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  1. There are New Answers for Your New and Old Ankle Sprains
  2. What Causes Shin Splints?

There are New Answers for Your New and Old Ankle Sprains

Dr. Marcus O. Schuster

The three biggest concerns for any athlete are performance, recovery and injury management. From a clinical perspective, we see that athletes are getting stronger, faster and are able to put more demand on their bodies because of new methods of training. Until recently, what we haven't seen is a dramatic change in the way soft tissue injuries are treated and how recovery time can be minimized.

Most time athletic injuries are categorized as soft tissue injuries, which include any damage done to the muscles, ligaments and/or tendons. Acute soft tissue injuries present in the form of sprains, strains and tears. These injuries become chronic if they have not had the proper treatment or no treatment at all. This will cause scar tissue to form and will limit movement and cause pain. When this happens, other muscles have to compensate for the damaged tissue and cause muscular overload. This in turn will cause further soft tissue damage and pain.

Whether you are a runner, cyclist or any type of organized sports player one of the most common injuries is ankle sprain. Typically this type of injury is the result of the foot rolling inward (medially) damaging the outside (lateral) ligaments causing an enthesis disruption or an enthesopathy. The enthesis is the area where a ligament or tendon actually attaches to the bone, and the disruption occurs when a portion of that ligament or tendon gets pulled away from the bone (see fig 1). What also happens is the muscles on the outside of the leg become disrupted producing pain that radiates up the leg to the knee. The bottom line is you will suffer pain, immobility and swelling.

Enthesopathy 
 
Figure 1

 

Most people, including doctors and trainers, think swelling is the major problem with a sprained ankle. While swelling is a problem, new treatments are now showing that it is only a small portion of the problem. Research is showing that it is the fascia (the packing material that surrounds all muscles and tendons) that is causing all the pain in most soft tissue injuries.

As most people who have had an ankle sprain have experienced, the most popular treatments are ice, electric stimulation and immobilization. The newest treatment for ankle sprains and other similar soft tissue injuries is a procedure called MyoFascial Disruption Technique (1). The treatment is based on the premise that the pain originates mostly, if not always, from disrupted fascia. Fascia can disrupt in several ways. In an ankle sprain it occurs in two ways. First it occurs where the muscle or tendon separates microscopically from the bone where it is attached, kind of like pulling a tent stake out of the ground. This is the enthesis disruption (see fig 1). The treatment is to re-attach the fibers to the bone, much like pushing a tent stake back into the ground.

The other way the fascia becomes disrupted is when the muscle separates along a vertical line, traveling along the length of the muscle. It is similar to opening a zip lock bag (see fig 2). The treatment for this is to seal the fascia in the similar fashion as sealing a zip lock bag.

Myofasial Band 
 
Figure 2

 

Athletic injuries, including ankle sprains, should be considered as a mechanical problem. Most mechanical problems will have a mechanical solution. The unique thing about this new treatment is that once the disruptions have been corrected, the treatment is complete. Pain is reduced, motion is restored and the ankle can function normally. The opposite is true for ankle sprain that is incorrectly treated or not treated at all. The joint will continue to experience pain until the distortions are removed.

The other biggest difference in this treatment is the recovery time. For a mild ankle sprain: 1-2 treatments and about 1-7 days. A moderate sprain: 3-4 treatments and 7-10 days. For severe or chronic ankle sprains: 3-5 treatments and 7-14 days.

1. Gemmell HHayes BConway M. A theoretical model for treatment of soft tissue injuries: treatment of an ankle sprain in a college tennis player. J Manipulative Physiol Ther. 2005 May;28(4):285-8.


 

What Causes Shin Splints?

Dr. Marcus O. Schuster

It seems just about anyone who has some distance under their feet, has experienced shin splints at some point in time or another. They [shin splints] are notorious for being difficult to treat and recover from. The pain at fist is mild, only occurring after 1-2 miles. Then the pain can become severe, as if the front of your legs are on fire. The frustrating part is it comes out of nowhere. Questions I often hear are "I didn't hurt myself so... how did this happen?" or "what caused this?" It is frustrating to have pain and not know where it came from. This is especially true if there was no trauma involved. Pain is the body's way of telling you something is wrong, so we have to listen and look carefully.

Shin splints can occur from a number of different reasons. The most common reason I find is chronic, abnormal pronation of the feet caused by instability of the lower leg and ankle. Foot pronation occurs when your foot strikes the ground and accepts the weight of your body. Your foot should normally flatten slightly and roll slightly outward. Over-pronation however, occurs when the muscles that support the ankle and lower leg breakdown and become unstable. This breakdown is initially caused by an injury. This can be big, like a fall or small, such as repetitive trauma (running).

Before we talk about how muscles breakdown and create unstable joints, we need to talk a little biomechanics. Muscular imbalance is the result of tightened and weakened muscles. This imbalance disrupts the muscles and fascia. Simply put: there are muscles that stabilize joints (accept load) and there are muscles that perform work (the force that pushes you along). If there is a breakdown in one of these muscle groups, the other has to pick up the slack. This will result in joint breakdown, muscle overload, and finally pain.

Without a traumatic onset, an injury can come from a joint's inability to absorb force. First, the stabilizing muscles surrounding a joint become weak. This will secondly cause an overload in the muscles that perform work. The end result is myofascial disruption and then PAIN! Shin splints to be precise. The thought "I run, therefore my legs are strong" can be a sure way to injury. The muscles that most commonly weaken are the quads, medial quads to be precise. I know it's hard to believe that someone who can run over 10 miles has weak quads, but remember were talking stability not power.

Athletic injuries are not usually caused by poor equipment, rather more commonly by impact and not training correctly. Your equipment is your shoes. And if you are a serious runner, you're most likely using the right equipment. If you are suffering from shin splints, you're most likely a victim of joint instability and muscle breakdown.

A simple rule in the treatment of muscular problems can apply... the time it takes to repair a problem depends on how long it has been going on. Chances are if you are experiencing shin splints, the break down process has started long ago. Once you have shin splints [they] never really go away. Remember: when one muscle group breaks down, another group has to pick up the slack. This means your shin pain may improve but there is now another muscle group under attack. You will notice this pain as a new knee pain, low back pain or IT band pain.

There are ways to identify muscular breakdown before shin splints occur. One of the ways it to not ignore pain of any type when you run. The pain is trying to tell you something, so listen. Running through the pain will not make it go away, it just causes more injury. If you don't know what your pain is telling you, have it examined by a doctor experienced in treating soft tissues injuries. A Functional Evaluation will specifically identify where the breakdown is occurring.

Other signs of early breakdown are poor gait and abnormal running mechanics. For instance: if you notice one of your arms swinging more than the other, one of your legs not going into full extension or uneven shoe wear, breakdown is happening. You may not notice this on yourself, so have your running partner observe how you are running. Remember "an ounce of prevention is worth a pound of cure".

Shin splints should be considered as a mechanical problem. Like most mechanical problems, they will have a mechanical solution. The key to a fast recovery is identifying the problem and using the right procedure to correct it. I recommend a new procedure called Myofascial Disruption Technique. Once the myofascial disruptions are removed, the proper mechanics are restored and the pain will go away. Active rehabilitation should only be started after the myofascial disruptions are removed and the pain is gone. If left untreated the problem will move somewhere else and continue to breakdown.

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