SHIN SPLINTS - MEDIAL TIBIAL STRESS SYNDROME

Definition:

 The pain known as shin splints, generally starts with a tight and painful feeling along the side of your shin bone (tibia). This is classed as MTSS, as the tibia bone is being stressed through dysfunction of the surrounding muscles. If these muscles continue to work in a dysfunctional way, they create more and more stress through certain points of the bone and this can then develop into a stress fracture of the bone.

Causes:

There are many risk factors to the development of tibial stress, some of which can be helped and others that can’t. These are known as intrinsic (things inside your body – some that you can’t change) and extrinsic (external things you can change) risk factors, as you will see below:

Intrinsic factors:

• Poor conditioning and high BMI (Body mass index)
• Previous MTSS or lower leg injury
• Lack of running experience and competitive running
• Female
• Increase in navicular drop (bone stability in your foot)
• Increased hip external rotation in males

Extrinsic factors:

• Type of sport
• Training frequency
• Shoes and orthotics
• Hard and uneven training surfaces

Prevention:

For those factors that can be changed, there are a few things you can do to help prevent shin pain, or at least avoid making it worse.

First there is the training frequency and load. For a high performance athlete this will be huge, but most of us can’t go straight to that level! It is important to start at level that is achievable for you. This is especially important if you have never been a runner or you have never played a particular type of sport before. The same goes for the type of surface you are running on. If you are on grass for every run until one day you decide you are only going to run on concrete, your body can’t adapt to the change fast enough, and hence you start to get dysfunction in the muscle and stress points.

The type of shoe you wear is also important, as you need to have the correct stability and flexibility for the type of activity you want to do.

Obviously some of the intrinsic factors can be changed too. However these factors are something you have no matter how fast or slow you start out and therefore you need to be extra careful if you have them. For instance, if your BMI is higher there is an increased risk of MTSS and stress fracture. This seems ironic in the fact that you need to do exercise to decrease your BMI, but it is as we have mentioned above…you need to start at a level that is achievable for you and your body. 

Now if you do have “shin splints” then the first thing to do is REST! I know you don’t want to hear that, but I actually mean relative rest from the intensity and frequency of training that you are currently at. For example if you think about a scab from a cut – if you continue to pick at it and pick at it when it is only half healed, the whole healing process has to start again and you are back to square one. It is the same with injuries on the inside, if you have MTSS and you keep stressing those muscles, they will not heal and you may develop a stress fracture.

It is best to see a physio as fast as possible, to help you get back on track as quickly as you can and set up your activity plan. They will help you build your training up specifically for you and your body, help prevent stress fractures and most importantly get you back to your best!

Treatment for Shin Splints

1 - Early Injury Protection: Pain Reduction & Anti-inflammatory Phase

As with most soft tissue injuries the initial treatment is - Rest, Ice and Protection.

In the early phase you may be unable to walk or run without pain, so your shin muscles and bones need some active rest from weight-bearing loads. Your physiotherapist will advise you on what they feel is best for you.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. As you improve a kinesio style supportive taping will help to support the injured soft tissue and provide some stress reduction for your shin bone.

Anti-inflammatory medication (if tolerated) and natural substances e.g arnica may help reduce your pain and swelling. 

2: Regain Full Range of Motion 

If you protect your injured shin muscles while they heal and strengthen. This may take several weeks. During this time period you should be aiming to optimally remold your scar tissue to prevent a poorly formed scar that will re-tear in the future. It is important to lengthen and orientate your healing scar tissue via massage, muscle stretches, neuro-dynamic mobilizations and specific exercises. Your physiotherapist will guide you.

3: Normalize Foot Bio mechanics

Shin splints commonly occur from poor foot bio mechanics e.g flat foot. In order to prevent a recurrence, your foot will be assessed. In some instances you may require a foot orthotic (shoe insert) or you may be a candidate for the Active Foot Posture Stabilization program. 

4: Restore Muscle Strength

Your calf and shin muscles will need to strengthened to enable a safe resumption of sport or training.

5: Modified Training Program & Return to Sport

Most shin splints occur due to excessive training loads. Running sports place enormous forces on your body (contractile and non-contractile). In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with training schedules and exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance. 

Depending on the demands of your chosen sport, you will require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

Your  physiotherapist will discuss your goals, time frames and training schedules with you to optimize you for a complete return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimized your chance of future injury.

Prognosis:

There is no specific time frame for when to progress from each stage to the next. Your shin splints rehabilitation status will be determined by many factors during your physiotherapist's clinical assessment. You'll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.

It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration. The severity of your shin splints, your compliance with treatment and the workload that you need to return to will ultimately determine how long your injury takes to successfully rehabilitate.

RHEUMATOID ARTHRITIS- PHYSIOTHERAPY INTERVENTION

Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition also can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels.

An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body's tissues. Means your immune system attacking your own body tissues.

Causes for RA:

Rheumatoid arthritis occurs when your immune system     attacks the synovium — the lining of the membranes that surround your joints.In this stage joint space will be widens. The resulting inflammation thickens the synovium, which can eventually destroy the cartilage and bone within the joint. In this stage, joint space will be likened less. In third stage, there is no space in between bones. The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment.

In fact we don't know the exact cause, although a genetic component appears likely. While your genes don't actually cause rheumatoid arthritis, they can make you more susceptible to environmental factors — such as infection with certain viruses and bacteria — that may trigger the disease.

Risk factors

Factors that may increase your risk of rheumatoid arthritis include:

Your sex. Women are more likely than men to develop rheumatoid arthritis. Likely more than 70 percentage.

Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between the ages of 40 and 60.

Family history. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease.

Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis, particularly if you have a genetic predisposition for developing the disease. Smoking also appears to be associated with greater disease severity. But actual reason we don't know.

Environmental exposures. Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.Although uncertain and poorly understood, some exposures such as asbestos or silica may increase the risk for developing rheumatoid arthritis. 

Obesity. People who are overweight or obese appear to be at somewhat higher risk of developing rheumatoid arthritis, especially in women diagnosed with the disease when they were 55 or younger.    

Symptoms

• Signs and symptoms of rheumatoid arthritis may include:
  • Tender, warm, swollen joints
  • Joint stiffness that is usually worse in the mornings and after inactivity
  • Fatigue, fever and weight loss
  Early rheumatoid arthritis tends to affect your smaller joints and distal joints first — particularly the joints that attach your fingers to your hands and your toes to your feet.As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body. About 40 percent of the people who have rheumatoid arthritis also experience signs and symptoms that don't involve the joints. Rheumatoid arthritis can affect many non joint structures, including:
  • Skin
  • Eyes
  • Lungs
  • Heart
  • Kidneys
  • Salivary glands
  • Nerve tissue
  • Bone marrow
  • Blood vessels
  Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. 

  Complications

  Rheumatoid arthritis increases your risk of developing:
• Carpal tunnel syndrome. If rheumatoid arthritis affects your wrists, the inflammation can compress the nerve that serves most of your hand and fingers. Who are all having Rheumatoid Arthritis, there is a lot of chances to have a carpel tunnel syndrome.
• Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of blood cancers that develop in the lymph system , because of auto immune attack.
•  Lung disease. People with rheumatoid arthritis have an increased risk of inflammation and scarring of the lung tissues, which can lead to progressive shortness of breath.
• Heart problems. Rheumatoid arthritis can increase your risk of hardened and blocked arteries, as well as inflammation of the sac that encloses your heart.
• Abnormal body composition. The proportion of fat compared to lean mass is often higher in people who have rheumatoid arthritis, even in people who have a normal body mass index (BMI).
• Infections. The disease itself and many of the medications used to combat rheumatoid arthritis can impair the immune system, leading to increased infections.
• Dry eyes and mouth. People who have rheumatoid arthritis are much more likely to experience Sjogren's syndrome, a disorder that decreases the amount of moisture in your eyes and mouth.
• Rheumatoid nodules. These firm bumps of tissue most commonly form around pressure points, such as the elbows. However, these nodules can form anywhere in the body, including the lungs.
• Osteoporosis. Rheumatoid arthritis itself, along with some medications used for treating rheumatoid arthritis, can increase your risk of osteoporosis — a condition that weakens your bones and makes them more prone to fracture. 

  Diagnosis

• Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases. There is no one blood test or physical finding to confirm the diagnosis.

  Blood tests

  People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR, or sed rate) or C-reactive protein (CRP), which may indicate the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.

  Imaging tests

  Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in your joints over time. MRI and ultrasound tests can help your doctor judge the severity of the disease in your body.

• Medications

  The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you've had rheumatoid arthritis.
  • NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). 
  • Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. .
  • Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. 
  • Biologic agents.  this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz).
  • Rheumatoid arthritis surgery may involve one or more of the following procedures:
    • Synovectomy. Surgery to remove the inflamed synovium (lining of the joint). Synovectomy can be performed on knees, elbows, wrists, fingers and hips.
    • Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
    • Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option.
    • Total joint replacement. During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic                                                                                                                                                                                                                          A structured exercise program can be greatly beneficial to the overall well-being and functioning of the individual with rheumatoid arthritis. Such a program should focus on stretching, strengthening and aerobic conditioning while conserving energy. We will discuss it  clearly on upcoming post.

PES ANSERINE BURSITIS

Pes Anserine Bursitis:

             Pes anserine bursitis (tendinitis) involves inflammation of the bursa at the insertion of the pes anserine tendons on the medial proximal tibia.

The pes anserine or goose's foot is composed of the sartorius, gracilis, and semitendinosus tendons.The superficial medial collateral ligament inserts onto the proximal tibia deep to the pes insertion.Symptoms include medial pes swelling, pain to touch, warmth, and pain with hamstring activation.

The cause is usually overuse. Treatment involves modification of activities, icing, and stretching. Conservative treatment usually resolves this condition. 

Signs and symptoms

Acute trauma to the medial knee, athletic overuse, chronic mechanical (pes planus) process or degenerative process.

Pain, tenderness, and localized swelling over the medial knee.

Worse on ascending and possibly, descending stairs and when rising from a seated position; typically deny pain with walking on level surfaces.

May have chronic, refractory pain in setting of arthritis or obesity. More common in sports requiring side-to-side movements and cutting. May have coexistent medial collateral ligament pathology (tenderness superior and posterior to the pes bursa).

Bilateral symptoms in one third of patients.

Physical Examination:

a) Observation - Localized swelling present

b) Palpation

• Tenderness over the proximal medial tibia at the insertion of the pes anserine, approximately 2 to 5 cm distal to the anteromedial joint line.
• Bursa usually not palpable unless effusion and thickening present.
• Crepitus over the bursa occasionally present.
• Absence of joint line pain.
• Exostosis (a benign outgrowth of cartilaginous tissue on a bone) of the tibia may contribute to chronic symptoms in athletes.

c)Range of motion - May have pain with resisted internal rotation, resisted flexion, and valgus stress (especially in athletes). 

Exercises for pes anserine bursitis

Stretching of Quadriceps: This can be performed in either standing, or laying on your front. Pull the foot of the injured leg towards your buttock until you can feel a gentle stretch on the front of the thigh. To increase the stretch, tilt your hips backwards. Hold for 20-30 seconds and repeat 3 times.
Stretching of sartorius, gracilis, and semitendinosus tendons is very useful.

Calf Stretch: 

Keep your right leg forward, foot flat on the floor, and extend your left leg straight back, placing your heel flat on the floor. Don't bend your back knee. Lean into the wall until you feel thestretch in the calf of the straight leg. Hold for 30 seconds and switch sides

Butterfly stretch- seated adductor stretch. Passive and active stretching can promote an important reduction in the tension on the anserine bursa.

Heel Slides- Slowly begin to slide your heel toward your buttocks, keeping your heel on the floor or bed. Your knee will begin to bend. Continue to slide your heel and bend your knee until it becomes a little uncomfortable and you can feel a small amount of pressure inside your knee. Hold this position for about 6 seconds.

Isometric Hamstrings- 

Aim: The aim of this exercise is to start strengthening the hamstrings and prevent wasting.

Technique:The patient lies on their front with the knee slightly bent. The therapist grasps around the back of the ankle. The athlete tries to bend their knee against the therapists resistance. Start with a gentle contraction and gradually increase force as pain allows. The knee should not move. 

Isometric Quadriceps:

EXERCISES FOR PES ANSERINE BURSITIS

PARKINSON'S DISEASE - PHYSIOTHERAPY REHABILITATION

What is  Parkinsonism?

Parkinsonism is any condition that causes a combination of the movement abnormalities seen in Parkinson's disease — such as tremor, slow movement, impaired speech or muscle stiffness — especially resulting from the loss of dopamine-containing nerve cells 

Difference between Parkinsonism and Parkinson's Disease:

Parkinsonism is a generic term for a group of symptoms that can be seen in someone with Parkinson's disease such as tremor, stiffness, and slowness of movement. There are several conditions other than Parkinson's disease which can cause these symptoms.

Drugs might be a cause?

Sodium valproate, used to treat epilepsy, and lithium, used in depression, both commonly cause tremor which may be mistaken for Parkinson's. 

Secondary parkinsonism is similar to Parkinson disease, but the symptoms are caused by certain medicines, a different nervous system disorder, or another illness. Parkinsonism refers to any condition that involves the types of movement problems seen in Parkinson disease.

Causes:

Medications:those used to treat psychosis, major psychiatric disorders and nausea

Repeated head trauma: injuries sustained in boxing

Certain neurodegenerative disorders: multiple system atrophy, Lewy body dementia and progressive supra nuclear palsy

Exposure to toxins: carbon monoxide, cyanide and organic solvents

Certain brain lesions: tumors, or fluid buildup

Metabolic and other disorders:chronic liver failure or Wilson's disease 

Parkinson's signs and symptoms may include:

Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor. One characteristic of Parkinson's disease is a tremor of your hand when it is relaxed (at rest). This is the positive sign for the Parkinsonism

Slowed movement (bradykinesia).  Parkinson's disease may reduce your ability to move and slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, you may drag your feet as you try to walk, making it difficult to move.

Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can limit your range of motion and cause you pain. This may lead to mild contractures

Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson's disease. 

Loss of automatic movements. In Parkinson's disease, you may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.

Speech changes. You may have speech problems as a result of Parkinson's disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone.

Writing changes. It may become hard to write, and your writing may appear small.

Exercise and Physical Therapy

Research has shown that regular exercise benefits people with Parkinson’s disease. Aerobic exercise increases oxygen delivery and neurotransmitters to keep our heart, lungs, and nervous system healthy. General exercise may also reduce depression. Learning-based memory exercises can also help keep our memory sharp. Postural awareness exercises to improve the posture. Balance and co- ordination exercises help to improve balance and co-ordination.

Exercise:

• reduces stiffness
• improves mobility, posture, balance and gait

BALANCE EXERCISES FOR PARKINSON'S DISEASE

Best exercises for Parkinson’s disease

There is increasing evidence that aerobic and learning-based exercises could be neuroprotective in aging individuals and those with neurodegenerative disease.  Facilitating exercise programs that challenge our heart and lungs as well as promote good biomechanics, good posture, trunk rotation and normal rhythmic, symmetric movements are the best.  Dancing to music may be particularly good for decreasing stiffness.

Exercises that require balance and preparatory adjustment of the body are also important along with rhythmic activities such as dancing, skipping and cycling can maintain the ability to perform reciprocal movements.   Finally, exercises that promote attention and learning are beneficial. 

Types of exercises that do this:

• Walking outside or in a mall
• Dancing
• Yoga classes
• Stepping over obstacles
• Marching to music with big arm swings
• Sports (ping pong, golf, tennis, volleyball)
• Aerobic classes  

Types of exercises that promote cardiopulmonary fitness:

• Paced walking (treadmill walking at different speeds and different inclines)
• Hiking using walking sticks
• Swimming with different strokes to increase heart rate and provide good cardiopulmonary conditioning.
• New body weight-supported treadmills can also be helpful to protect from falling, and to facilitate easier coordinated movements for fast walking with a long stride or jogging.

These exercises for cardiovascular, endurance and strengthening could be enriched by performing simultaneous activities such as reading, writing, problem solving, singing, watching the news or a movie or throwing and catching balls. Exercises that demand attention, repetition, progression of difficulty with spaced practice over time are the best exercise routines to promote learning.

Strengthenind exercises:

Individuals need to be careful how they perform strengthening exercises to minimize increasing stiffness and rigidity. When performed properly, strengthening exercises do have some value.

As one ages, more exercise must be performed to maintain muscle mass.  Muscle mass and strength allow an individual to complete daily chores and to maintain balance. Additionally, strengthening postural muscles may help to maintain a more upright posture. Infact, functional exercises other than weight-training may strengthen muscles in ways that are more beneficial to individuals with Parkinson’s disease.  

Walking with ankle and wrist weights can help strengthen while encouraging increased awareness of arm swinging and high stepping. Moderation is the best word for strength training without other forms of exercise.  However, integrating strengthening and flexibility exercises into aerobic, rhythmic and learning-based exercise routines that are fun, engaging, progressing in difficulty and rewarding are the best.

Swimming can help?

Swimming provides good cardiopulmonary training and maintains muscle strength.   The arms, legs and head may be doing different things, it may increase coordination.  The resistance of the water increases stiffness in some people and decreases it in others.  

Activities to try:

• Adding resistance with paddles and trunk support – provides more opportunity for reciprocal movements and circling movements of the arms and the legs
• Rolling and somersaults – in the pool are good for those who are particularly comfortable in the water

Will exercise make my muscles less stiff?

Exercises that require large, rhythmical movements through a full range of motion have been shown to decrease rigidity.  For example, in a program of aerobic exercise using music, there was a reduction in rigidity in 9 out of 10 participants immediately after the exercise program.

Exercises to reduce stiffness:

• Large, rhythmical movements
• Rotating the trunk
• Vibration, rocking and swinging

How often should I exercise?

The guidelines for people with Parkinson’s disease are no different from those without the disease (i.e. 4-5 times a week for at least 30-40 minutes).  This assumes that your heart is beating at 70 to 80% of maximum (220 – your age times 70 or 80%).  

Make the exercise time fun:

Engage in group exercise, movement or dancing classes.  For many, participating in activities with other people, can be more stimulating and increase compliance. 

Stay active :

• Walk whenever possible instead of driving
• Climb the stairs instead of taking the elevator
• Take regular 5 minute breaks every 30 minutes (lifting the arms up over your head, performing wall glides, breathing diaphragmatically, getting up to get a glass of water, or putting theraband on chairs to work on some strengthening)
• Avoid long periods of time watching TV and or using a computer

 Is there anything else I should know?

A “cool-down period” is important.  After exercise, allow yourself a longer time for a cool-down than others would need (Individuals who exercised before developing Parkinson’s disease typically double their cool-down time).  

A cool-down period accomplishes 2 goals:

1)      Promotes a slow decrease in heart rate

2)      Allows the muscles time to cool down gradually so they do not become stiff.  

Learn something new every day:    

If you listen to the news, talk to someone about it.  Listen to educational programs and discuss what you learned.  Do crossword puzzles or participate in memory training programs on the web or from a CD.

Challenge yourself to go out each day:       

Practice writing:        

Exercise your voice: 

To help decrease freezing movements:

• Reciprocal arm swinging
• High long steps
• Scanning the environment and using visual fixation on an object in the distance or auditory cues (listening to music, singing to yourself, counting)
• Thinking about making big steps to clear obstacles on the floor or marching (high steps)
• Walking hand-in-hand, swinging the arms with a friend or family member
• Having someone place their foot in front of you as a cue to step high and over
• One person found that throwing pennies and stepping over them was helpful (“But,” he added, “don’t bend down to pick them up.”). 
• Loud rhythmical clapping
• Paced walking with high stepping. 
• Using walking sticks (using them for sensory feedback and sense of stability may be more important than using a cane. Of course, using a cane or a walker can be helpful if there is a lot of weakness and stiffness.) 

Pushing one’s self to stay active should be the goal. To get improvement from the Parkinson's disease.