Shin Splints Management: A Physical Therapy Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for the management of shin splints, specifically Medial Tibial Stress Syndrome (MTSS). This protocol is a guideline and should be modified based on individual patient presentation, symptoms, and response to treatment. Close communication between the physical therapist, patient, and referring physician is essential.

Pathophysiology

Medial Tibial Stress Syndrome (MTSS), commonly known as shin splints, is an overuse injury resulting in pain along the medial tibia. The exact etiology is still debated, but it is thought to be due to repetitive stress on the tibia, periosteum, and surrounding musculature (tibialis posterior, soleus, and flexor digitorum longus). Contributing factors include:

• Sudden increases in training intensity or volume
• Improper footwear
• Running on hard or uneven surfaces
• Biomechanical abnormalities (e.g., excessive pronation, leg length discrepancy, decreased ankle dorsiflexion)
• Muscle imbalances (e.g., weak calf muscles, tight hip flexors)

Common Special Tests

• Palpation of the Tibia: Direct palpation along the medial tibial border to assess for tenderness and pain reproduction.
• Hop Test: Single leg hop test to assess for pain provocation. This can be a single hop, triple hop, or timed hop.
• Navicular Drop Test: To assess for excessive pronation.
• Gait Analysis: Visual observation of gait pattern to identify biomechanical abnormalities.
• Ankle ROM Assessment: Assessing for limitations in dorsiflexion, plantarflexion, inversion, and eversion. Consider both weight-bearing and non-weight-bearing ROM.

Phase I: Protection (Pain and Inflammation Management)

Goals: Decrease pain and inflammation, protect injured tissues, and restore pain-free range of motion.

• Duration: Typically 1-2 weeks, or until pain is well controlled at rest and with light activity.
• Treatment:
  • Rest/Activity Modification: Cease or significantly reduce aggravating activities. Consider cross-training activities that are pain-free (e.g., swimming, cycling with minimal resistance).
  • Pain Management:
    • Ice: Apply ice packs to the affected area for 15-20 minutes, several times a day.
    • Modalities: Consider other modalities such as electrical stimulation (TENS, NMES), ultrasound, or phonophoresis as indicated.
    • Pain Medication: Discuss the use of over-the-counter pain relievers (e.g., ibuprofen, naproxen) with the patient and their physician.
  • Range of Motion (ROM):
    • Ankle Pumps: Perform gentle ankle pumps (dorsiflexion and plantarflexion) to maintain ROM and reduce stiffness.
    • Towel Stretch: Use a towel to gently stretch the calf muscles (gastrocnemius and soleus).
    • Alphabet Tracing: Trace the alphabet with the foot to improve ankle mobility.
  • Soft Tissue Mobilization: Gentle soft tissue mobilization to the calf muscles (gastrocnemius, soleus, tibialis posterior) to address muscle tightness and improve circulation.
  • Orthotics: Consider orthotic intervention if biomechanical abnormalities (e.g., excessive pronation) are present.
• Criteria for Progression:
  • Pain level at rest is minimal (0-2/10).
  • Pain-free ROM of the ankle.
  • Ability to perform basic activities of daily living without significant pain.

Phase II: Loading (Strengthening and Early Return to Activity)

Goals: Gradually increase load on tissues, improve strength and endurance, and begin a controlled return to activity.

• Duration: Typically 2-4 weeks, depending on individual progress.
• Treatment:
  • Strengthening Exercises:
    • Isometric Exercises: Progress through isometric ankle exercises in dorsiflexion, plantarflexion, inversion, and eversion.
    • Theraband Exercises: Implement theraband exercises for ankle strengthening in all directions (dorsiflexion, plantarflexion, inversion, eversion).
    • Calf Raises: Start with seated calf raises and progress to standing calf raises (bilateral then unilateral). Consider variations with bent knee (soleus focus) and straight knee (gastrocnemius focus).
    • Tibialis Anterior Strengthening: Heel walks to strengthen tibialis anterior.
    • Hip Strengthening: Include exercises for hip abductors (e.g., side-lying hip abduction, clamshells), hip extensors (e.g., glute bridges, hamstring curls), and hip external rotators (e.g., resisted hip external rotation).
  • Proprioceptive Training:
    • Balance Exercises: Begin with double-leg standing balance and progress to single-leg standing balance. Consider using unstable surfaces (e.g., foam pad, wobble board).
  • Cardiovascular Training: Begin low-impact cardiovascular exercises (e.g., elliptical, cycling) and gradually increase intensity and duration.
  • Gait Retraining: Focus on improving running form and addressing any biomechanical abnormalities. Consider reducing stride length and increasing cadence.
  • Soft Tissue Mobilization: Continue soft tissue mobilization as needed to address muscle tightness and improve flexibility.
• Criteria for Progression:
  • Minimal pain with strengthening exercises.
  • Adequate strength and endurance to perform functional activities.
  • Ability to tolerate low-impact cardiovascular exercise without pain.

Phase III: Return to Function (Advanced Strengthening and Sport-Specific Training)

Goals: Restore full function, return to sport or activity without pain, and prevent recurrence.

• Duration: Typically 2-4 weeks, depending on individual progress and sport.
• Treatment:
  • Advanced Strengthening Exercises:
    • Plyometric Exercises: Gradually introduce plyometric exercises (e.g., jumping jacks, squat jumps, box jumps) to improve power and explosiveness.
    • Sport-Specific Drills: Incorporate sport-specific drills that mimic the demands of the patient's activity.
    • Agility Training: Introduce agility drills (e.g., cone drills, shuttle runs) to improve speed, coordination, and agility.
  • Cardiovascular Training: Progress to higher-impact cardiovascular exercises (e.g., running, sprinting) and gradually increase intensity and duration.
  • Running Progression: Follow a structured running progression program, gradually increasing distance, speed, and intensity. Consider interval training.
  • Maintenance Program: Develop a home exercise program to maintain strength, flexibility, and proprioception and prevent recurrence.
  • Footwear and Surface Evaluation: Optimize footwear and running surfaces to minimize stress on the lower legs.
• Return to Sport Criteria:
  • Pain-free with all activities.
  • Full strength and ROM.
  • Successful completion of sport-specific drills.
  • Passing a functional test (e.g., hop test, agility test).

Disclaimer: This protocol is a general guideline and should be adapted to meet the individual needs of each patient. It is essential to consult with a qualified physical therapist or healthcare professional for a thorough evaluation and personalized treatment plan.