Brian Schiff’s Blog

Well, it is just days before I embark on my 3rd half marathon.  Just one short run to go.  And no, I am not suffering from shin splints (lol).  But as I approach the Columbus Half Marathon on 10/18, I am reminded about all the patients and clients I see who are in some way affected by shin splints.

Shin splints, more commonly referred to as medial tibial stress syndrome (MTSS) in medical circles, plague many runners, walkers and athletes.  So, what is a shin splint?  People often report pain and tenderness along the outer or innermost portion of the lower leg.  Anterior shin splints affect the anterior tibialis muscle and are seen more commonly (my experience) in people who walk rapidly for the first time or do several hills without training for them.  I saw a camper of mine who runs regularly develop shin splints doing a 5K walk and trying to walk fast and keep up with another camper.  She never has had shin splints in years of running.

Posterior shin splints are probably more widely seen among most runners.  They tend to be more common in females as well.  The source of pain was commonly linked to the posterior tibialis muscle, but is now thought to be along the origin of the medial soleus muscle and its deep fascial insertion.  Hmmm….. the soleus – now if you have read my earlier posts, that is a muscle I personally know a thing or two about when it comes to injury.

 What are some causes of shin splints?

• Tight hamstrings (affects closed chain biomechanics)
• High or low arches (twice the injury incidence as those with normal arch height)
• Faulty training surfaces (uneven sidewalks and asphalt can be brutal)
• Improper training technique or progression (this is a biggie for sure)
• Muscular imbalances (weak hips anyone?)
• Excessive foot pronation (flattens out or rolls in too much during gait)
• Worn out or improperly fitted/cushioned footwear

What else may cause such pain?  It may be a good idea to see a medical professional for diagnostic testing to rule out a stress fracture (often severe pin point pain along the medial tibia), exercise-induced compartment syndrome, and a possible popliteal artery entrapment (Tolbert and Binkley – NSCA Journal 2009). 

Outdoor boot camps and running are gaining in popularity these days.  Both activities are great for weight loss but also carry a higher risk of shin splints for participants, especially overweight women.  Proper warm-up, selective footwear and stretching are great strategies to reduce or prevent injury.

If you have been affected already and are seeking help, I suggest the following:

1. Relative or absolute rest from the offending activity
2. Ice the affected area daily (2-3x/day)
3. Standing hamstring stretch (flat back) with and without foot rotation in and out – hold for 20-30 seconds in each position (repeat twice)
4. Calf stretching on a step – knee straight – hold for 20-30 seconds (repeat twice)
5. Soleus stretching ona  step (knee slightly bent) – hold for 20-30 seconds (repeat twice)
6. Single leg calf raises to strengthen the posterior tibialis muscle (once able to do pain free) Perform 2-3 sets of 10-15 reps
7. Single leg balance on a slightly bent knee – perform 2 sets of 30 seconds without touching the other leg down (advance to eyes closed for more difficulty)

In the end, combine prevention with sound footwear and a proper training progression and you will have no trouble at all with shin splints.  At the first sign of pain, step back and evaluate if you need to adjust your training as trying to go through it will not make things better.  Happy training all!

Since publishing my rotator cuff manual over 4 years ago, I have received emails from all over the world with shoulder related lifting questions.  Invariably, I discover that many shoulder injuries are simply caused by repetitive micro-trauma in the weight room.

What does this mean?  In effect, it is like taking sand paper and rubbing it over your rotator cuff day in and day out for weeks, months and years until you either create tendinitis or wear a small hole in it.  Exercises that often get people in trouble are bench press, dips, flies, lateral dumbbell raises, and military press to name a few.  I show modifications for all these in my book.

In my shoulder rehab programs, I have always advocated front lat pull downs.  Why?  Simply because I can strengthen the posterior chain muscles, improve posture and activate scapular stabilizer muscles while encouraging retraction and downward rotation of the shoulder blade.  These are necessary things to balance the shoulder.

Some experts and customers question this technique from time to time because they disagree with taking the arm above shoulder height during periods of inflammation.  I say this  varies from person to person.  I have worked with over 10,000 people and can tell you there is never one certainty among symptoms and response to exercise.  With that said, I do not want people to exercise through pain.

To that end, I offer a modified version of the pat pull down to accomplish a similar movement.  The straight arm lat pull will effectively target the same things when done properly.  I have included  a video below showing the technique with a traditional straight bar on a pulley as well as with resistance tubing.

The key points to remember are these:

1. Begin at or below shoulder height
2. Keep the knees slightly bent at all times
3. Maintain a tight core (contract abdominals throughout)
4. Keep the elbows straight at all times
5. Focus on pulling the shoulder blades closer together on the pulling motion
6. Return to the start position under control to avoid momentum taking over
7. Breathe out on the way down and in on the way up

I have found this to be an excellent alternative for those unable to continue with traditional lat pull downs during the course of a shoulder injury or rehab.  It is 100% safe.  The only precaution would be not going forcefully past the hips with the tubing pulls for those with anterior shoulder instability or a known labral tear.  This is not an issue with the cable pull as the bar stops prior to this point.

So, one of the newest treatments being touted in the sports medicine arena is platelet rich plasma (PRP) therapy.  What is this exactly?  It is not an easy thing to explain in plain terms, but here goes my best attempt.

Platelets help the repair process in the body as they contain growth factors like platelet derived growth factor (PDGF), transforming growth factor (TGF)-ß, insulin-like growth factor (IGF) and fibroblast growth factor (FGF) to name a few.  Upon activation, these factors are released and sent to aid the injured site in healing.  In this therapy approach, a centrifuge is used to increase concentration the concentration of platelets.  PRP has up to 8x the concentration of platelets that whole blood does.

The PRP is then usually injected into the injury site.  This is commonly being used to treat ligament sprains such as an MCL sprain in soccer players.  A recent study was released in the American Journal of Sports Medicine in March 2009 in regard to the effects fo PRP on muscle strains.  Muscle strains are largely considered the primary injury in sports medicine today (think about hamstrings, quadriceps, groin and calf strains to name a few).

Keep in mind muscle injuries typically occur when the muscle is lengthening under tension (eccentric contraction).  Why so?  In eccentric contractions the muscle force produced is approximately twice that of a maximal isometric contraction (max muscle force against static resistance without motion).

In this study, researchers looked at rats and induced a muscle injury to the TA (tibialis anterior muscle) in one of two ways: Group A underwent a single eccentric (lengthening) injury over a 90 degree arc of motion, while Group B underwent 45 smaller strains over a 60 degree arc to simulate more of a chronic muscle strain as opposed to an acute injury in Group A.

To summarize the results, researchers found that the PRP had little effect on Group A other than to noticeably affect force production in a positive way on day 3 post-injury.  They are unsure if this is simply due to reduced inflammation (PRP should help with this).  Otherwise, full force production with the single acute strain was back in 7 days relative to pre-injury levels whether using PRP or not.  However, in the repetitive or chronic strain group (group B) the PRP had significantly positive effects at day 7 and 14 and led to a faster overall recovery.

Does this mean we should use PRP on all muscle strains??  Not so fast.  What is clear are that injuries in need of myogenesis (muscle rebuilding) are better candidates for this therapy.  The tricky part is the great degree of variability in muscle strains and determining if the science is transferable from the rat to human model.  In the end, the treatment is promising as there appear to be no harmful side effects, but further research will be needed to validate the impact on healing tendons and muscles alike.

Also keep in mind that progressively rehabbing the injured part with systematic eccentric loading to restore the tissues’ threshold to stress is necessary to accurately gage response to functional mechanical loads.  My hope is that this procedure will be used in conjunction with rehab to speed healing and get athletes back on the field faster.  Its greatest use may come in dealing with chronic tendinitis or partial tears.  Only time will tell, so stay tuned.

Well, I have become somewhat of a runner in the past 2 years.  I have run two half marathons and have been training for a third.  That is until my right lower leg has gotten in the way.  In May, I ran 1:40:08 at The Flying Pig Half in Cinci (tons of hills).  Not bad for a 184 pound former football player, right?  My goal was to crush that time in Columbus on 10/18.

About 5 weeks ago I felt intense pain near the medial head of my right calf during the end of a 4.5 mile run.  I iced immediately afterward, but I knew something was wrong.  I had to take about 10 days off from running.  I had recently made it back to 4-5 days per week running and thought all was fine.  I even completed an 8 mile run in 60 minutes without incident two weeks ago.

But alas, the pain returned last week on a 10 mile run.  Only 2 miles into it I felt horrific sharp pain just below the calf.  I had to hobble back to my car.  This is a frustrating and defeating experience to be sure.  While I suspected a small medial head gastroc (calf) tear, I wanted to get my friend and orthopedic surgeon’s medical opinion.  So, I went and saw the man I send all my hurt athletes to yesterday.  I wanted him to confirm that my achilles tendon was indeed OK.  That he did.  Whew!!  What a relief.  X-Rays revealed no stress fractures either.

We talked and decided I would wear a heel lift to off load the calf for a short while and try to run in the half on 10/18.  As I continued to marvel at my scenario today, I began testing my leg and thinking, “Why can I do a single leg calf raise and single leg hop without pain if my calf is injured?”

Then the light bulb went on.  It dawned on me the pain was deeper and perhaps just below the calf.  The thing that hurts the most is descending stairs.  Of course!  The injury (or strain if you will) is of the soleus, a smaller muscle deep to the calf and responsible for assisting the calf with push-off and preventing excessive dorsiflexion (foot moving toward to head) of the foot with gait.

You see the pain is almost non-existent when my knee is straight.  But, once the knee bends and I transfer weight forward over the foot I feel significant pain/weakness.  Yes, the soleus is not quite right.  The calf is less responsible for controlling the body weight as the knee bends which makes sense to me based on the symptoms.  I can honestly say I am not sure I have treated anyone with a soleus strain.

See the soleus in red below:

So, what is the course of rehab?  Cross training on the elliptical this week and then gradual integration of running again.  The real challenge for the soleus occurs at heel strike to foot flat as it works to slow the dorsiflexion down and take all the weight of the body during single leg support.  Ouch!!

The good news is my tendon is fine.  The bad news is that the half marathon involves so many steps it may become an endurance based issue.  I will be adding knee bent stretching, single leg calf raises (straight and bent knee), anterior reaches, step downs and lunges into the program as pain allows this week.

So, for all the runners out there keep in mind pain around the calf may actually be related to a soleus strain.  Identifying whther the pain occurs mostly with a straight or bent knee will be key in finding the tissue at fault.  The two may be linked as I had a bad medial calf tear many years ago.

The take home message is listen to the body and develop the right strategies to maximize recovery and rehab.  Hopefully, I will still hit that goal on 10/18.  Then, perhaps I will take a short hiatus from distance running until 2010 to allow it to heal 100%.

Have questions and want answers to your sports training issues or injuries?  Let me know and I will attempt to answer them as part of my blog posts.

Over the past few weeks I have had numerous questions and comments on the blog about SLAP tears.  So, I thought I would add another post with more in depth information on classification of tears, typical treatment and outcomes.  This is a relatively common injury that many know so little about.  To see a diagram, click here.

Different types of SLAP tears

1. Type I – Fraying of the edge fo the superior labrum
2. Type II – detachment of the biceps anchor from the glenoid labrum (most common)
3. Type III – Bucket handle tear of the superior labrum with otherwise normal biceps anchor
4. Type IV – Bucket handle tear of the superior labrum extending into biceps tendon causing detachment of the biceps anchor

Other surgeons have expanded on these classifications as well, but i will not go into that depth here.  You should know that some sub classify type II tears into anterior, posterior and combined anterior and posterior lesions.  In effect a SLAP tear can cause a microinstability thereby leading to articular sided rotator cuff tears.  In plain terms, a posterior labral tear could create a posterior partial thickness rotator cuff tear and an anterior labral tear could create an anterior cuff tear.

The shoulder exam itself often reveals pain with passive external rotation at 90 degrees of abduction (picture the cocking phase of throwing here).  Weakness and instability may also be present depending on the type of tear and if there is already a cuff injury present as well.  There are a number of diagnostic clinical tests done including the O’Brien test, Speed’s test, crank test and biceps load test to name a few.  Many have been successful at confirming labral pathology.  In the end, the MRI is the gold standard in confirming an injury.

Non-operative treatment is often unsuccessful in most cases.  Patients with Type I tears may do better than most (JOSPT February 2009).  Therapeutically, we often see GIRD.   GIRD stands for glenohumeral internal rotation deficit, meaning the affected shoulder has significant posterior capsule tightness and decreased internal rotation (common among overhead athletes and throwers).  Restoring this motion may prevent injury that often occurs between the supraspinatus tendon and the posterior superior labrum.  Research is unclear if GIRD increases risk for a labral tear.

In addition to this stretching the posterior capsule, it is critical to strengthen the scapular muscles and rotator cuff to restore optimal mechanics and motion between the humerus and scapula.  Due to poor posture, flexibility issues and muscular imbalances, the average person may have an altered scapulo-humeral rhythm.  If non-operative treatment fails, one typically opts for surgery.

Arthroscopic surgery is the standard procedure today with debridement of the labrum and reattachment via sutures.   In many cases, surgeons debride rotator cuff tears with less than 50% torn, while opting for primary repair if greater than a 50% tear.  According to a leading surgeon, David Altchek, he will excise a longitudinal biceps tear that is less than 1/3 of the diameter of the tendon, while optiong to repair one that is greater in size back to the major portion of the tendon.

Common rehab timetable 

• Max protection for 0-3 weeks in sling with limited external rotation and overhead activity
• No biceps strengthening for 2 months
• Focus on motion restoration in weeks 3-8
• More aggressive strengthening begins at week 8
• Return to throwing begins at month 4 in most cases

These are some rough guidelines and progressions vary based on each case and the type of tear and associated damage as well as desired activity level.  About 90% of patients experience good to excellent results with Type II repairs in the short to mid term follow-up, but there is not extensive long term data out there.  It should also be noted that throwers and overhead athletes tend to exhibit lower satisfaction with repsect to return to pre-injury levels after surgery.  Recent studies also seem to indicate throwers with an overuse related injury do not do as well as those with a specific traumatic injury resulting in a type II tear.

I hope this post is helpful for those suffering from labral tears or who suspect they may have one.  It is an intricate injury but quite disabling to function with long term implications for the health and function of the shoulder.