Category Archives: Ankle/Foot

Injuries and exercises relating to the ankle and foot

Beginning Therapeutic Exercise for Inversion Ankle Sprains

With a grade 1 ankle sprain, you can begin gentle therapeutic exercise even while there is some swelling and pain (in standing/walking) that remain.  These exercises are designed to be very gentle – and it should be noted that they should be pain-free at all times.   All of them are non-weight bearing and designed to reduce swelling, regain motion, and begin re-training proprioception.

Beginning exercises for a grade 1 sprain (while there is still swelling/pain):

Ankle circles: With the leg supported (or elevated if there is still some swelling), make circles with foot at the ankle.  The goal is to make the largest circles possible, but it is essential that you stay within a pain-free range.  As the ankle continues to heal, you can make the circles larger and larger.  Do 15-20 times both clockwise and counter-clockwise.  This can be repeated 2-3 times a day.

Ankle Circles

Ankle plantar flexion/dorsiflexion: this is simply pointing and flexing the foot in a pain-free range.  With the leg supported (or elevated if there is still some swelling), focus on moving the foot without it twisting in or out.  The goal is smooth and controlled motion.  Do 15-20 times, 2-3 times a day.  Again, keep the motion in a pain-free range and progress when able.

Ankle alphabets: With the leg supported (or elevated if there is still some swelling), write the alphabet with the foot by moving at the ankle.  Be sure to keep the leg still and move slowly and in a pain-free range.  Start with 1-2 times through, from A to Z, and do this 2-3 times a day.

Ankle alphabets: draw the alphabet (upper or lowercase doesn’t matter)

Beginning exercises for a grade 1 ankle sprain (after the pain had subsided):

Once you no longer have pain in the ankle with walking and the swelling is beginning to subside, you can progress to some more advanced exercises.  The goal of this phase of rehab is to continue to restore motion, strengthen the affected muscles, and begin re-training proprioception (in closed chain  – aka in weight bearing).

First, begin by doing all of the exercise listed above for 1 set as the “warm-up.”  Then also include the exercises listed below:

Ankle PREs (progressive resistive exercises): Done with the therapy band, these movements strengthen the muscles of the lower leg that help to externally stabilize the ankle.  The key to these exercises is to only move the foot/ankle and keep the lower leg still.  Be sure to have the leg supported.  Do 10-15 reps for 1-2 sets, only once per day.  Choose a band that is mildly to moderately difficult, but not painful or hard.  You can tie the band to anchor it, have a partner help you, or can use the other foot to anchor it.  (see the therapeutic resistance bands link under “rehab modalities for more info on band difficulty/progression)

Ankle PREs (includes all 4 directions – not sure about the eye guard, but it can’t hurt)

Single Leg Stand (SLS):This exercise is designed to retrain balance and proprioception.  Be sure to start with the hands on or near a cabinet for protection in case you lose your balance.   Try and balance on the foot for 30-45 seconds without using your hands/stepping down.  Do this 2-3 times, once a day.  Keep the heel flat (do not rise onto the toe).

SLS

Gastroc & Soleus Stretches: (calf stretching): In an ankle sprain, especially if there was some immobilization, the calf muscles will likely tighten.  It is essential to stretch them out to allow the right amount of dorsiflexion on a landing (so that the anterior ankle structure are not over-stressed and re-injured).  There are two main muscles that attach into the achilles, the gastroc (short for gastrocnemius) and the soleus.

The gastroc stretch is the traditional calf stretch.  Start with the affected leg behind you, toes forward, heel flat.  Then lean forward until a stretch is felt in the upper portion of the calf.  Hold for 30 seconds.  Do 4 repetitions, 1-2 times a day.

Gastroc Stretch (the back leg is straight; the front leg carries the weight.  The stretch should be felt high up in the calf muscle.)

The soleus stretch is similar to the traditional calf stretch, but the back leg is bent. This focuses the stretch on the soleus muscle (which lies deep to the gastroc).  This will likely be felt lower down in the leg (more along the achilles tendon).  Hold for 30 seconds. Do 4 repetitions, 1-2 times a day.

Soleus stretch (notice that the back leg is bent; the weight should be over the front leg)

Once these exercises become easy and your form is consistent (no loss of balance, no pain, and no “shaking” with movement), you can consider progressing to the next block of exercises.  In most cases, it will take about 1-3 weeks to progress through these exercises.  Be sure to take your time and don’t rush – if the ankle is not appropriately retrained, there is a VERY high risk of re-injury.

Remember, a grade 2 sprain is more severe, and should be checked out by a medical professional prior to the initiation of any self-rehabilitation.  That said, once the ankle has healed > 4 weeks, (ligamentous injury takes 4-6 weeks), you can try the grade 1 exercises and progress through as if it were a grade 1 injury.  It is even more important to rehab the grade 2 ankle sprain carefully and fully as there was more ligamentous and nerve injury than in a grade 1 sprain.

(And because I know you need reminding, be sure to ice after these exercises if they make the ankle sore or if any swelling remains.  72 hours is not the “limit” and rather ice should be used any time the healing joint is painful or swollen.)

 

Inversion Ankle Sprains

An inversion ankle sprain is one of the most common injuries to the ankle and extremely common in the sport of gymnastics.  An inversion ankle sprain occurs when the foot rolls inward and the lateral (or outer) ankle muscles and ligaments are stretched beyond their normal limit.

Common on a landing/jump, an inversion sprain involves rolling the foot inward; the lateral ligaments are injured

Gymnasts are at a particularly high risk of inversion ankle sprains for several reasons.   First, they enter into many landings from a skill in the air that requires a toe point (aka plantarflexion).  If the landing “comes up short” or they are twisting into the ground, the foot/ankle doesn’t have time to dorsiflex and the force causes the foot to twist in.  Second, on take off, a sudden force into plantarflexion is required to propel the gymnast upward.  If the lateral ankle muscles aren’t as strong as the medial (aka the inside doesn’t balance the outside), the ankle can roll on the way off the ground.  Third, the risk goes up when the landing is on a soft surface (mat) due to the increased requirement of the leg muscles to stabilize the joint.  This task involves a significant amount of proprioception/kinesthesia (awareness and neurological control of joints relative to body position).  Since the mat is complaint and can give unexpectedly, the gymnast’s ankle must react very quickly and exactly to keep the ankle neutral.  This requires a significant amount of practice and often is something that has to be trained with each new skill (we all know that the landing out of a back tuck is very different than that of a front tuck).  And finally, the risk goes up if the landing is on an uneven surface (such as half on the mat and half off, or on the edge of the beam).  While training, these “imperfect” landings are common and often, that’s when the injury occurs (rather than in competition or while performing).

The severity of the sprain:

Inversion sprains are categorized by the amount of damage done to the lateral ligaments.  These 3 ligaments: the anterior talofibular, the calcaneofibular, and the posterior talofibular all limit inversion and stabilize the joint (see the ankle anatomy post under ankle/foot).  The severity is “graded” on a 1-3 scale with 1 being the least severe and 3 being the most.  Arguably there is a grade 4 (total dislocation of the ankle), though that will not be discussed here.

Grade 1 Sprain

Grade 1 Inversion Sprain

This type of sprain characterized by a slight or mild stretching of the lateral ligaments probably is the most common of all. Usually just the anterior talofibular ligament is stretched, though the calcaneofibular ligament can become involved if the amount of inversion and the amount of plantarflexion are just right.

Signs and symptoms of a Grade I sprain are mild pain and weakness when stepping or standing on that foot. There will be some tenderness when the outside of the ankle is touched (minimal to moderate). Swelling most likely will occur in the injured area and there can be some bruising around the lateral malleolus.

Treatment of this type of sprain constitutes using the RICE method — rest, ice compression and elevation. As soon as the injury occurs, the gymnast should get off his or her feet and ice should be applied to help limit the swelling. Icing should not be any longer than 15 minutes at a time and only once every two hours for at least the first 48 to 72 hours (and continued after activity until the swelling and pain are completely resolved). If possible, the ankle should be elevated above the level of the heart to also help in reducing the inflammation.  It is important to also wrap/brace the ankle and minimize weight bearing/walking for the first 7 days (or until there is NO pain with walking).

Rehabilitation can begin once the person is pain-free and the swelling has subsided. Rehab can constitute some range of motion exercises several times per day. (see attached rehab for ankle sprains (beginning level).

Once the person returns to normal activities (only after all the strength and balance in that ankle has been restored) some bracing or athletic taping is recommended to help provide some support and prevent further injury.

Grade 2 Sprain

Grade 2 Inversion Sprain

A Grade 2 sprain is characterized by a moderate to severe stretching of the ligaments on the lateral side of the ankle. In some cases. the anterior talofibular ligament might have been torn and almost always, all three ligaments are involved.

The signs and symptoms are similar to a Grade I, but the intensity of those symptoms is increased. Standing or walking is more difficult and not tolerated for longer than a few seconds. Swelling most likely will be immediate and there will be enough to mask the shape of the lateral malleolus.  The swelling may spread into the top and outside of the foot and there will be bruising (though some people do not show it as clearly).  There will be moderate to severe tenderness to palpation and it may extend up into the lateral lower leg as these muscles may also have become strained in an attempt to prevent the inversion. The ankle may also be sore on the medial (inside) as the bones on this side of the joint tend to be compressed and bruised during the inversion motion.

In treating a Grade 2 sprain, the RICE method should be followed. For this type of injury, an X-ray exam is strongly recommended to rule out the possibility of a fracture (often the distal fibula breaks off/cracks instead of the ligament tearing). The ankle should be placed in a walking boot and/or crutches should be used until the pain is gone.  All training and activity MUST stop as the risk of re-injury and PERMANENT damage is very high.

Rehabilitation can begin once pain has subsided and a fracture has been ruled out. A more specialized rehabilitation will be needed, and consultation with a professional is STRONGLY RECOMMENDED.  The exercises listed in the attached rehab for ankle sprains (beginning level) is helpful, but will not be enough.  After these have been mastered, the gymnast must progress to the intermediate level (also in the ankle/foot & ankle sprains section).  With this grade of injury, there is damage to a proprioceptive nerve that runs along each of the ligaments.  If balance and proprioception are not adequately retrained, the gymnast will likely become a chronic ankle sprain victim and will have limited ability to progress, and will face permanent joint degeneration.

People likely will experience long-term effects from a Grade 2 sprain. This is because ligaments, unlike muscles and bone, do NOT repair. Rather they can “scar down” to mimic their original function.  Think of this as a patch/stitch in a torn pair of jeans. It is not as good as the original and ofter does not last as well.  The use of a brace or taping will be required when performing any athletic activity for several weeks/months, until it is certain that balance and proprioception are equivalent to the uninjured ankle.

Grade 3 Sprain

Grade 3 Inversion Sprain

A Grade 3 sprain is very uncommon (though not as uncommon in gymnastics) and usually results from a very violent impact or fall. In this sprain, all three ligaments will sustain severe damage. Ligaments likely will be torn and a fracture can also be present.  The prioprioceptive nerves that travel with the ligaments will be severely damaged or torn as well.  In almost all cases, the inside (medial side of the ankle) will sustain a “compression injury” as the bones will slam together at the joint.  This often causes a bone bruise and can cause a compression fracture on that side.

The injured person usually hears or feels a snap or pop on the lateral side of the ankle. Pain and swelling will be severe (into the entire ankle, the lower leg, and top and outside of the foot) and immediate. There will be an obligate loss of motion and the gymnast will not be able to bear weight on that side without considerable difficulty (even though I’d argue most gymnasts are stubborn enough to try). The ankle should be splinted to restrict any movement. Once splinted, ice can be applied intermittently (15 min on, 30 off and repeat until medical attention is available).

An X-ray is REQUIRED and a visit to a doctor should occur as soon as possible (yes folks, I’m talking the same day). The use of crutches will be required and under no circumstances should walking be attempted.  This can result in further injury/a fall.

A doctor will advise you on the best treatment. Rehabilitation will require supervision from a licensed professional.  Again, this IS NOT an injury that should be treated at home.  With a grade 3 tear, all of the permanent risks from a grade 2 tear are still present, and in some cases even surgery is required to permanently stabilize the ankle joint.

Taping for shin splints

Materials:

You can use any type of “stretchy” support.  In the following photos and descriptions, the material that I’ve use is called “Powerflex” and it’s made by a company called Andover.  It adheres to itself and does not have any type of “sticky” surface (so no pre-wrap required).

That said, you can also use a sticky tape (but be sure to use pre-wrap so you’re not waxing when you remove it) or an Ace bandage – just be sure to anchor it with tape and not the metal clips (they can fall off/cause cuts and other injuries).

The process:

  • Start with the athlete standing up, partial weight on the affected side.  Slide a roll of tape under their heel to elevate it about 2 inches.  With part of their weight on the toes they will contract the calf.  This prevents the tape from being “too tight” and cutting off circulation after.
    • Begin wrapping the tape from medial to lateral (inside to out) just about the malleoli (the ankle bones on the inside/outside).  Be sure to fully overlap once, and then begin a diagonal up the leg.
    • Continue up the leg.  Pull on the tape somewhat so that there is a moderate stretch (this will compress and anchor the lower leg muscles to the shin, thus decreasing the force on the periosteum).  As you wrap, be sure to overlap the layer below by 1/2 (so each layer is double thick).
    • When you reach the top of the shin, stop at the tibial tuberosity (the bump on the front of the shin just below the knee) and anchor with a full overlap (the same as the start point). Then wrap at a downward angle to anchor.  Tear the tape here.
    • Using sticky, non-stretch tape.  Anchor this piece (so it doesn’t come loose). 
    • Have the athlete move the foot and ankle and check circulation in the foot (make sure there is still pink under the toenails).  The final product should look like the photo below.

Anatomy of the Ankle

Osteology of the Ankle:

The tibia and fibula are the two bones of the lower leg.  The fibula terminates and is palpable as the “lateral malleolus” at the outside of the ankle.  The tibia is thicker, but it has a bony prominence on the medial side (inside of the ankle) known as the medial malleolus.

Traditionally, most anatomy textbooks will argue that the connection of the tibia, fibula, and the talus is the “true” ankle joint.  When considering the ankle relative to gymnastics, it can be argued that the ankle joint is composed of three separate articulations.  This is due to the complex motion required of the ankle with the sport (rarely is the motion just one dimensional).  These three articulations (joints) are:

  1. The distal tibiofibular joint: The first joint, the distal tibiofibular joint is the articulation between the tibia and the fibula just above the ankle.  Though not a true synovial joint, (not encased or filled with fluid) this joint is what gives stability to the ankle mortice (the bottom of these two bones form the “dome” for the talus (part of the next joint).  The distal tibiofibular joint consists of the articulation of the medial side of the fibula and the lateral side of the tibia.  It is supported by the interosseus membrane of the lower leg, and two small ligaments. It allows only a small amount of movement with plantar flexion/dorsiflexion of the ankle.  This is the joint that is most affected during a “high ankle” sprain.
  2. The talocrural joint: (or “True Ankle Joint”) This is composed of the dome formed by the ends of the tibia and fibula and the the talus.  This joint is encased by a joint capsule and is a true synovial joint.  This joint allows only plantarflexion and dorsiflexion (pointing the ankle down and flexing it up respectively).
  3. The subtalar joint: Located just underneath the talocrural joint, the subtalar joint (meaning “under the talus”) allows for the side to side motions of inversion (ankle and foot twisting in) and eversion (the ankle and foot twisting out).  This joint can arguably also be considered part of the foot as it is formed by the talus and the calcaneus (the heel bone).

Ligaments of the Ankle:

There are six major ligaments in the ankle.  Five are along the lateral (or outside) of the ankle and one is on the medial (or inside).

Lateral view of the ankle ligaments

The posterior inferior tibiofemoral ligament and the anterior inferior tibiofemoral ligament stabilize the distal tibiofemoral joint.  These are important in gymnastics as they can be weakened by landing “short” on a backward tumbling element repeatedly. When this happens, the talus is jammed up into the space between the tibia and fibula and over time this mortice becomes more flexible.  With this, the talus can move beyond the normal range.  This leads to an unstable talocrural joint and can cause the talus to “sublux” or get stuck out of place.  In this case, the gymnast will complain of anterior ankle pain with flexing the ankle/foot or when squatting and may have a noticeable loss of dorsiflexion.  It also predisposes a gymnast to ankle sprains and can lead to an earlier onset of arthritis in the joint.

The other three ligaments are the ligaments most often injured in ankle sprains.  These support the subtalar joint, though they cross the talocrural joint as well.  They include: the anterior talofibular ligament, the calcaneal fibular ligament, and the posterior talofibular ligament.  All three originate from points on the lateral malleolus and terminate on either the talus or the calcaneus.

Medial ankle ligaments – “The Deltoid Ligament”

The ligaments along the medial side of the ankle are more numerous and thicker (making them stronger than the lateral ligaments).  They share common origins and insertions and are collectively known as the deltoid ligament.  This ligament prevents eversion and is traditionally only injured in the most severe of ankle injuries (dislocations, fractures with dislocation).

Muscles of the Ankle:

There are many muscles that contribute to the mobility and stability of the ankle.  In gymnastics, several play a more key role.  They are listed below by the motion they perform:

Posterior view of the lower leg musculature

  • Plantarflexion: gastrocnemius, soleus, flexor hallucis longus, flexor digitorum longus, and the tibialis posterior
  • Inversion: tibialis anterior (shown below) and tibialis posterior (shown above)

Anterior view of the lower leg musculature

  • Dorsiflexion: tibialis anterior, extensor hallicus longus, extensor digitorum longus, and peroneus tertius (not shown)
  • Eversion: peroneus longus and peroneus brevis (also known as fibularis longus and fibularis brevis because they run along the fibula)

These muscles all sit in the lower leg and cross at the ankle.  Their tendons are longer and are covered in tendon sheaths that protect and lubricate them as the run along the medial and lateral malleolus of the ankle.

Therapeutic Resistance Bands

So, while there are many levels of resistance bands, I’ll start by describing those that I use in the clinic (and are provided in the Gymkana gym).

The levels are progressive, building from an easy to more difficult level.  Because the band stretches to provide resistance, the amount of resistance increases the more the band is stretched (keep this in mind when you are anchoring it while you are exercising).  Also know that the bands have a breaking point – if you are pulling as hard as you can and you can’t get enough resistance, move up a band (rather than snap it on yourself – it is painful).

The levels progress from easy (1)  to hard (5) and super (6):

  1. Yellow
  2. Red
  3. Green
  4. Blue
  5. Black
  6. Silver (these are not as common)

For you Gymkana folks, there is a box of these bands by the taping table/cabinet.  These are FREE for you all to use.  Feel free to take a band with you, but when you progress please bring it back and exchange it so there are enough to go around!

Beginning Therapeutic Exercise for Shin Splints

Strengthening:

So, now that you know the importance of it, how do you strengthen to prevent or treat shin splints?  There are a variety of ways and which you choose will depend on:

  1. the severity of your shin splints
  2. the intensity of the rebound apparatus (impact activities) you’re involved in and
  3. your baseline strength level.

My recommendation is that everyone begin with the exercises listed below (on the attached PDF).  These exercises are dosed for daily use – this means they aren’t designed to strengthen by adding bulk.  Rather the goal is to build endurance and retrain the neuromuscular system (basically make these muscles faster and more efficient).  This is why it’s okay to do them everyday.  That said, do them AFTER you practice or workout – not before.  Since they are designed to fatigue, if you do them before practice/exercise, it’s likely your performance will suffer and you might actually increase your risk of injury!

Introductory Therex (Stage 1):

* Note: the dosage is on the attached PDF – the descriptions below are just to help clarify!

Shin splints – introductory therapeutic exercise

Breakdown of the exercises on the sheet:

(see the section in the “rehab modalities” category for the levels of resistance bands)

Page 1:  PREs (progressive resistive exercises)

These exercises are done with resistance bands.  As mentioned before, the muscles that control the ankle are located along the tibia/fibula in the lower leg and are the same muscles that contribute to shin splints.  At the ankle, there are four directions of movement: dorsiflexion (ankle/foot flexion), plantarflexion (ankle/toe point), inversion (tilting the ankle in), and eversion (tilting the ankle out).

  1. Theraband resisted dorsiflexion: Hook the band around the ball of your foot while it is pointed (with the heel free to move – either rest the back of the ankle on a towel roll or on the edge of the table) and slowly pull the toes and foot up to a flexed position.  The key to this is a SLOW motion both in the exercise and the return to the starting position.  This will require a partner to hold the band OR you can tie it to a chair/doorknob and do it yourself.
  2. Theraband resisted plantarflexion: The exact opposite of the above exercise.  Start with the foot flexed, loop the band around the ball of your foot and point the toes.  You can hold the band yourself with this one, but again – focus on a slow and controlled motion.
  3. Theraband resisted inversion: (this is when you pull the ankle INWARDS).  Cross the other leg on top to provide a fulcrum for the band (or have a friend hold it for you).  Wrap the band around the ball of your foot and then loop the length of the band around the other foot.  Without turning the leg, twist the ankle and foot inwards against resistance.
  4. Theraband resisted eversion: This is the exact opposite of the last one (this is where you pull the ankle OUTWARDS). Start seated, with your legs about a foot apart.  Wrap the band around the ball of the foot and anchor it around the other foot so you can pull the ankle out (of have a friend hold it for you).

Page 2:

  1. Calf stretch (on the step): Stand on a step and hang one heel off the back.  Keeping the leg straight, drop the heel off the step until a stretch is felt in the back of the calf/heel and perhaps into the foot.  Be sure to keep the stretch gentle and have the other foot firmly on the step – it can also be beneficial to have something to hold onto so you aren’t balancing yourself too (this takes away from the stretch).  The ideal hold time is 30 seconds (it takes 20 seconds for the muscle to even begin to stretch).
    Why stretch? Well, if the calf is tight, the gastroc/soleus (main calf muscles) will put additional stress/strain on the anterior lower leg muscles (by overpowering them during activity) which leads to increased force along the periosteum and the interosseus membrane.  As mentioned in the article on shin splints, this overwhelming of forces is a main cause of the associated pain.
  2. Single leg balance: This trains isometric contraction (meaning contracting without changing muscle length) in the lower leg muscles.  It also improved balance and makes your landings safer and less jarring on the shin.  To make the exercise more challenging, try closing your eyes or standing on a wobbly surface (an 8-inch mat or a pillow work great).
  3. Heel raises: Seems simple enough right? Wrong – doing these right involves a SLOW up and down without the ankles rolling out (twisting) and without you moving you feet.  If it feels easy, you’re doing them too fast.  Focus on a slow controlled motion and be sure to tighten all the muscles in your core throughout.
  4. Ankle alphabets: Sitting with the ankle free, write the alphabet with your foot and ankle (be sure to keep the lower leg still).  Make BIG, CLEAR letters and go SLOW!

Page 3:

  1. Toe curls: (aka towel scrunches) Sitting in a chair, lay a towel out on the floor.  Using the toes and foot, scrunch up the towel.  You can do a certain number of reps (as listed on the PDF) or do it for a set amount of time – I recommend about 3-5 minutes.
  2. Seated ankle dorsiflexion: (against gravity with a weight):  Wrap a cuff weight (between 2-5 lbs) around the foot.  Slowly lift the foot up from a pointed to a flexed position and then return.  You should feel this along the length of the shin, but be sure to keep the weight in a comfortable range – you don’t want the “burn” to be more intense than a 3-5 out of 10.

If you have any questions, drop a comment below and I’ll get back to you!  And be certain to ICE afterwards!

Shin Splints

Shin splints (also known as medial tibial stress syndrome or tibial periostitis) is the term used to describe pain and inflammation along the tibia in the lower leg.

Etiology:

Shin splints are a common complaint among all rebound athletes (runners, gymnasts, dancers, etc).  Although there are a variety of different causes, shin splints are generally accepted to be a cumulative stress disorder rather than an acute injury.  This means that they are not sudden in onset (though the pain may occur suddenly).  Rather, they consist of many overlapping factors that eventually overwhelm the leg and lead to pain.

Causes:

Traditionally, shin splints occur with unusual loading on the lower leg during activity.  In this case “unusual loading” could be due to an increase in force (weight gain, higher forces with new landings), a sudden increase in activity (too many rebound skills at the beginning of the season or more walking/running than usual), or poor anatomical loading (flat feet, bad footwear, weak & de-conditioned muscles).  The body is designed to “repair” itself by adapting to new forces.  In the case of shin splints, the body is overwhelmed and the bones/muscles can’t keep up.  The end result: lower leg pain with walking, running, jumping, and sometimes just pressure over the area.

Pathophysiology:

The “shin” or lower leg is composed of two bones.  The tibia and the fibula.  The tibia is the weight-bearing bone while the fibula acts as a stabilizer and an attachment point for muscles.  The bone are connected by a thick, fibrous membrane known as the interosseus membrane.  This is what gives the lower leg stability, provides attachments for deep blood vessels/nerves, and anchors many of the lower leg muscles.

The tibia and fibula, like all bones, are covered by a saran-wrap-like cover known as periosteum.  This tissue protects the bone and allows for its nutritional support.  It is very tough and inelastic which prevents it from stretching and gives it its strength.  Small fibers known as Sharpey’s fibers connect the periosteum to the muscles and fascia (connective tissue) of the lower leg.  With normal running/walking, the anterior tibial muscles contract to slow the foot down on heel strike (prevents your foot from “slapping” the ground).  This contraction pulls on the tibia (periosteum) and stresses the surrounding fascia. When an activity changes and the muscles pull on the Sharpey’s fibers (attached to the periosteum) more than usual, the periosteum (and the underlying bone) have to adapt by becoming more thick and dense.  In the case of shin splints, the forces are too great and too frequent, and the periosteum cannot adapt fast enough. It becomes inflamed (swollen) and causes irritation/pain along the length of the bone.  In many cases, the swelling can be palpable (small squishy bumps along the length of the tibia) and even a gentle touch can be very painful.

In severe cases, when pain is ignored and the activity is continued, the tibia itself begins to break down.  Small stress fractures (hairline cracks) develop as the bone cannot build its density up fast enough to deal with the forces placed along it.  If left untreated, the tibia itself becomes more prone to pathologic fracture (meaning fracture with a lower stress than expected).

Gymnasts are more prone to shin splints for several reasons.  First, they train barefoot.  The muscles of the foot and lower leg have to work harder to maintain the shape of the foot and stabilize the ankle without a shoe, thus increasing the pull on the periosteum. Second, the surfaces are more firm and the impact is transferred up into the tibia.  Third, the landings are heavier and more frequent than most other sports.  While a runner’s foot strikes the ground 760 times per mile, it is from a height of 2-4 inches.  A gymnast’s foot strikes the ground less frequently (not including the run in a vaulting/tumbling pass), but from up to 8 or 10 feet off the ground.  I’m not a physicist, but if F = ma then it’s a wonder every gymnast isn’t walking around with this injury.

Treatment:

What you’ve all been waiting for I’m sure…The most commonly accepted treatment for shin splints is rest.  However, while effective, this is useless for the gymnast in training or in the middle of competitive season.  Plus, once you’ve rested, you still have to strengthen to prevent them from a speedy return!

  1. Ice: In the early, middle, and late stages ice is a key factor in dealing with the pain.  Ice over the shin for 15 min after ANY ACTIVITY (this includes walking to and from class) to decrease pain (ice slows the transmission of the pain signal along the nerve) and to decrease swelling (along the periosteum/interroseus membrane).  Be sure to keep a layer between the skin and the ice to prevent ice burn.
  2. Strengthening: using ankle and foot exercises to strengthen the muscles of the lower leg and foot is key.  There are several methods to use (photos to follow soon).
  3. Wearing a shoe with a good arch support (if you’re flat-footed) can help rest the lower leg muscles

    Footwear:  While a change of footwear in the gym isn’t practical, a change for every other activity of your life is.  Toss the flats, the heels, the flip-flops, and the Crocs.  Put on a pair of sneakers with a good sole and cushion.  It doesn’t matter much the type (barefoot, neutral, motion-control, or stability) – rather it’s the support and the shock-absorption that are key.  If you have a very flat foot, try a more supportive shoe (motion-control or stability) whereas if you’ve got a good arch, a barefoot or neutral shoe might work for you.  The reason this matters is that the lower leg muscles support the arch of the foot – so if you add external support for that arch, you give them a rest.  You could even try buying an arch-support insert and putting it in your current shoe (I know money can be tight).

  4. Skill progression: If you’re working new skills, build up your tolerance on that piece of equipment.  Start with 10-15 minutes of DMT/tumbling one day and add up to 5 min to that number per week. (And here’s where I know I’m going to lose some of you).  It takes your body time to adapt, and if you’re pushing through the pain, odds are you are making the problem worse and prolonging your recovery.  Also – try running more on the balls of your feet.  (This means avoid heel striking by taking shorter steps).  This will give those muscles a break and allow you to keep training.
  5. Taping/external bracing: Using an ace wrap around the shin or having a coach do a compression tape can help support the periosteum/muscles in the short-term.  Just know that this is a temporary fix and ultimately strengthening and activity progression are the only true cures!
  6. NSAIDs: Non-steriodal anti-inflammatories.  These common over the counter pain medications can help take the edge of the pain and decrease the inflammation.  Good right?  Well – mostly.  Be sure to stay within the recommended doses, take with food, and only take for a few days time.  They are tough on the digestive system and can slow the rate of healing when used in excess.  As a general rule, check with your doctor if you’re unsure of how these can affect you and/or if you’re on other medication to prevent interactions.
  7. Nutrition: As a general rule, getting the right amount of calcium and protein are essential in preventing and treating shin splints.  If possible, it’s worth avoiding foods that can increase inflammation in the body, such as: fatty meats, fried foods, whole milk, sugary foods, processed grains (white bread, etc), foods with excess salt, and butters/oils.  Be sure to stay hydrated and if you’re really working out hard, add a low-sugar sports drink to replenish minerals and prevent muscle cramping (could make the shin splint pain worse).

Summary:

  • Shin splints is the term for generalized anterior lower leg pain
  • Caused by repetitive impact activities (running, jumping, walking) and the body’s inability to adapt to new forces
  • Treatment: rest (if possible), Ice for 15 min after activity, strengthening (see attached), NSAIDs, and improved footwear when not training (sneakers vs. flats/flip-flops)