Case Study March 2017 – Sports Podiatrist Treats Shin Splints

In March 2017, a keen runner and athlete of 41 years of age presents to the sports podiatrist complaining of pain in the lower half of both legs. This patient is 176 cm tall and weighs 98 kilos. His typical training regime is to run approximately 15 km on a Saturday and approximately 20 km on a Sunday. He reports to the sports podiatrist that he also attends a gymnasium in Sydney by the name of F45 training.  He describes a sharp pulling pain in the lower part of his tibia on the medial aspect, just around the ankle area. He informs the sports podiatrist that the pain has been mild for approximately 12 months but more severe for the last 3 months. He explains that previously he was able to push through and keep running and the pain would become manageable. However, more recently the pain has spiked considerably and the longer runs are now unbearable, and he has been forced to stop running. The patient explains to the podiatrist that he has flat feet and has always suffered with this biomechanical anomaly. He recalls as a child having to wear special shoes and later in life required orthotics. This gentleman runs in a Brooks adrenaline sports shoe with a prescription orthotic inside. Prior to the Brooks adrenaline, informed the sports podiatrist he was running in the Nike lunar glide which offers less support. His current orthotics are approximately 7 years old and are made from a flexible polypropylene material. Prior to exercise he performs several stretches and pays close attention to the hamstring and calf muscle range. Post exercise he carries out the same stretches.

The sports podiatrist requests to examine the patient’s day-to-day footwear in addition to his running shoes. It becomes apparent that the footwear that this patient is using on a day to day basis is inappropriate. He walks to and from the office in very soft flat and flexible business shoes which compress under load and do not offer support. In the evenings and weekends this patient walks in Converse street shoes and Asics tiger which are also very flat and flexible offering minimal support.  The sports podiatrist explains to the patient that he will need some education surrounding the types of shoes that he should be wearing.

Before coming to the sports podiatrist, this patient attempted dry needling and deep tissue massage. While the massage provided some short-term relief and the acupuncture reduced the pain significantly, both of these treatments provided only short-term benefit and the pain would return quickly. This gentleman reports to the sports podiatrist that he does in fact feel the pain in his shins when walking the streets to and from work and in the evenings and weekends if he walks for long enough.

Physical Assessment by Sports Podiatrist – Karl Lockett

The sports podiatrist carried out a thorough physical assessment to determine which part of the leg had been affected by this gentleman’s running. This involved palpation of the muscles and tendons around the tibia, ankle joint, subtalar joint, rear foot and midfoot. The patient reported pain when firm pressure was applied to the tibialis posterior tendon, inferior to the ankle, and at the navicular insertion. Pain was also apparent more proximally in the lower third of the tibia, medially. The sports podiatrist confirmed and advised the patient that he had a condition known as tibialis posterior tendonitis, also known more generically as shin splints.

The Sports Podiatrist Checks the Patient’s Orthotics

The podiatrist advised the patient that it was important to carry out an orthotic check up to determine whether or not his current devices we’re providing sufficient support and control.  The orthotics were removed from his running shoes and placed on a hard flat surface and the patient was asked to stand on top of them in his bare feet. It was immediately apparent that this patients’ existing orthotics had compressed over time and no longer provided the support that he needed. Both of the orthotics compressed under load as the patient stood on top of them and failed to keep their shape. They no longer possessed the recoil properties that they would have had when new.

Biomechanical Assessment by Sports Podiatrist

The patient was asked to walk and run on a treadmill in his bare feet while the sports podiatrist recorded his gate using digital software. The footage was replayed in slow motion and it became quite clear that this patient had an extremely unstable foot type which over pronated significantly. More often than not, this foot instability is due to an inherent weakness caused by loose ligaments. Unfortunately, foot exercises and muscle rehabilitation of the intrinsic foot muscles do very little to help the situation. Foot orthosese provide the support and control that the ligaments do not offer.

Treatment Plan by Sports Podiatrist – Karl Lockett

The patient was advised by the sports podiatrist that his treatment plan would involve replacing his existing orthotics. The technology used to scan the foot and manufacture foot orthoses had improved significantly since this patient’s last pair of orthotics. The podiatrist captured 3D digital foot scans for the patient. The patient was given the option to have his orthotics manufactured using polypropylene or carbon fibre. Most runners agree that carbon fibre is a preferred material as it is stronger thinner and lighter, and does not occupy as much space inside the running shoes. The patient agreed that the feel good factor from the carbon fibre material would be preferred. To this end, the sports podiatrist designed sports orthotics for this patient running shoes. The orthotics designed by Karl were to be significantly different to his existing orthotics. This patient would not receive sufficient control from a standard modified root device. The podiatrist explained to the patient that he needed a much more controlling orthotic with significant levels of rear foot inversion, such as a Blake device.

Orthotic Fitting Into Running Shoes

This patient returned to the sports podiatrist to have his new orthotics fitted into his existing running shoes. The patient was observed walking and running on the treadmill and the video footage was replayed in slow motion. The foot and ankle alignment was satisfactory and the patient reported to the podiatrist that his orthotics felt comfortable.He patient was asked to refrain from running for two weeks, and to walk with his orthotics as much as possible.

The sports podiatrist also recommended that the patient continue to carry out rigorous stretching, in particular the calf muscles. However, this patient was carrying out stretches with his foot in an pronated position. This rendered his calf stretches ineffective. The sports podiatrist demonstrated and educated the patient, realigning his foot to achieve maximum benefit. The patient immediately reported that he could feel a significant difference in the calf muscle while performing the stretches.

Orthotic Follow Up with Sports Podiatrist – Karl Lockett

After 3 weeks, this patient returned to the sports podiatry clinic for a follow up with Karl Lockett. He reported that he had been using his orthotics on a daily basis and had been walking only, not running. He was feeling comfortable in his orthotics and his shin pain had reduced by approximately 30%. The sports podiatrist suggested that the patient commence some short runs. The advice was 2 to 3 km Max and only two runs per week.

A follow-up was carried out after a further 6 weeks.The patient reported a further reduction in pain. He had increased his runs to 6 km 3 times a week and overall was feeling 60% better. He had also been applying cold ice packs to the affected areas on a daily basis.

The patient returned to see sports podiatrist Karl Lockett again after a further 6 weeks. He reported a further reduction in pain and also a much improved range of motion in his calf muscles.

The patient was advised to continue to run and perform in a way that he was comfortable and able to do. He was advised to pull back from exercise if his condition deteriorated and to return to the clinic to see the podiatrist if he was concerned.

This case study is not general advice. If you have shin splints you should seek the advice of a sports podiatrist or other medical practitioner.