Stepping Up the Research on Shin Splints

Shin splints often happen to athletes, especially runners, ballet dancers, and soldiers in basic training. Though shin splints are a common problem, not much is known about what causes this painful condition and what to do about it. Since many athletes lose time in training and performance to shin splints, this condition requires careful study.

A group of researchers took a step back to get a broad view of this problem. They reviewed many articles and textbooks with information about shin splints. They noticed the following:

  • Many different conditions have been labeled “shin splints.”

  • The definition of shin splints is confusing and varies.

  • Symptoms vary by sport because different muscles and tendons are used in different activities.

  • Coaches and trainers see the athlete when the problem first develops, but the problem may look different when the athlete goes to see the doctor later.

  • There are specific risk factors for shin splints including excessive or competitive running, previous injuries, and poor physical condition.

  • Evidence for treatment that works is very limited. Most studies are done on soldiers and may not reflect how the general population responds to treatment.

Two things are clear from this review of the literature. First, the use of shock-absorbing inserts or insoles can reduce the occurrence of shin splints in young male athletes. These insoles may have the same effect on other people, but no study has been done to prove this. Second, preseason conditioning has been shown to prevent shin splints.

Researchers now have a series of new questions to ask. Answering these questions will help coaches, trainers, and athletes prevent this and other injuries.

Giving Ankle Injury the Third Degree

Here’s a dilemma for sports medicine. Say an athlete sprains an ankle. Can the medical examiner tell the coach how soon the athlete can return to the sport? Right now, ligament sprains are divided into first, second, and third-degree sprains. The first-degree sprain is mildest and usually means a faster recovery. But how quickly can the athlete return to competition? And how does this compare to a second-degree or third-degree sprain?

A group of physical therapists wanted to classify ankle sprains based on prognosis, or expected treatment results. Such a method would help predict what will happen with each degree of ankle sprain. No test is known to predict the time required to return to play, so the therapists decided to see if a patient’s report of the injury could help predict how soon the athlete returned to sport. Number of days to return to sport may be one way to classify ankle injury. This could then be used to predict the outcome of other athletes’ injuries.

Twenty athletes who had sprained an ankle participated in this study. The athletes gave the therapists information right after the injury about their pain level and ability to walk or use the leg (compared to the uninjured leg). The therapists measured ankle motion and strength. Treatment was provided twice a day beginning the day after the sprain. Treatment continued until the athlete returned to sport.

The ability to walk and use the leg as reported by athletes was the best predictor of number of days to return to sport. There may be other ways to predict return to sport that are more accurate. Further research will help identify these for use by sports health professionals.

Do Tired Feet Cause Defeat? The Effects of Fatigue on the Ankle

Do you ever consider how hard your ankles are working to hold you in a steady position? Most people don’t give this much thought, but the ankle is actually a very important part of standing and moving.

Control of movement depends on information that comes to the ankle from the skin, muscles, and surrounding joints. In order to move, the ankle must know the speed and direction of motion. Without this important information, the ankle is more likely to be injured. To keep balance, the ankle must be able to tell what position the joint is in. The ankle is an important link between the ground, gravity, and center of balance.

Injuring the ankle can change the joint’s sense of position and motion. The technical name for this “position sense” is proprioception. Researchers wanted to know whether there’s anything that can alter proprioception. Perhaps changes in proprioception make the ankle prone to injury.

What about the effects of fatigue? Does intense physical activity change the joint’s sense of position? In other words, are athletes more likely to injure their ankles after working or competing hard enough to affect the proprioceptive system?

A small study of eight men looked at this question. Proprioception was measured by placing one foot and ankle in a position and asking the person to match that position with the other foot and ankle. Differences in ankle position can be accurately measured with today’s advanced technology.

Before measuring position sense, the foot was fatigued by strapping it to a footplate and working it. Muscle contractions at a load equal to 70 percent of the maximum contraction capacity were done until the foot was fatigued. Electromyographic (EMG) measures were taken to document the fatigue.

Results showed that fatigue affected position accuracy. When the foot was fatigued, there were larger errors in matching movement and position between feet. The two areas of movement that were the most affected were large movements bending the ankle up and small movements bending the ankle down.

Fatigue seems to affect the ankle’s ability to detect its position. This may contribute to ankle injuries after periods of intense exercise or competition. It may also have an effect on other joints, such as the knee. The knee depends on the ankle for stability and support. If fatigue alters the ankle’s sense of position, then decreased ankle proprioception may also contribute to knee injuries.

High Hopes for Ankle Scopes

Ankle injuries can be difficult to diagnose. The ankle itself is very complex with many bones in a small space. The two lower leg bones form the top of the ankle joint. The large shinbone is called the tibia; the small bone next to it is the fibula. The lower end of these two bones is connected by four ligaments. Together, these four ligaments form a structure doctors refer to as the syndesmosis.

Doctors often use X-rays to look for fractures in the anklebones. Even with two different views of X-rays, it isn’t always clear what’s wrong. Sometimes a bone in the ankle can be broken, but the ligaments that make up the ankle syndesmosis are not damaged. Other times, there can be a bone fracture, and the syndesmosis is also torn. In these cases, the X-rays sometimes show an abnormal separation between the tibia and fibula. Providing the right treatment depends upon the right diagnosis.

Doctors now have a new way to look inside the ankle joint. They can use an arthroscope, a tiny TV camera that can be placed inside the ankle to see the bones and ligaments directly. The arthroscope helps doctors see if any structures are broken or torn.

Doctors wanted to make sure that using an arthroscope to check for syndesmosis problems (compared to just an X-ray) is worth the risk. One group of doctors was able to study 38 people with ankle injuries. Doctors checked the accuracy in diagnosing syndesmosis problems by comparing arthroscopy to two different X-ray angles.

Is it worth the extra expense and risks to use arthroscopic examination for injuries in the ankle syndesmosis? Yes, definitely! The arthroscopic exam was 100 percent accurate in showing both bone fractures and syndesmosis injuries. By comparison, X-rays were accurate less than half the time (48 percent) for one view and only 64 percent for the second view.

Ankle arthroscopy provides a view of the ankle that allows doctors to see if anything is broken. It is also superior to X-rays for showing if an injury has occurred in the ankle syndesmosis. Making the correct diagnosis ensures that patients get the best treatment right away.

Is Swelling a Puffed-Up Measure of Ankle Wellness? The Relationship between Swelling and Function in Sprained Ankles

Ever had a physical therapist wrap a measuring tape in a figure eight around your ankle? If you sprain your ankle, this measurement can tell how much swelling there is from the injury. Therapists sometimes compare these measurements over time, to see whether you’re getting better.
But how well does the figure-of-eight reading gauge pain and function? Is amount of swelling related to patients’ ability to do activities after an ankle sprain? These authors wanted to find out.

Twenty-nine patients were in the study. They were all active in the military. Two-thirds of them were men. Their average age was 31, though ages ranged from 18 to 59.

Patients came into the clinic about three days after an ankle sprain. The authors watched patients walk in; then they gave a score for how much weight patients put on their hurt legs. Patients’ ankles were measured with the figure-of-eight. Amount of swelling was determined by comparing patients’ injured and uninjured ankles.

Patients filled out two questionnaires. The questions had to do with the amount of pain patients had at different times. Questions also asked about patients’ ability to do sports and daily activities.

As the authors expected, results from the two questionnaires were very similar. And questionnaire results were strongly related to how much weight patients were able to put on their hurt legs.

However, the figure-of-eight was not related to any of these measures of pain and function. This suggests that ankle swelling may not be a good measure of how patients are getting along after an ankle sprain.

The authors think that the figure-of-eight is helpful in determining whether swelling has gone down over the course of treatment. But it is not a good way of gauging whether patients are returning to the activities of their daily lives. When it comes to treatment results, questionnaires may do a better job of showing changes in ankle pain and function.

A Helpful Twist for Ankles That Turn

The scourge of ankle sprain–when it happens once, it’ll probably happen again, an occurrence called recurrent ankle sprain. The first sprain often harms the sensors within the joint, muscles, and ligaments of the ankle. Many times, this causes the ankle to become unsteady, a condition called functional ankle instability.

An effective treatment for ankle sprains is “disk training.” A circular platform with a small sphere under it, the disk looks a bit like a spaceship. Patients place their feet on it and work the ankles by tilting the disk in various positions.

Doctors and therapists are convinced the disk works. Rightly so. These treatments are proven to improve balance, decrease ankle pain, and help keep people from having another ankle sprain. Okay, so the treatment works–but how? What does it do to help people get better and protect them from reinjury?

A unique study looked at whether disk training quickened the response of muscles around the ankle at the moment the ankle begins to sprain. Researchers had eight patients with past ankle sprains stand on a platform with a trapdoor. Without warning, the trapdoor would release, causing patients’ ankles to turn in–the most common position of the ankle when it sprains. Electrical tests measured how quickly the muscles around the ankle joints responded. Both ankles were tested, giving a comparison between injured and healthy ankles.

After the test, the patients were sent home with a disk and instructions to work the injured ankle 15 minutes per day. Participants came back eight weeks later, and the trapdoor tests were repeated.

The training made a difference in how quickly ankle muscles responded. The main shin muscle, the anterior tibialis muscle, showed the greatest improvement. What’s even more peculiar is this muscle got faster on the other leg too, the one that wasn’t worked on the disk. The effect of training somehow crossed over to the other side. This raises the question whether patients with severe ankle sprains might benefit by starting disk treatments right away on their uninjured ankles.

These research findings shed light on how disk training works. The results add valuable information for those who are involved in designing the best methods for rehabilitating ankle sprains.

Tracking Tibial Stress Syndrome among High School Runners

Up to sixty percent of recreational runners may get injured over the course of a year. Most of these injuries come from overuse. Ten to 15 percent of them are thought to be tibial stress syndrome.

Formerly lumped under “shin splints,” tibial stress syndrome happens when muscles tear away from the shinbone, causing inflammation. When the syndrome strikes along the inside edge of the lower shin, it’s called “medial tibial stress syndrome,” or MTSS. Symptoms of MTSS may be anything from a dull ache to intense pain with touch. The pain usually gets worse with repetitive weight-bearing activities like running.

Researchers think that runners who wind up with MTSS may be compensating for structural problems in their feet. If the feet are not properly aligned, runners may pronate–or put excessive downward pressure on the big-toe sides of the feet. This motion can tug at the muscles in the shins, leading to MTSS.

These authors studied the foot structure of 125 runners from three high school cross-country teams. The runners were roughly half male, half female. They were an average of 16 years old and had been running for about two years.

During the first three weeks of the cross-country season, the authors took a series of measurements of the runners’ feet. These measures included heel position, leg angle, and the ability to flex the foot up.

Pronation was measured for this group with a navicular drop test. The navicular bone is on the big-toe side of the foot. The test measures how far the navicular bone “drops” when the foot goes from a corrected alignment to a pronated one. The test was also done on 15 noninjured runners, to act as a comparison group.

The study showed that a pronated foot posture was related to symptoms of MTSS. Injured runners showed much greater pronation as measured by the navicular drop test. Their measurements were almost twice those of noninjured runners. And of the 25 legs with MTSS, almost a third showed nearly three times the “drop” of noninjured legs. Other measures of foot structure, including heel position and leg angle, were not related to injury, however.

Fifteen runners (12 percent) developed symptoms of MTSS within eight weeks. Yet there were no differences between injured and noninjured runners in age, years running, or years in school. Notably, girls were a lot more likely than boys to develop MTSS. Thirteen of the injured runners were girls. That means 19 percent of female runners developed MTSS. Meanwhile, only two boys showed symptoms. It could be that girls are more likely to report symptoms than boys.

The authors conclude that sex and pronation are the best predictors of MTSS. Sex correctly predicted MTSS 74 percent of the time. And pronation predicted MTSS 68 percent of the time. Together, these two characteristics accurately gauged who developed MTSS 76 percent of the time.

The authors intend to test their model over a longer period of time. If runners susceptible to MTSS can be identified early, symptoms might be successfully prevented by using orthotics.

Snowboarders Fly High and Land Hard: Ankle Injury on the Slopes

Snowboarding entered the winter sports scene in the 1970s. Since then, it has become increasingly popular. More and more people are taking up snowboarding, and their ankles may pay the price.

Fractures of the anklebone are common among snowboarders and can lead to serious problems if left untreated. Too often, the injury is overlooked as a simple ankle sprain. The fracture involves a small bump on the outside edge of the main anklebone, the talus. The talus connects with the end of the large lower leg bone, the tibia. What landing position can cause the anklebone to break?

These authors took ten cadaver ankles and placed them in positions that were thought to cause ankle fractures. First, to mimic the snowboarder’s foot position when landing from a high jump, the authors flexed the foot in an upward direction and rolled the heel slightly inward while applying heavy downward pressure. Even in these older ankles (ages 60 to 92), no injuries resulted from this combination of movement and pressure.

The authors then recreated the same landing position, but this time, they pointed the foot out at the same time. This position resulted in injury in six of the eight ankles tested.

These results suggest that landing with the foot lined up or slightly turned in at the ankle probably doesn’t lead to an ankle fracture. It’s landing with the foot pointed out that is mainly responsible for fractures of the talus bone. More research could lead to the development of boots and bindings that keep ankles safer on the slopes.

Sick of Your Sprained Ankle? Spice Up Your RICE

Ankle sprains happen often in sports, especially to runners and athletes in jumping sports. To treat an ankle sprain, RICE–or rest, ice, compression, and elevation–is just what the doctor ordered. But can anything else be done to get you back on your feet more quickly?

When you sprain your ankle, you lose the ability to fully bend your foot and ankle upward. When this movement, technically known as dorsiflexion, is painful, standing and walking on the injured ankle can hurt.

Physical therapists try to improve ankle dorsiflexion using a technique called joint mobilization. With the patient lying down, the physical therapist supports the ankle at about a 90-degree angle with one hand and assists movement of the ankle joint with the other. In this study, the authors wanted to know whether this technique, in which the therapist adds hands on mobilization, helped patients more than RICE alone. 

Thirty-eight people with sprained ankles were divided into two groups. One group got regular RICE treatments. The other group got RICE plus joint mobilization. Patients were treated every other day for two weeks, or until they felt able to return to normal activity. They were tested before and after each treatment to check for changes in their ankle movement and walking.

Though patients got better no matter what their treatment, they got better faster when they had joint mobilization in addition to RICE. Patients who had joint mobilization needed fewer treatment sessions. They showed pain-free ankle movement sooner, and they were able to walk more quickly than those who only had RICE. A few other factors, such as how long patients could stand with their weight on the injured leg, did not change with the treatment they received.

Fortunately, the body has some natural healing mechanisms. Either on its own or with help, a sprained ankle will heal eventually. Still, this study suggests that a little “laying on of hands” can go a long way toward getting you back on the track or field.

Stepping Up the Standards for Achilles Surgery

Say you have chronic pain in your Achilles tendon and your doctor wants to operate. He read in a medical journal that surgery has a 90 percent success rate. The success rate sounds good, but is it a number that can be trusted?

These authors reviewed 26 studies that reported on Achilles surgery between 1969 and 1999. The authors looked at the studies’ scientific methods–the way they got their information–in order to figure out whether these published success rates were reliable. 

Ideally, scientific methods keep information pure and accurate. This makes published success rates more trustworthy. If, on the other hand, a researcher only chooses to report on patients who have good results from Achilles surgery, the success rate may paint an overly positive picture.

The authors scored each study’s scientific methods on a scale from zero to 100. A perfect score of 100 meant the study was completely sound and unbiased. Actual scores ranged from two to 74. Only nine studies got scores over 50. That means most of them got “failing” grades.

The average success rate of Achilles surgery in these studies was 77 percent. Compared to studies with lower success rates, the ones with rates over 70 percent tended to use poorer methods. Higher success rates may be unrealistic if they come from sketchy methods. 

Fortunately, success rates after Achilles surgery appear to have gotten more trustworthy over the years. The methods were better for recent studies than for those done back in the 70s. 

So, when checking out medical information, it’s a good idea to look at how it was gathered in the first place. The authors suggest ways for researchers to improve their analysis of Achilles surgery results. In the meantime, patients should be aware that if it all sounds too good to be true, it might be.

Ankle Bone Connected to the . . . Small Arthritic Foot Bones

Ankle fusion surgery (also called arthrodesis) is a last-ditch effort to relieve pain in arthritic ankle joints. The surgery involves making the bones in a joint grow together, or fuse. This stops the bone ends from rubbing against each other and causing pain. However, fusion means that the ankle joint loses its ability to move.

Doctors have been doing ankle fusion surgeries for about 100 years. Yet little is known about the long-term effects of ankle fusion. These authors studied the long-term effects of ankle fusion on the other joints of the leg. The study included 23 patients who had gone through ankle fusion an average of 22 years earlier. All 23 people originally had the surgery because of severe ankle osteoarthritis that developed after a traumatic injury. The authors did physical tests and X-rays of the patients’ affected legs and, for comparison, their healthy legs. The patients also answered questions about their pain, ankle function, and satisfaction with surgery.

The authors found that almost all of the patients walked with a bit of a limp. Most of the patients also reported increased pain and problems with activities. The X-rays and physical tests showed that the knees on the healthy and affected legs functioned about equally well, with little pain. However, many smaller foot joints in the affected legs showed signs of advanced arthritis compared to the healthy side. These results seemed to be true no matter what kind of techniques were used in surgery or at what age the patients had fusion done.

It is unknown why exactly an ankle fusion would cause degeneration in the other joints of the foot. The authors suggest that the lack of motion in the fused ankle might put more of a load on the foot joints. It could also be caused by long-term immobilization of the foot following surgery. It is also possible that the foot joints had been injured in the initial ankle injury.

Even though this isn’t particularly good news, it is important. Knowing the long-term effects of ankle fusion can help doctors and patients decide whether it is the best solution for their needs.

Taping Ankles Back to Health

Rehabilitation programs have proven successful in helping people regain stability after an ankle sprain. A hallmark of ankle rehabilitation has been the use of proprioception exercises. Proprioception refers to the awareness of positioning and balance that is sort of like a sixth sense. Proprioception exercises are designed to help patients become aware of joint alignment and positioning. By improving proprioception, the joint’s stability improves.

One type of proprioception exercise involves using a disk platform with a rounded undersurface–sort of like a flying saucer. Patients do special exercises while balancing on the disk. The exercises are designed to work the nerve receptors in and around the injured ankle, leading to improved ankle stability.

In this study, the researchers tested two groups of people with ankle instability. Both groups did exercises on the disk. However, one group also had two small strips of tape on their lower leg, from the outside edge of the foot to midway up the calf. Exercises were done for 10 minutes, five days a week. After 10 weeks, researchers measured ankle instability of the two test groups and a group of people with no ankle problems.

The group wearing tape showed dramatically better stability within four weeks. By six weeks, they were nearly as stable as the healthy group. Remarkably, their recovery rate was about two weeks faster than the group who did exercises without wearing the tape.

That may sound wacky, but there is a scientific reason behind the tape. The sural nerve supplies the sensation to the skin under the tape. Scientists think that the tape pulls on the skin, which stimulates the nerve. The stimulated nerve then keeps the surrounding muscles and ligaments alert to the position of the ankle joint.

Low-tech and unglamorous though it is, the tape definitely appeared to work in this study. This is good news for patients with ankle sprains who need to get back to their regular activities quickly.

Payment for Another’s Labor: Strengthening One Ankle Crosses Over to the Other

It’s like getting paid for someone else’s work. In a phenomenon called the crossover effect, the muscles of one ankle get stronger even when exercises are done only by the opposite ankle.

Researchers measured crossover improvements by comparing two groups of people. Half went through eight weeks of a supervised strengthening program for one ankle using specialized equipment. The other group did normal activities and avoided exercise for the legs. Afterwards, the people in the training group had as much as a 19% improvement in muscles of the untrained ankle.

The authors present a variety of theories on how this could happen. Of the many possibilities, they find it most likely that the nerves going to the muscles on one side of the body cause an effect on the same exact muscles on the other side of the body. The researchers suggest that this crossover effect is most likely controlled by the central nervous system. The authors are optimistic that people who are unable to use their ankle due to injury or surgery could benefit from the crossover effect by using the efforts of one ankle to keep the other ankle strong.

A Walk Through Time Shows Best Treatments for Ankle Sprains

Even though sprains of the outer (lateral) ankle ligaments are one of the more common types of injuries, opinions abound as to the best types of treatment. Over the years, treatments have ranged all the way from surgery to no treatment at all. Which treatments are best? To answer this question, the authors analyzed research articles spanning the years 1966 to 1998. In general, treatment options for lateral ankle sprains include surgery, casting for more than six weeks, or functional treatment. The authors also compared cases where patients had functional training or a cast after surgery. Time off work was one way to measure if the treatment was helpful. But the authors concluded that a more accurate test is whether patients had episodes of unsteadiness in the ankle, a condition called give-way. Give-way happens when a joint has become loose, either because the ligaments are unable to support the joint, or because the nerves that give sensations for position have been harmed. Results of the analysis showed that people treated surgically had fewer problems with give-way compared to those who had functional training. People with functional training had fewer problems with give-way than those who were casted. Pain was nearly the same in patients who had surgery and those who had functional training. However, people who had minimal or no treatment had significantly more pain in the long-term than either of the other groups. Also, patients who had surgery did better if they had functional training afterward instead of a cast. Even though surgery showed better results overall, the authors caution that surgery poses higher risks and costs. However, they concluded that surgery is a reasonable choice if functional treatment alone hasn’t helped.