I hope you enjoyed the last article, and those of you who put it to practice have seen results. In this issue I will cover treatments for lower extremities, moving finally to the calf.

Shin Splints

Shin splints are a common injury to all runners. Although it’s seen more with a beginner, even the most accomplished runners will at some time suffer from this prevalent runner’s injury. Most often it occurs when the runner is changing to a new shoe that does not have the same arch support. Another common initiation of the injury is when a runner changes the duration of training; in other words, overuse. Other contributing factors include a change of the runner’s training surface — harder surface may stress the shin with continuous use. Fallen arches will affect the shin muscles as well, and therapists might see a mild shin splint developing due to the arch going flat.

Of course, the simplest-made change to address shin splints is to deal with the cause of the shin splint (i.e. one of the above mentioned or other causes). The problem, however, is that the condition will not simply go away without weeks of rest or some form of therapy. Shin splints also can occur on either side of the shin. Let’s look at both the conditions and causes.

Anterolateral Shin Splints

The anterior muscles of the shin are the tibialis anterior, extensor hallucis longus and extensor digitorum longus. These muscles are used after the heel comes in contact with the ground surface — they hold the foot up during the foot’s contact with the ground. Heel spurs and regular overuse of these muscles lead to intermittent pain. If the athlete continues running, the pain progresses to a “constant” pain. The athlete will feel severe tenderness, especially with touch, due to edema from muscle inflammation.

Postermedial Shin Splints

The muscles which make up the posterior compartment are flexor hallucis longus, flexor digitorum longus and tibialis posterior. The function of these muscles is to supinate the foot. These muscles get overused during pronation while running, running on uneven surfaces (such as in the woods or on unleveled roads), or with fallen arches. Most often the pain begins near the foot (medial side) and progresses up to the knee. Standing on one’s toes causes more pain, and in time the pain can progress to the upper portion of the lower extremity. If the athlete continues to run, the tibialis muscle will start separating from its attachment to the tibia. This will cause severe edema in the areas where the muscle has separated from the bone, and even hemorrhage.

Treatment

As mentioned in the last column, the athlete will need to stop running in order to prevent any further damage. Taking a good look at the runner’s shoes, especially the heel and arch supports, is a must. A trip to a physical therapist can help the athlete evaluate the problems of how the foot comes in contact with the ground — excessive pronation or supination can be observed. Since runners are often seen while they’re training for competition, the idea of them not running may cause severe depression. I recommend running in deep water. This eliminates contact with the ground, during which the problem occurs, and the runner can keep his cardiovascular workout intact. This will also aid the healing process since the muscles will continually undergo the workout.

Hands-On Treatment

Due to the severity of the damage, and the presence of edema and possible muscle separation from its attachment to the bone, do not apply any downward pressure. The therapist should make sure their hands are relaxed when they come in contact with the tissue, since any “hard” touch will cause more tissue damage. If the area is very tender to touch, the therapist needs to use only gliding strokes for the first one to three treatments. The athlete should be supine, with the extremity resting on a few large, firm pillows. The therapist should spread his fingers and gently place them over the shin. Depending on the area of the shin splint (anterior or posterior), begin with the other side (for anterior damage address the posterior side first). After 2–3 minutes of continuous (i.e. one hand follows the other when the first one reaches the knee) gliding on the non-affected area, the therapist moves to the area of damage. If the athlete complains of any pain or discomfort, the therapist should move back to the opposite area, and every 3–4 seconds simply glide over the area of pain. The number of passes over the injured area should be increased, and after 1–2 minutes you will be able to work in the area of pain.

To reiterate, it is very important that the therapist not apply any downward pressure since this will increase the chance of edema, hemorrhage and possibly more tissue damage. The first treatment may only consist of gliding strokes, but might also incorporate some side-to-side, gentle shaking moves to begin muscle recovery. If this causes any pain, the therapist should stop immediately, and go back to gliding only. This treatment can be performed several times a day for best results, and it is important the athlete does not run on ground surfaces during the treatment period. As edema is resolved, the therapist can start working on getting greater arterial flow by doing pressure-stretching movements over the area of damage. Make sure wide touch (such as heel of hand, or ulnar side of the hand) is used and not fingers when pressing down. Make sure the depth of touch is fairly superficial at first — similar to rubbing the skin when you are cold. This will get the skin circulating with arterial blood, and the tissue underneath will get some of that circulation as well. This portion of the treatment can be done every other day. As the athlete’s pain decreases, the treatment may progress to a greater depth with the pressure stretching in order to increase elasticity of the involved muscles. This will allow faster healing of the tissue and a return to running. This condition, when treated correctly, can be addressed in six to 10 treatments (about two to three weeks). Each treatment should last 10–15 minutes.

Achilles Tendinitis and Calf Muscle Strain

T he Achilles tendon attaches the gastrocnemius muscles to the heel (that is why it is also called tendo calcaneus) and it participates in lowering the foot to the ground after the heel comes in contact with the surface, or raising the heel after “toeing off.” Since runners most often land on their heel, not the whole foot, the Achilles tendon experiences greater stress. This stress becomes more severe when athletes run up or down hills. Once again the type of running shoe can be of importance. If the heel does not have an extra support, or if the shoe is not laced properly and allows for side-to-side motion of the heel, the Achilles tendon is at risk of damage. Other causes of this condition can include fallen arches, which leads to over-pronation and overuse of the calf muscles, tight or strained calf muscles, or even strained hamstrings (causing gastrocnemius to contract in order to create a balance). Whatever the cause, however, the result is the same — the Achilles tendon becomes strained.

At the beginning stages of Achilles tendinitis, the tissue surrounding the tendon gets inflamed (inflammation of the paratendon). During this stage of the tendinitis, the pain is felt after prolonged rest (such as sleep), or at the beginning of exercise. As the athlete becomes active, the pain decreases. The tendon is tender when squeezed, but not to downward pressure. If this stage of tendinitis is not addressed, and the athlete continues to run, the inflammation will spread to the tendon itself. The pain becomes constant with movement increasing the pain, rather than making it go away.

Treatment

Please follow previous suggestions regarding shoes and running in deep water. All ground running should stop during the treatment. Begin with the muscles of the calf, since the tendon is a part of that structure. Also, address some of the symptoms of the tendinitis itself (such as edema), by working on the more vascular portion of the structure. The athlete should be placed in a prone position, with the foot resting on a few firm pillows. I prefer a few pillows to a small bolster, because this will provide a much better support for the whole calf. Divide the calf muscles into three sections: 1) the belly of the muscle, 2) the musculotendinous junction and 3) the Achilles tendon. The therapist’s work will begin with the “preliminary” treatment of the calf muscles.

The work begins over the belly and the musculotendinous junction with deep, continuous, gliding strokes. These strokes should move toward the knee, since this is how the draining of any swelling can be aided. These moves will also get the tissue ready to receive touch, which to an injured muscle is an intrusion. After 1–3 minutes of gliding, you should see a decrease of edema in the Achilles tendon. Progress to pressure stretching of the gastrocnemius belly by using heel of the hand or medial phalanges of the soft fist. At this point only the belly of the muscle is being worked.

After the tissue becomes more pliable and you see an increase in arterial flow to the area (increase in hyperemia), work may progress to the next section of musculotendinous junction. This portion of the muscle is made out of connective tissue and striated fibers. It is a lot less pliable than the belly of the muscle, but not as inelastic as the tendon. Continue with the same pressure stretching as before. After the change has occurred in the area beingworked, progress to the tendon itself. If the calf is constricted, 90 percent of the treatment may consist of calf pressure stretching (without moving the tendon itself). This will also be the case for the calf muscle strain. In fact, the treatment, which we call “preliminary” for Achilles tendinitis, also is the treatment I use for calf muscle strain.

On the tendon itself, gliding motions with a cupped hand over the heel and through the tendon should be used. This will prepare the tendon for the deeper touch, as well as move any leftover edema away from the tendon. The pressure on the tendon will go from light to moderate to great. This may not occur all in one treatment, but at times I am surprised to see how quickly the athlete responds, and I may go through the whole sequence in the same treatment.

The therapist should begin with deep, gliding strokes by creating a “pinching” grasp, and glide upward with the tendon in between your pincer grasp. After 30–45 seconds, progress to flat, two-finger pressure stretching (use middle and index fingers) of both hands. Start at the heel and in an “up-and-back” motion, slowly move through the tendon. At this time, both hands are moving in the same direction at the same time. To increase depth, the therapist should move the hands in alternate directions. After 1–2 minutes, place the ulnar side of the hand on either side of the tendon, and in a sawing motion, stretch the tendon. This area will have to be worked 5-plus minutes before you can progress to the next move, due to the depth of the next move. The therapist places flat thumbs on top of the tendon, while supporting it with the bent index finger on either side. Pressing the thumbs down, the therapist moves their elbows back and forth, pressure stretching the tendon. At this point, both hands are moving in the same direction, at the same time. Once again, the therapist may make the depth increase by moving your hands in alternate directions.

This treatment is best when done every other day, 10–12 times. The athlete may resume training after the seventh to ninth treatment, or when the pain is gone. It is very important to stretch the calf muscles before running to avoid this injury, and as I explained earlier, to address the shoe, heel, arch and over-pronation to prevent all of the injuries we discussed. In the next column, Al Devereaux will share his personal experience of hamstring strain, and we will also cover iliotibial band strain.