According to the Bureau of Labor Statistics, 19.3 % of the US population was engaged in a sports activity each day in 2019. Running is one of the most popular and practiced sports worldwide. Globally, the estimate of participation in running is 626 million people.
- Global running gear equipment sales were 36.8 billion dollars in 2021.
- 40-49 years old is the most popular age group in a review of data from 28 countries.
- The biggest number of formal race runners is in the United States.
- 18.1 million people in the US registered for a road race in 2018.
There has been a 65% increase in running and jogging participation in the US over the past 3 years. According to a 2017 survey, 60 million people run, jog, or trail run in the U.S. An estimated 110 million people engage in walking for fitness.
According to a Yale University study, 50% of runners get some type of injury yearly.
The most Common running injuries:
- Plantar Fasciitis
- Runners Knee
- Iliotibial Band Syndrome
- Achilles Tendonitis
- Shin Splints
- Stress Fractures
Medial Tibial Stress Syndrome- Shin Splints
Medial tibial stress syndrome (MTSS) is an overuse condition specifically a tibia bony overload injury. MTSS is an inflammation of the muscles, tendons, and bony tissues in the tibia area. It has an associated periostitis (a layer of connective tissue that envelops the surface of the bones)
Shin splints are commonly seen in runners, jumping sports and military personnel. The incidence ranges between 13 to 20% in runners to 35% in the military.
Cause of Shin Splints
Significant increase of loads, volume and high impact exercise predisposes to MTSS. In general, shin splints develop when the muscles and bony tissue (periosteum) in the anterior lower leg are overworked by repetitive activity such as sudden changes in physical activity. Changes in the duration and intensity such as military training or running flats surfaces to hills can cause shin splints.
Contributing Factors
- Female gender
- Previous history of shin splints
- Excess weight
- Flat Feet- foot pronation
- Improper footwear or worn-out footwear
- Vitamin D deficiency
Risk Factors For MTSS
Four significant risk factors have been identified in studies:
- Increased BMI is a poorly misunderstood index because highly trained athletes and the military both have increased BMI. Athletes because of the muscle mass and lower fat and the military because of the loads they carry in their packs and weapons. A better BMI might be mass relative to height. During exercise, the tibia bends and bows as a response to activity. This causes a micro-trauma which helps strengthen, build and the tissue learn to adapt. MTSS can occur when the load of normal micro-trauma is exceeded. A steady controlled increase in intensity during activity allows the tibia and surrounding tissue to adapt properly.
- Increased navicular drop is the second risk factor identified. When the navicular bone is loaded with increased pressure and travels greater than 10 mm, the likelihood of MTSS is doubled. It is felt the rigidity of the foot causes lower tibial rotation and impact forces are transferred up the leg causing MTSS.
- Greater plantar flexion is also a risk factor. This alters the mechanics of the foot and causes a greater push off while running. This greater angle of push off, causes pressures on the tibia.
- The fourth risk factor identified is greater hip external rotation. It is felt the alteration of the angle of the femoral neck at the hip joint increases torque on the tibia.
Pathophysiology
The overall process that results in MTSS is microdamage accumulation in the cortical bone of the tibia. This is a inflammatory process in the periosteum at the site of the injury. Usually, this site is the tendinous attachment of the soleus, flexor digitorum longus and the posterior tibialis muscles of the leg.
Sharpey’s fibers are a matrix of connective tissue consisting of strong collagen type 1 fibers connecting periosteum to the bone. It is felt that traction on these fibers pulls the fibers away from the bone causing a periostitis and ultimately a microtrauma to the bone.
Physical
- Shin Splints commonly occur in the distal 2/3 of the tibia along the medial border
- Pain is reproduced by exercise
- Pain is reduced or totally relieved by rest
- Total absence of cramping, burning or numbness of the foot is common
- Swelling, erythema, loss of distal pulses are NOT typical of shin splints
- Palpation of the posteromedial tibial border reproduces the pain in shin splints
Evaluation
Medial Tibial Stress Syndrome is a clinical diagnosis that can be made with a history and physical exam. Imaging or other testing is done to exclude other common exercises induced lower extremity injuries.
- X-rays- Plain radiographs are normal even in an early stress fracture. However, findings of a “black line” in this area is indicative of a stress fracture
- MRI- indicated for imaging of stress fractures or bone injury
- CT scans- can be used however lower sensitivity than MRI or nuclear scans
- Nuclear Imaging- can be used and often in severe MTSS will show increased uptake in the area
For repeat cases, testing vitamin D levels is indicated to rule out a deficiency.
Differential Diagnosis
- Tibial Stress Fractures
- Chronic Exertional Compartment Syndrome
- Popliteal Artery Entrapment
- Peripheral Arterial Disease
- Tendonitis
Tibial Stress Fractures are difficult to distinguish from MTSS and are a continuum of the same disorder. Shin splints can lead to tibial stress fractures.
Chronic Exertional Compartment Syndrome is a muscular disorder characterized by pain during exertion and relief with rest. Pressure builds up with exercise. It is commonly seen in both lower extremities and other symptoms associated with this problem are paresthesias, pallor, cold skin and loss of pulses distally in the extremity. The diagnosis is made by measuring the compartment pressures before and after exercise.
Popliteal Artery Entrapment is due to anatomic variation causing entrapment of the popliteal artery in the popliteal fossa during exercise. During exercise, the circulation is compromised.
Peripheral Arterial Disease has many etiologies, commonly seen in atherosclerosis. Claudication, a crampy pain in the leg induced by exercise is caused by the obstruction of the arteries.
Tendonitis occurs when the tendons which attach the muscles to the bones get inflamed. Tendons can also be partially torn causing pain.
Treatment
Non Surgical
- Rest- Treatment of Shin Splints is usually conservative. Rest and activity modification. (There are no recommendations for duration of rest.)
- Lower impact types of activities can be substituted while healing occurs such as swimming or stationary biking.
- NSAID- such as Motrin for pain and swelling
- Ice- cold packs for 20 minutes several times a day
- Compression- for short term use
- Shoes- foot-ware is extremely important and should have good cushioning
- Orthotics- people who have flat feet or recurrent shin splints may benefit from orthotics
- Others- iontophoresis, ultrasound, extracorporeal shockwave therapy
- Limited value but mentioned in the literature- low energy laser, lower leg braces, compression stockings
- Physical Therapy- helping to address altered body mechanics
- Platelet-Rich-Plasma
Surgery
Surgery is rarely used for shin splints. It has been done in refractory cases however it is not clear how effective surgery is in this condition unless there are severe stress fractures.
Prevention
- Proper fitting athletic shoes for runners and the shoes should be replaced often.
- Cross train- runners should alternate jogging with lower impact sports such as swimming or cycling
- Slowly build the fitness level by increasing duration, intensity and frequency gradually
- Barefoot running- there are some claims that barefoot running spreads the impact throughout the lower extremity and therefore no area is overloaded. No studies are currently available to prove or disprove this theory
Editor’s note
It is quite obvious to this author, rest may alleviate the symptoms but the overall problem still exists. One of the risk factors for shin splints is a prior episode. The problem must be addressed with the regeneration of the tissues and then altering the body mechanics if necessary, so the problem does not reoccur or develop into a stress fracture.
Platelet-Rich-Plasma
Platelet-Rich-Plasma is an autologous blood derived concentrate with increased cytokines and growth factors needed to heal damage tissues. The healing is accomplished by the alfa granules contained on the platelets releasing the substances needed for this repair to take place. The mechanism behind PRP is to enhance the healing cascade in a controlled fashion due to the higher concentration of growth factors and cytokines that are normally physiologically present.
Studies
- Effects and Mechanism of Platelet-Rich-Plasma on Military Drill Injury; A Review Mil Med Res 2020, 7:56 PMID 33220700
With continuous intensification of military drill, the incidence of fatigue injuries, bone and joint injuries, ligament and other soft tissue injuries have gradually increased leading to soldier disability rate and a decrease in attendance rate, which is very detrimental to the improvement of military force. Consequently, it is very necessary to find safer, more effective and minimally invasive rehabilitation treatments to improve soldiers’ physical fitness and combat effectiveness. In this article, we will review the possible role of PRP in the treatment of military drill injury.
Conclusion: Studies affirmed the value of PRP in rehabilitation treatment and laid a foundation for the application of PRP in the post-rehabilitation treatment of military drill injury
- Past, Current and Future Interventional Orthobiologics Techniques and How They Relate to Regenerative Rehabilitation: A Clinical Commentary Int J Sports Phys Ther 2020 Apr; 15(2) : 301-325 Extensive review of the healing process and various orthobiologics
Conclusion: PRP works by providing growth factors that help the conjugation of collagen back to Type 1 collagen and providing collagen that is stronger and more robust than the injured structure.
The author also stated, “ To move orthopedics and sports medicine away from the current emphasis on pain management, the use of NSAID, steroid injections and rest, toward progressive movement combined with strengthening is desired. A combined rehabilitative approach to improving biomechanics along with utilizing regenerative injections such as PRP to induce healing…”
- Platelet-Rich-Plasma in Orthopedic Sports Medicine: State of the Art ISAKOS Vol 4,Issue 4, P188-195 July 01,2019 doi.org/10.1136/jisakos-2019-000274
Platelet-Rich-Plasma is one of the many new developments within the expanding fields of regenerative medicine. It aims to improve the process of tissue repair through local delivery of autologous bioactive agents to influence critical physiological mechanisms such as inflammation, angiogenesis or extracellular matrix synthesis. The current review explores the latest findings on PRP efficacy in several musculoskeletal conditions.
Conclusion: PRP injection combined with a rehabilitation program was significantly more effective in functional recovery time to return to sport than a rehabilitation program alone.
The author did state more rigorous cost-effective analysis, defined algorithms and evidenced- based protocols are needed.
- Platelet-Rich-Plasma Therapy in the Treatment of Diseases Associated with Orthopedic Injuries Tissue Engineering; Part B Vol 26, Number , 2020 DOI:10.1089/ten.teb.2019.0292
The aim of this review is to explore future research in the field of PRP therapy in the treatment of diseases associated with orthopedic injuries
Conclusion: Standardized platelet activation is a crucial step for optimizing the release of various GFs and cytokines during application
In ligament, muscle and tendon injuries, acute and chronic injuries to these tissues are frequently treated in sports medicine and orthopedic associated practice and are the result of excessive and repetitive loading. Studies have demonstrated that activated PRP can stimulate the proliferation of stem cells and the production of tenocytes and abundant collagen.
In the treatment of acute trauma and chronic nonhealing after acute trauma, such as bone injury, wounds, skeletal muscle, ligament, tendon, articular cartilage lesions, OA, and nerve injury, PRP therapy plays a prominent role and leads to good outcomes.
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet-Rich-Plasma Kits are FDA approved and designed for safety and effectiveness. They are cost effective and easy to use. Our kits have been scientifically proven to provide consistency of product concentrations when taken from the same source.
Juventix Regenerative Medical offers a patent pending LED Activator to activate the platelets and begin the regenerative process. The activation, a critical step in the release of cytokines and growth factors, is accomplished with light and not with the addition of other chemicals such as Calcium Chloride or Thrombin.
Juventix Regenerative Medical supplies a Bio-Incubator that transforms the Platelet-Rich-Plasma into an Injectable Platelet-Rich-Fibrin. The Platelet-Rich-Fibrin, commonly referred to as the “second generation of platelet products” has a broader range of clinical applications and provides outstanding outcomes.
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Regenerative Regards,
Dr. Robert McGrath
