Treadmill gait evaluation indicates obvious hyperpronation of the left foot and ankle when running. Standing Q-angle is measured at 27° on the left and 22° on the right (20° is normal for women).
Chiropractic evaluation. Motion palpation identifies a limitation in her left sacroiliac motion, with mild tenderness and loss of endrange mobility. Yeoman’s provocative test elicits moderate pain upon prone extension of the left leg. Neurologic testing is negative.
Primary complaint. Palpation of the left lower leg finds tenderness and tightness of the muscle insertions in the lower third of the tibia, along the anterolateral aspect. Manual testing identifies mild weakness of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles, and the isometric testing elicits increased pain in these muscles. There are no sensory or reflex changes, and no significant asymmetry in muscle mass or leg diameter. All ankle joint ranges of motion are full and pain-free, bilaterally.
Imaging
No x-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
“Shin splints” in the deceleration muscles of the left ankle, along with an elevated Q-angle and foot pronation. This is accompanied by left sacroiliac joint motion restriction and dysfunction.
Treatment Plan
Adjustments. Specific side-posture adjustments for the left sacroiliac joint were provided. Manipulation of the left navicular and calcaneal bones was performed to reduce the biomechanical stress on the medial arch and sub-talar joint.
Support. Individually designed stabilizing orthotics were provided to support the arches and decrease impact at heel strike. Two pairs of orthotics were ordered: one for her job-related dress shoes and the other for her running shoes.
Rehabilitation. Full-range resistance exercises (using surgical tubing) for the anterior tibialis muscles were performed daily; her efforts were recorded in a log. This program progressed to focus on strengthening the eccentric (deceleration) phase in particular. She was able to continue her distance-running training program.
Response to Care
She responded well to the sacroiliac and foot adjustments, and reported a rapid decrease in her leg symptoms. Within two weeks (after introducing the orthotics), she was able to return to her previous distance-running training program. She reported that she felt that her gait was smoother, and that she felt her heel strikes were less stressful. After a total of eight treatment sessions she successfully completed her first 10k race. She described moderate, bilateral post-run leg soreness, which resolved within two days. She then returned to regular running with no persistent or recurrent discomfort.
Discussion
Moderate biomechanical asymmetries can become more prominent (and symptomatic) when levels of physical stress and training volume increase. This seems to be especially true in the lower extremities. Shock-absorbing stabilizing orthotics incorporate support for the arches while they reduce pronation and decrease the stress of repetitive heel strikes on the foot and spine. Anterolateral shin splints indicate a problem with deceleration of the foot at heel strike, which requires improvement of eccentric strength of the anterior tibialis muscle and its co-contractors.