Medial Tibial Stress Syndrome (MTSS)
- Shin Splints
Medial Tibial Stress Syndrome (MTSS) – commonly referred to as ‘Shin Splints’ – is pain along the medial side (inside) of the tibia (shin), commonly affecting athletes whos sport/activity involves running and jumping. MTSS is the most prevalent lower leg injury in the active population and is the most common lower limb complaint that we see in the clinic.
Treatment of MTSS can be categorised as:
- What we can affect in the clinic (muscle length/flexibility, education of gait)
- Passive modalities (orthotics, taping)
- What you can do at home to rehabilitate and prevent further flare-ups (targeted strength work, exercise modification, training load modification).
Hip Focussed Lower Back Pain
Lower back pain is caused by many factors. However, in western society where a large portion of our day is spent in a seated position, there is an ever-growing correlation between lower back pain and hip dysfunction. Whilst a patient may complain of lower back pain during or after a bout of exercise, it is often our daily activities rather than exercise that drives the symptom.
Initial treatment, therefore, needs to be focused on improving daily behaviours, as well as the addition of a daily mobility intervention, in addition to good quality mobility drills prior to exercise. Secondary to a mobility intervention, attention needs to be paid to dysfunction in the way that the hip accelerates and decelerates load. This can be by way of improving recruitment or force production of muscles of the lumbopelvic girdle and hip.
Subacromial (Shoulder) Impingement
Subacromial impingement occurs when the tendons of the rotator cuff muscles become compressed and subsequently irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion (the bony point on the top of the shoulder), resulting in pain, weakness and loss of movement.
Outside of trauma, a common cause is a loss of function of the rotator cuff muscles. These are a group of muscles that control the intrinsic deceleration of the glenohumeral (ball and socket) joint. When they become dysfunctional, a decrease in joint coordination occurs, exacerbating closure of the subacromial space, in particular during overhead or dynamic movements.
A very common mechanism of injury is a historically dysfunctional shoulder being used to repetitively throw a ball for a dog!
Treatment initially focusses on reducing any protective mechanism around the shoulder girdle and giving the anterior shoulder space to settle/move - cryotherapy often helps in this case to reduce any inflammation. This would run in combination with rotator cuff and scapula control strength work. Due to the inherently unstable nature of the shoulder girdle, control of shoulder movement relies heavily on active control mechanisms. As such, many of the exercises found in a robust subacromial impingement rehabilitation programme will continue once symptoms have settled with a view to preventing further symptoms in the future.
A common theme with non-specific general neck pain is the issue of “posture” as a driving mechanism. It would be incorrect to suggest that there is a correct posture that everyone should adopt, rather that there are common themes that should be replicated. Prevalent in western society is an increased volume of computer work, a behaviour that reinforces a forward head posture and ever-increasing extension of the cervical spine (neck). This position not only creates the compression of the facet joints higher up the spine but also increases the shear force at the cervicothoracic junction (base of the neck). To compensate and stabilise the neck, we will often find the shoulders in an elevated and protracted state, further reinforcing the forward head posture.
Treatment takes two paths;
Mobility work is focussed on decreasing the hyperactivity of the neck extensors/shoulder elevators/shoulder upward rotators, allowing patients to find a more appropriate cervical and shoulder girdle position. This improved positioning then needs to be reinforced with strength work.
Initially, this is a low force in an application and centred on finding a better thoracic/scapular/cervical position whilst providing high levels of feedback. As the patient progresses, that feedback is reduced and they will find it easier to reproduce those themes during the day to day activities. There must also be a focus on neck flexor and shoulder retractor strength to increase the robustness of the model and support this position all day.
Lateral Knee Pain
Lateral knee pain is commonly associated with the ITB, a length of strong, tough, non-contractile tissue running from hip to knee along the lateral thigh. The age-old advice has always been to foam roll or massage the ITB; being fascia, this tissue cannot change length on its own. Therefore the tension applied to the ITB must come from the surrounding musculature.
The prime culprit is the TFL, a small muscle sitting in the anterior-lateral hip. It would be very fair to reflect that the ITB is a fascial continuation of the TFL, therefore controlling TFL hyperactivity is of utmost importance when treating lateral knee pain. To reduce the overloading of the lateral knee and prevent the injury returning, it is also important to address why the TFL is hyperactive, with particular note paid to the behaviour driving the shortened position of the TFL (high volume of sitting), and how the hip controls loading during daily and sporting movements.
Rehabilitation should focus more on the behavioural change and improved loading characteristics than mobility as this will drive a lasting positive change, thus improving sport and exercise participation.
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