Abstract
Shin splints, also known as medial tibial stress syndrome, is an overuse injury often caused by running. This injury occurs more often in women than men and is the third most common injury in runners. Research on rehabilitation and training plans to return to running after shin splint injuries, especially to return to exercise phase, has not been extensively researched. The aim of this article was to study the training to return to running and physiotherapy management in rehabilitation programs for amateur runners experiencing shin splints in the return to exercise phase. A male amateur runner who met the requirements, including had completed a long distance run (at least 21 km) and experienced shin splints in the return to exercise phase, was the subject of this case report study. The patient did not have any new complaints or specific complications, especially after starting an exercise program. On the contrary, the patient progress im- proved over time. Based on research findings, an amateur runner with complaints of shin splints in the superolateral third of the tibia, in the return to exercise phase, gained a benefit from the therapeutic intervention in the form of an exercise and rehabilitation program based on the FITT concept. The program includes a variety of training com- ponents, including strengthening, plyometrics, and running, and can also improve per- formance. Correspondence Address : Ahmad Yani Street, Kartasura, 57169, Jawa Tengah-Indonesia E-mail : j120210188@student.ums.ac.id https://ejournal.upi.edu/index.php/penjas/index
47 INTRODUCTION Around 621.16 million people are running world- wide. The running trend increased during the COVID- 19 pandemic, with 28.76% of new runners discovering running for the first time during the pandemic and 72% of those runners motivated to stay healthy (Widia, 2024). Once considered an introverted activity for the few, running has become increasingly popular, becom- ing a symbol of fitness, self-improvement, and ubiqui- tous community (Scott, 2019). Running is frequently associated with overuse injuries of the lower extremi- ties and lower back (Mendez-Rebolledo et al., 2021). Running-related injuries consist of complications in- volving the muscles, tendons, joints, or bones that occur during a training or competition (Mayooran et al., 2019). Medial tibial stress syndrome (MTSS), also known as "shin splints," is a prevalent group of injuries that occur specifically in the distal third or middle sec- tion of the posteromedial tibial border. It impacts the majority of runners, athletes, and military personnel (Deshmukh et al., 2022). Particularly due to overuse, running-related musculoskeletal injuries (RRMIs) are prevalent among runners (Kakouris et al., 2021). The etiology of shin splints is complex, involving various intrinsic factors such as age, BMI, biomechani- cal factors (Q angle, limb length discrepancy, and foot arch), and previous injury history. Additionally, extrin- sic factors like training duration, warm-up and cool- down routines, training intensity, training patterns, and changes, as well as the type and usage of running shoes, contribute to the development of shin splints (Mayooran et al., 2019). Pain in the medial aspect of the lower tibia may be attributed to periostitis. In con- trast, pain in the lateral aspect of the upper tibia may be the result of higher pressure in the compartment (Bhusari and Deshmukh, 2023). Lower extremity stress injuries give rise to a multitude of functional compro- mises and also compromised mobility and joint, bone, reflex, and muscle functions in the lower limbs, with patients encountering difficulties in plantar ankle flex- ion (Mattock et al., 2021). Consequently, patients may encounter restrictions when it comes to their ability to take part in running. Agustin (2022) conducted a study on 55 runners at
to a multitude of functional compro- mises and also compromised mobility and joint, bone, reflex, and muscle functions in the lower limbs, with patients encountering difficulties in plantar ankle flex- ion (Mattock et al., 2021). Consequently, patients may encounter restrictions when it comes to their ability to take part in running. Agustin (2022) conducted a study on 55 runners at Playon Jogja, which yielded findings on the prevalence of injuries among runners. Shin splints were observed in 50.9% of the participants, ranking third after ITBS (54.5%) in first place and calf injuries (52.7%) in sec- ond place. The prevalence of shin splints is greater among females than males (Patel and Patil, 2020; Wu et al., 2022). Because shin splints are so common, it is important to have the right plan, especially for rehab programs and running back training after an injury. Ac- cording to Liem et al. (2013), there is little written about rehabilitation and functional development after lower limb stress fracture injury. This study is quite important in the rehabilitation scope, especially in phase IV, as it incorporates functional training treat- ments specifically for running sports, primarily focus- ing on plyometric exercises, so researchers are interest- ed in conducting comprehensive research on rehabilita- tion programs and running back training for a male am- ateur runner with shin splints in the return-to-sport phase. In accordance with the Medial Tibial Stress Syn- drome Rehabilitation Guideline (2016) published by Sanford Orthopedics & Sports Medicine, patients are required to satisfy various criteria in order to progress to phase 3, which involves the return to running. These criteria include the ability to perform 15 painless jumps on the injured leg, the capability to walk for 30 minutes with minimal to no pain increase, the capability to per- form 6 squats with 60% body weight for 6 seconds, and the capability to tiptoe more than 25 times. Assuming the patient meets these criteria. The physiotherapist can then design a rehabilitation exercise regimen and run back training course of action for the patient, with the ultimate goal of restoring normal strength and length of the lower
capability to per- form 6 squats with 60% body weight for 6 seconds, and the capability to tiptoe more than 25 times. Assuming the patient meets these criteria. The physiotherapist can then design a rehabilitation exercise regimen and run back training course of action for the patient, with the ultimate goal of restoring normal strength and length of the lower limb kinetic chain muscles and enabling the patient to resume running and recreational/sports activi- ties. The patient is focused on getting back to preparing for his performance in participating in future events. During the rehabilitation phase, physiotherapists have the ability to design various exercise programs including weight training, muscle resistance training, plyometrics, core and pelvic girdle stability training, multicomponent neuromuscular training, flexibility training, gait retraining, proprioceptive and balance training, and cross-training exercises such as deep water running and antigravity treadmill workouts. The objec- tive is to enhance the patient's muscular strength, partic- ularly in the core and calf muscles, improve endurance, boost speed, enhance neuromuscular coordination and explosive power, train for controlled landing and hip Copyright © 2024, authors, e-ISSN : 2580-071X , p-ISSN : 2085-6180 Dipta Hiqmal Wirananta & Farid Rahman / Jurnal Pendidikan Jasmani dan Olahraga 9 (1) (2024)
48 strategies, and minimize the impact on the lower ex- tremities (Davies et al., 2015; Deshmukh et al., 2022; Doyle et al., 2022; Li et al., 2019; Liem et al., 2013; Mendez-Rebolledo et al., 2021). The return to running program involves a 6-week training regimen based on the FITT (frequency, intensi- ty, time, type) principle. The goal is to ensure the run- ner can continue running and daily activities without pain or discomfort. A cooperative approach between the runner and physiotherapist is crucial for effectively managing shin splints, ensuring the runner can partici- pate in running and daily activities without experienc- ing pain or discomfort. METHODS The case report study method with a standardized CARE checklist (Riley et al., 2017) entailed providing a comprehensive account of a patient's symptoms, signs, diagnosis, treatment, and subsequent monitoring. Case reports typically documented atypical or novel occur- rences and, therefore, continued to be fundamental to advancements in medicine (García-Doval et al., 2018; Rison, 2013). The research was carried out at the Physi- otherapy Clinic of Muhammadiyah University of Sura- karta in October 2023. Sampling Procedures This study used purposive sampling, a deliberate method that deviates from random sampling (Campbell et al., 2020). The researcher chose a respondent for this study in the 'Akamsi Runners Solo' running community based on specific criteria that were pertinent to the issue being investigated. A male athlete who had completed a lengthy run of at least a half marathon (21 km) and had experienced shin splints throughout the period of re- turning to sports, which had lasted for more than 2 months but less than 6 months, was selected. The ath- lete committed to four sessions per week for a duration of six weeks. The objective of this research was to as- sess the efficacy of running training and physiotherapy interventions in the treatment of shin splints among am- ateur runners. Following an extensive interview proce- dure with several runners in the community, a runner who met the pre-established criteria was identified. Participant Mr. F, a 22-year-old male runner affiliated with the 'Akamsi Runners Solo' running community, re- ceived
was to as- sess the efficacy of running training and physiotherapy interventions in the treatment of shin splints among am- ateur runners. Following an extensive interview proce- dure with several runners in the community, a runner who met the pre-established criteria was identified. Participant Mr. F, a 22-year-old male runner affiliated with the 'Akamsi Runners Solo' running community, re- ceived a medical diagnosis of shin splints after an ex- tended period of rest from running. After completing his run, he suffered cramp-like pain in the upper outside part of his shin, which persisted for around three days and gradually improved. The patient had not previously sought medical attention from a doctor, physiotherapist, hospital, or any other healthcare institution and had not participated in any intervention program. The patient had reported several grievances over the last year, including sensations of pulling or strain at the base of the rear calf and experiencing slight pain on the lateral side of the knee. The patient experienced reduced discomfort when maintaining a consistent and relaxed moderate exertion level. The patient engaged in regular running sessions four times weekly, maintaining an average pace of 5-7 km/h. Before experiencing shin splints, the patient jogged short distances of 2-3 kilometers and then ab- ruptly transitioned to running longer distances of 7-10 kilometers after a prolonged period of not exercising. During the previous week, the patient extended his dis- tance to 25 kilometers, began interval training, and in- tensified his exercise. The patient tends to supinate in his foot landing pattern, resulting in complaints of dis- comfort on the superolateral aspect of his tibia, where most of the load is concentrated. There was no correla- tion between the patient's shin splints and any medical, familial, or psychosocial history. Materials and Apparatus In this study, researchers used various methods to measure pain, muscle strength, joint motion, and func- tional limitations in the patient. The Numerical Rating Scale (NRS) was used to assess pain levels (Lazaridou et al., 2018), while Manual Muscle Testing (MMT) was used to measure muscle strength in knee and ankle movements. The Range of Motion (ROM)
Materials and Apparatus In this study, researchers used various methods to measure pain, muscle strength, joint motion, and func- tional limitations in the patient. The Numerical Rating Scale (NRS) was used to assess pain levels (Lazaridou et al., 2018), while Manual Muscle Testing (MMT) was used to measure muscle strength in knee and ankle movements. The Range of Motion (ROM) was meas- ured using a goniometer (Deshmukh et al., 2022), and the leg length was examined using a meterline (Gordon and Davis, 2019). The Foot & Ankle Disability Index (FADI) was utilized to assess functional limitations in daily activities and sports (Hale and Hertel, 2005). The Copyright © 2024, authors, e-ISSN : 2580-071X , p-ISSN : 2085-6180 Dipta Hiqmal Wirananta & Farid Rahman / Jurnal Pendidikan Jasmani dan Olahraga 9 (1) (2024)
49 patient's running shoes, size 42 and classified as moder- ate daily trainer shoes (260 grams), were measured us- ing a durometer to determine their midsole hardness. Finally, both the researchers and the patient used an online running tracker application on their smartphones to record the patient's running activity. Procedure The procedure began with a physical examination: NRS measurements for the degree of pain (resting, movement, tenderness), a goniometer for measuring ROM in limited regions (hip, knee, ankle), a meterline to compare the length of the right and left limbs (appearance length), and MMT to assess muscle strength in the knee and ankle regions. This was fol- lowed by a static inspection of the knee and foot align- ment, and then a dynamic inspection during walking, knee bending, or squatting movements. In addition, leg muscle palpation was performed. The baseline data of these measurements are presented in Table 1. The FADI index was used to measure the func- tional limitations experienced by the patient in daily activities and sports (Hale and Hertel, 2005). The over- all score obtained was 90 out of 104, which correspond- ed to 87%. This indicated that the patient had mild limi- tations or difficulties in performing certain functional activities such as walking on uphill or downhill surfac- es, going up and down stairs, reaching the tip of the foot (limited ankle dorsiflexion), walking for 10-15 minutes or more, and experiencing moderate pain dur- ing general activities and everyday tasks. The patient's sports score was 25 out of 32, equivalent to 78%. This indicated modest limitations in activities such as run- ning, leaping, landing, rapid starting and stopping mo- tions, completing activities with normal technique, and engaging in chosen sports. Diagnosing the patient's problem was straightforward. The patient's running shoe midsole material had a durometer measurement of 35 on the shore hardness scale, specifically in the 35A group. This indicated a lower or softer hardness level, suitable for activities requiring significant shock absorption, such as long- distance walking or jogging, or for everyday comfort. Based on feedback from runners and the patient's expe- rience, the shoes
The patient's running shoe midsole material had a durometer measurement of 35 on the shore hardness scale, specifically in the 35A group. This indicated a lower or softer hardness level, suitable for activities requiring significant shock absorption, such as long- distance walking or jogging, or for everyday comfort. Based on feedback from runners and the patient's expe- rience, the shoes were suitable for various types of daily training, including easy runs, speed workouts, and long runs. Patient Mr. F had not undergone X-rays, MRIs, or ultrasounds for his medical concerns. Consequently, the researcher performed specific examinations utilizing the Hop Test, Resisted Ankle Plantar Flexion, and Achilles Tendon Palpation on the right side. Further- more, researchers performed a differential diagnosis to validate the diagnosis of shin splints and distinguish it from other conditions. Ober's Test and the Capillary Refill Test are presented in Table 2. Copyright © 2024, authors, e-ISSN : 2580-071X , p-ISSN : 2085-6180 Table 1. Pain, ROM, Leg Length, and Muscle Strength Measurements Measurements Baseline data NRS (pain) (Lazaridou et al., 2018) Rest 3/10 Movement 5/10 Tenderness 6/10 Goniometer (ROM) (Deshmukh et al., 2022) Hip S: 20° - 0° - 120° Knee S: 0° - 0° - 110° (dextra & sinistra) Ankle S: 20° - 0° - 35° (dextra & sinistra) R: 45° - 0° - 50° (dextra & sinistra) Meterline (leg length) (Gordon and Davis, 2019) Appearance length 100cm (dextra & sinistra) MMT (muscle strength) (Deshmukh et al., 2022) Knee flexion (M. Quadriceps) 5 (maximum resistance) Knee extension (M. Hamstring) 5 (maximum resistance) Ankle dorsi flexion (M. extensor ankle) Dextra: 4 (minimum resistance) Sinistra: 5 (maximum re- sistance) Ankle plantar flexion (M. flexor ankle) Dextra: 4 (minimum resistance) Sinistra: 5 (maximum re- sistance) Static Inspection Knee joint 5cm (genu varum) Base of the back calf Pain-like pulling Foot allignmet Neutral Dynamic Inspection Squatting Patellar Crepitation Palpation Leg muscles Normal, no muscles imbalance Dipta Hiqmal Wirananta & Farid Rahman / Jurnal Pendidikan Jasmani dan Olahraga 9 (1) (2024)
5cm (genu varum) Base of the back calf Pain-like pulling Foot allignmet Neutral Dynamic Inspection Squatting Patellar Crepitation Palpation Leg muscles Normal, no muscles imbalance Dipta Hiqmal Wirananta & Farid Rahman / Jurnal Pendidikan Jasmani dan Olahraga 9 (1) (2024)
50 Copyright © 2024, authors, e-ISSN : 2580-071X , p-ISSN : 2085-6180 Table 2. Physical Examinations No. Physical Examinations Results Descriptions Specific Examinations 1 Hop Test Positive (+) The patient had cramp-like pain in the superolateral region of the right leg's tibia. 2 Achilles Tendon Palpation Positive (+) Palpation of the right foot revealed tightness in the achilles tendon. 3 Ankle Plantar Flexion Resisted Positive (+) The patient experienced discomfort during resisted plantar flexion motions in the right foot. Differential Diagnosis 4 Ober’s Test Negative (-) It aims to determine the possibility of ITBS injury, also caused by overuse, and the expected results; the patient only feels mild pain and tends to be faint on the lateral side of the knee 5 Capillary Refill Test Negative (-) The examination of blood flow to the leg tissue showed normal re- sults, with no evidence of vascularization or blood flow abnormali- ties in the patient's leg. Table 3. ICF Browser diagnosis Impairment Code ICF Description Body function b28015 Pain in lower limb Cramp-like pain at the superolateral tibia and base of the back calf b7100 Mobility of a single joint Limited ROM in the patient's right ankle region, especially during ankle dorsi flexion. b7300 Power of isolated muscles and muscle groups Decreased muscle strength, especially in the right calf region, so that it is unable to support the body when standing perfectly b770 Gait pattern functions Improper walking pattern due to overuse of the right calf region, so that it tends to rest on the healthy side (left) only Body structure s75011 Knee joint Genu varum was found in the patient's knee of 5cm, and frequent crepitation during knee flexion or squatting. s75012 Muscles of lower leg Tightness of the Achilles tendon and cramping at the base of the back calf Activities and participation d4500 Walking short distance The patient has difficulty walking short distances. d9108 Community life, other specified The patient has difficulty participating in routine activities of his/her running community. d9201 Sports The patient has difficulty exercising, especially in lower extremity exercises such as running and strengthening. d9301 Spirituality The
and cramping at the base of the back calf Activities and participation d4500 Walking short distance The patient has difficulty walking short distances. d9108 Community life, other specified The patient has difficulty participating in routine activities of his/her running community. d9201 Sports The patient has difficulty exercising, especially in lower extremity exercises such as running and strengthening. d9301 Spirituality The patient complains of difficulty when worshiping (prayer movements). Environmental factors Facilitators e1401 Assistive products and technology for culture, recreation and sport The shoes used by the patient are very suitable for supporting his running activities. e320 Friends Friends in his running community are very supportive, so the patient can run again together. e310 Immediate family The family is very supportive of the patient's recovery. Inhibitor/ Barrier e2100 Landforms The surface used by the patient when running is asphalt, sometimes a road with a slope/uphill. Dipta Hiqmal Wirananta & Farid Rahman / Jurnal Pendidikan Jasmani dan Olahraga 9 (1) (2024)
Description
This case report studies rehabilitation for amateur runners with shin splints.