Encourage patients who are concerned about shin splints to decrease the intensity of their running; suggest rest and ice and foot orthoses, to treat the condition. Reducing running intensity probably reduces lower extremity soft tissue injuries (strength of recommendation [SOR]: B, low-quality randomized controlled trials [RCTs]), although doing stretching exercises doesn't

Carr, Kathleen

Sevetson, Erika

University of Missouri: MOspace

CLINICAL INQUIRIES Evidence Based Answers from the Family Physicians Inquiries Network❚ Evidence summaryCopy starts here...  Copy for evidence-based answerEvidence-based answerClinical commentaryCopy for clinical commentary406 VOL 57, NO 6 / JUNE 2008  THE JOURNAL OF FAMILY PRACTICEFAST TRACK How can you help athletes prevent and treat shin splints?Encourag  patients who are concerned about shin splints to decrease the intensity of their running; suggest rest and ice and foot orthoses, to treat the condition. Reducing running intensity probably reduces lower extremity soft tissue injuries (strength of recommendation [SOR]: B, low-quality randomized controlled trials [RCTs]), although doing stretching exercises doesn’t. Rest and ice alone promote faster recovery than rest and ice combined with nonsteroidal anti-infl ammatory drugs (NSAIDs), a walking cast, or heel-cord stretching. (SOR: B, low-quality RCT). Although foot orthoses or insoles don’t prevent lower limb injuries (SOR: A, systematic review), they do signifi cantly relieve symptoms and promote return to running (SOR: C, poor-quality cohort studies). Lower limb fasciotomy can reduce symptoms caused by shin splints in athletes, but the rate of return to previous level of sports activity is modest at best (SOR: C, case series).Clinical commentaryReview, rest, follow-upShin splints are an early indicator of abnormal stresses that cause periostitis along the tibia. Medial tibial stress syndrome (MTSS) is best thought of as part of a continuum, with shin splints at the mild end and tibial stress fracture at the severe extreme. I fi nd that reviewing biomecha i al forces and training schedules oft n helps prevent and treat injury. Aging footwear and training errors, including a rapid increase in training volume, are common culprits when biomechanics are normal. Adequate rest to allow the body to respond to the stresses of training can help prevent stress-related injuries.  My treatment regimen for shin splints includes a period of relative rest that allows the runner to remain active but reduces the stresses placed on the tibia and musculature of the lower leg. Relative rest may comprise either reducing running distance and intensity or changing the mode of exercise to deep water running or cycling. Consider follow-up examination to ensure that the tibial pain doesn’t become more localized, indicating a possible stress fracture.Doug Aukerman, MDPennsylvania State University, State College ❚ Evidence summaryMTSS, or shin splints, is the most common cause of exertional leg pain in athletes. MTSS is an overuse injury characterized by pain along the posteromedial aspect of the distal two-thirds of the tibia. Reduced running time, frequency, and distance may prevent injury A systematic review of 12 trials of 8806 Kathleen Carr, MD, and Erika Sevetson, MLSUniversity of Wisconsin, MadisonStretching exercises don’t reduce lower extremity soft tissue injuries 406_JFP0608   406 5/20/08   1:04:49 PMCopyright® Dowde  Health Media  For persona  use nlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.FAST TRACK VOL 57, NO 6 / JUNE 2008 407www.jfponline.commostly young male military recruits, evaluated nonsurgical interventions to prevent lower limb soft tissue running injuries, including MTSS.1 Five trials in-vestigating stretching and 4 trials of shoe insoles showed no benefi t. Three studies showed that reducing the duration of running (to between 15 and 30 minutes), frequency (to 1 or 3 days a week), or dis-tance (to 16.5 fewer kilometers over 12 weeks) reduced the risk of all injuries. Methods and outcome measures of the studies were heterogeneous, limiting the generalizability of these results. A prospective RCT of custom semi-rigid shoe orthoses in the boots of Danish army recruits found a signifi cantly lower prevalence of MTSS at 3-month follow-up in the intervention group (13% compared with 24%, P=.005; NNT=5).2 However, a systematic review of methods to prevent MTSS in sports found no high-quality studies in nonmilitary populations.3 No difference in the incidence of MTSS was noted with shoe inserts, different combat boots, or stretching routines. To treat shin splints, consider orthotics, rest, and ice Two studies retrospectively surveyed runners about their response to orthot-ics to treat MTSS.4,5 In one study, 16 of 41 collegiate cross-country runners were prescribed orthotics; 14 (88%) reported relief or improvement in their symptoms and return to running within 4 weeks.4 The other survey, of long-distance run-ners, found that 70% who had used or were using orthotics for a presumed di-agnosis of MTSS reported complete relief or great improvement.5A study of 97 US naval midshipmen who developed MTSS during summer training programs compared randomly assigned treatments of rest and ice to rest and ice plus anti-infl ammatory medica-tion (aspirin or phenylbutazone), rest and ice plus heel-cord stretching, or use of a short walking cast for 1 week.6 Subjects assigned to a treatment program of rest and ice alone lost signifi cantly fewer days from running than the other treatment groups (P<.03).A recent RCT of soldiers with MTSS compared treatment with a leg orthosis with no orthotic use; all subjects under-went icing and activity modifi cation.7 No signifi cant differences in outcome mea-sures (days to completion of a 0.5-mile run, global rating of change, or number of treatment sessions) were noted between the treatment groups. Small sample size, high dropout rate, and small effect size limit the power of this study. Fasciotomy can relieve symptoms but may not improve postop activityThree case series reported on deep pos-terior compartment fasciotomy to treat MTSS in athletes.8-10 Surgery signifi cantly reduced pain levels (P<.001) by an av-erage of 72% on the visual analog pain scale for 46 patients who had failed con-servative therapy for at least 12 months.8 However, only 41% returned to their pre-symptom level of sports activity. Another case series of mostly running athletes reported that 21 (78%) of 27 patients exhibited excellent or good healing after surgery.9 In a series of 9 patients with an average of 39 months of symptoms, 5 re-ported complete relief at follow-up (42±6 months), and 7 trained more than they had preoperatively.10One case series of superfi cial poste-rior compartment fasciotomy for MTSS in 35 athletes reported that, among the 32 athletes available for follow-up, 72% (23) reported improved symptoms, but 69% (22) had a lower level of activity postop-eratively.11 Recommendations The American College of Sports Medi-cine (ACSM) recommends at least 7 to 10 days of rest from painful activities to treat MTSS.12 Running in a pool and cy-cling to maintain aerobic fi tness during the rest period are considered safe activi-ties. Stretching and strengthening exercis-es are not recommended while symptoms persist. Patients should return to running Worn shoes and training errors are common culprits when biomechanics are normal407_JFP0608   407 5/20/08   1:04:53 PMCLINICAL INQUIRIESAmealPeptide® and ameal bp™are trademarks of Calpis Co., Ltd.,Tokyo, Japan  ©2008*This statement has not been evaluated by the Food and DrugAdministration. This product is not intended to diagnose,treat, cure, or prevent any disease.Introducing ameal bp™ – containingthe breakthrough, naturally derivedactive ingredient AmealPeptide®,clinically shown to help maintainhealthier blood pressure.*Start prehypertensive patients onameal bp™ when you start themon a diet and exercise program.Significant difference from placebo (t-test): **P<0.01, ***P<0.001.Diastolic blood pressure (mmHg)Systolic blood pressure (mmHg)Stratified analysis of 8 clinical studies by start value of blood pressure (Post-hoc analysis, 606 subjects from 8 studies)AmealPeptide®Placebo~100 99~95 94~90 89~85******-30-20-10010~160 159~150 149~140 139~130*** *********Reference: 1. Data on file. Post-hoc analysis adapted from AmealPeptide® clinical studies.Visit www.amealbp.com formore information.ameal bp™ is available online or atmajor drugstores in easy-to-swallowcapsules and chewable tablets.I,m getting aggressive with prehypertension,naturally.VOL 57, NO 6 / JUNE 2008  THE JOURNAL OF FAMILY PRACTICEgradually. ACSM also suggests that orthotics are useful for preventing injury and treating some patients. ■References 1.  Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue inju-ries in runners. Cochrane Database Syst Rev. 2005;(4):CD001256.  2.  Larsen K, Weidich F, Leboeuf-Yde C. Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther. 2002;25:326-331.  3.  Thacker SB, Gilchrist J, Stroup DF, et al. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34:32-40.  4.  Eickhoff CA, Hossain SA, Slawski DP. From the fi eld. Effects of prescribed foot orthoses on medial tibial stress syndrome in collegiate cross-country runners. Clin Kinesiol. 2000;54:76-80.  5.  Gross ML, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med. 1991;19:409-412. 6.  Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg Am. 1974;56:1697-1700. 7.  Johnston E, Flynn T, Bean M, et al. A randomized controlled trial of a leg or-thosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med. 2006;171:40-44. 8.  Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. J Bone Joint Surg Am. 2003;85-A:1974-1980. 9.  Järvinnen M, Aho H, Niittymäki S. Results of the surgical treatment of the medial tibial syndrome in athletes. Int J Sports Med. 1989;10:55-57. 10.  Wallenstein R. Results of fasciotomy in patients with medial tibial syndrome or chronic anterior-compartment syndrome. J Bone Joint Surg Am. 1983;65-A:1252-1255.  11.  Holen KJ, Engebretsen L, Grontvedt T, et al. Surgical treatment of medial tibial stress syndrome (shin splint) by fasciotomy of the superfi cial posterior compartment of the leg. Scand J Med Sci Sports. 1995;5:40-43.  12  Beck BR. Exercise-induced leg pain. Current Comment. March 2002. Ameri-can College of Sports Medicine. Available at: www.acsm.org/AM/Template.cfm?Section=Search&section=20026&template=/CM/ContentDisplaycfm&ContentFileID=299. Accessed December 14, 2006. Have a comment on an article, editorial, illustra-tion, or department? Drop us a line and let us know what you think. You can send a letter 1 of 3 ways.Letters should be addressed to the Editor, The Journal of Family Practice, and be 200 words or less. They may be edited prior to publication.Fax201-391-27782MailThe Journal of Family Practice110 Summit Ave.Montvale, NJ 076453E-mailjfp@fammed.uc.edu 1We want to hear from you!Please take a moment to share your opinion!408_JFP0608   408 5/20/08   1:04:57 PM

How can you help athletes prevent and treat shin splints?

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