Seven Practical Observations on Dealing with Shin Pain in Athletes

After seeing plenty of shin pain in ballet Nutcracker performers , Olympic Volleyball players and various other athletic activities , here are 7 practical clinical observations to help assess and treat this common problem.

1)      Look above the shin

Landing  from a jump with inadequate hip or buttock strength can lead to an inward collapse of the knee, placing abnormal rotational forces on the shin.  Similar lack of upper leg control can lead to collapse of the foot arch in running, again causing increased stress on the shin. Any complete evaluation of shin pain should include some form of hip/buttock strength- my favorites include the single-leg squat, step-ups,or plie in 2nd position for dancers. Ideal alignment has kneecap directly under the hip and over the 2nd toe.

Plie in second position: note kneecap directly under hip and over 2nd toe

2)      Look immediately below the shin

Decreased ankle dorsiflexion (ability to move shin towards the foot or foot toward the shin)is yet another contributor to increased stress of the shin bones. Common causes include tight calf muscles or restricted movements between the tibia (shin bone) and the talus (first bone of the foot).  Side-to-side dorsiflexion motion comparisons can help identify abnormalities.

3)      Try to stand on toes or walk on the outside of the foot

If the calcaenous (heel bone) doesn’t move inward when standing on the toes, or if there is an inability to walk comfortably on the outside border of the foot, start thinking about restricted midfoot subtalar joint motion. Much like limited dorsiflexion, subtalar dysfunction transmits excessive forces to the shin region.  Tarsal coalition is a fairly common and under-recognized form of subtalar restriction.

4)      Never under appreciate the importance of the big toe

Amazing how restrictions within the small 1st metatarsophalangeal joint (aka big toe joint) can lead to big problems in the shin. Limited ability to raise the big toe off the ground toward the shin leads to either increased pressure on the outside of the foot or higher forces on the front of the shin during foot impact with the ground.  Stretching of the flexor hallicus longus muscle that controls big toe motion can be life and career-saving.

• Click here for more information on limited toe motion in dancers

5)      Stressful causes of cramping calves

While most forms of generalized tightness or cramping in the calves are usually due to muscle fatigue and relative overuse, be more suspicious of cramps that can be pointed out by a finger tip and are located right next to the upper part of the tibia bone. Have found 2 recent cases of tibial stress reactions that presented with the primary concern of localized calf cramps.

Click here for more information on tibial stress injuries

6)      How are the iron stores?

Some cases of long-standing or difficult to treat shin pain may be complicated by low ferritin (measure of iron stores in the body).  More likely in females with heavier menstrual losses or those athletes and performers with restricted dietary iron intake.  I will routinely order laboratory testing in my evaluation of challenging shin pain.

7)      What are you wearing on your feet?

source:http://runhealthylifestyle.com/2016/08/25/careful-flip-flops-dangerous-summer-choice/

Practicing in Southern California, I often see patients who will select the best in athletic footwear, but then come into my office and routinely report wearing ill-fitting or poorly supportive shoes or sandals for non-athletic activities.  I’ve learned that if you can twist a shoe or sandal like a rolled newspaper, then there isn’t much mid-foot support. Use of relatively inexpensive over-the-counter arch supports in daily use shoes can allow one to be both fashionable and functional, while leaving sandals for the pool or beach.

Back Pain with Volleyball Serving or Hitting? Look at Shoulder Function for Possible Cause

Whether you are a junior level or even an Olympic caliber volleyball player dealing with back pain during serving or hitting, chances are that shoulder mechanics are part of the problem.

Starting the serving or hitting motion requires both extension (leaning backward) and rotating or turning of the lower back in the direction of ball contact. For a right handed hitter or server, that would mean having the trunk and lower back rotate toward the right.

Dave Smith (#20) in early hitting phase shoulder position

Finishing a serve or hit requires rotation of the lower back away from the side of ball contact. Again, for that right handed hitter or server, that would mean having the trunk and lower back rotate towards the left after ball contact. 

Kim Hill (#15) with late hitting phase shoulder position

This normal flow of movement puts localized stressors on the lumbar vertebrae bones that surround and protect the spinal cord in the lower back region between the rib cage and the pelvic bones.

Certain parts of these lumbar vertebrae, called the posterior elements which include the pars interarticularis,  pedicles, and articular process/facet joints that are at unique risk for overload injuries due to repetitive compression forces and somewhat limited blood supplies to these regions. 

Courtesy of www.studyblue.com

In medical terms, we would call pain coming from these movements extension or rotational-based lower back pain, and it thus would seem very logical then to focus evaluation and treatment on the lumbar spine mechanics themselves.

However, my experience in working with higher level volleyball players has taught me that often the dominant shoulder can be a primary contributing culprit to this extension or rotational-based back problem, so now when I evaluate any such type of back pain in a volleyball player, I start by looking at the shoulder.

There are commonly two types of shoulder tightness patterns that can lead to both shoulder problems and pain at the lumber spine.

• TIGHTNESS OF THE FRONT OF THE SHOULDER AT THE CORACOID PROCESS

The pectoralis minor, coracobrachialis and biceps short head muscles all attach to the coracoid process, which is a bone prominent coming off of the scapula.

Courtesy of fashions-cloud.com

Tightness at this attachment site can create a hunched over posture that moms always like to warn about, but also can limit the ability to raise and reach back the shoulder which provides the power needed to hit a ball at the high end of a set or the toss before serve. 

If a player has limited flexibility in the front of the shoulder at the coracoid, one frequent way to compensate (or some would say, cheat) is to over-rotate at the lumbar spine in an effort to get the hitting hand far back enough to generate powerful hits or serves.

This over-rotation, while at first might allow the player to maintain high performance, may ultimately cause higher cumulative overload forces on those posterior elements of the lumbar vertebrae and those undesired stress injuries.

This condition causes pain EARLY (before ball contact) in the hitting or serving motions, and  proper identification and correction of tightness at the coracoid process can lead to healthier shoulder and back function.

• TIGHTNESS OF POSTERIOR SHOULDER CAPSULE

The glenohumeral joint is the "ball and socket" joint that is surrounded by a soft tissue joint capsule.

Courtesy of heyyoungbeliever.com

Repetitive overhead motion such as hitting or serving can lead to tightness in the back of this capsule, leading to limitations in shoulder internal rotation or the follow-through phase after ball contact.

Called Glenohumeral Internal Rotation Deficit (GIRD), this tightness can lead to reduced accuracy and speed of hits/serves.

Many volleyball players will compensate (aka cheat) by increasing rotation of the lumber spine away from the side of ball after making contact, and eventually this too will place unwanted forces on those posterior elements of the lumbar vertebrae.

GIRD causes pain LATER (after ball contact) in the hitting or serving motions, and just like with anterior shoulder tightness, proper identification and correction can reduce both shoulder and back issues while allowing more high level function.

PRE-EMPTIVE PREVENTION

Volleyball players do not have to wait for the onset of back or shoulder pain to address potential problems. Fairly quick measurements of both anterior and posterior shoulder motion patterns can lead to suggestions for stretching programs, and I routinely incorporate these into pre-season or pre-participation evaluations as part of sensible injury prevention programs.

How to Keep Volleyball Knees Healthy

Kudos to accomplished writer and volleyball coach Eric Hammond for an insightful article on keeping knees healthy in volleyball players. I appreciated the opportunity to work with him and USA Women's National Team ATC Jill Wosmek on this important article.

The following table summarizes some key points, but I highly recommend you click here to read the entire piece originally published in VolleyballUSA.

Healthier knees: 5 tips
 - Avoid landing on straight knees. Always land and move "softly" 
 with hips, knees and ankles bent.
 - Try to land in good alignment, with the hips and knees lined up 
 with the second toe. Don't let your knees collapse in or rotate.
 - The best time to stretch is after practice or after a match when the 
 muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors 
 and calf muscles.
 - Don't hesitate to ice sore knees for 20 minutes after practices 
 or matches.
 - Knee pads help reduce bruises and pounding, especially 
 with repetitive diving drills. 

Heart and Aorta Issues in Elite Volleyball Players

My role as a team physician for the United States National Volleyball Teams allows the fortune to work with not only with elite athletes and coaches, but also with an amazing group of medical colleagues.

Davis CK, Dyar DA, Vargas LA, Grossfeld PD. Cardiovascular and Musculoskeletal Assessment of US Elite Volleyball Players. Clinical Journal of Sports Medicine, 2015

Our goals are to provide our athletes the highest quality of injury and illness prevention and treatment with efforts to continually increase our awareness of volleyball-specific medical concerns.

Figure courtesy of www.columbiasurgery.org

Elite level volleyball tends to attract taller players who happen to have longer arms and fingers more conducive to blocking and hitting. Those same characteristics that provide a competitive advantage on the court may also unfortunately be a marker for a condition called Marfan Syndrome which has abnormalities in the connective tissue of the body leading to dilation (widening) of the aorta.

The aorta is the tube-like vessel that transports blood flow from the left side of the heart to the rest of the body. Widening of the initial segment of the aorta (known as the root and ascending aorta) can take place by itself and can also be found in cases of connective tissue disorders (like Marfan syndrome). A wider aorta may lead to higher risk of rupture (dissection) leading to sudden collapse and most often death. 

So when working with a group where everyone is tall and thin, is there sufficient information to help us determine individual player risk and proper modes of evaluation?

While it might be logical to think that taller people should have wider aortic measurements, there has been a lack of data determining normal versus potentially abnormal and even dangerous measurements in tall athletes. One study of Italian Olympic Athletes proposed aortic root measurements greater than 4 centimeters in males and 3.4 centimeters in women might be worrisome, but only a few volleyball players were included in this study.

Thus, I am so very proud to share the article Cardiovascular and Musculoskeletal Assessment of Elite US Volleyball Players that was published by trusted USA Volleyball cardiology specialty colleague Paul Grossfeld and his associates at Rady Children's Hospital in San Diego.

Paul's study attempted to fill a knowledge void by evaluating elite US Volleyball players using:

• medical and family histories
• targeted physical examinations specifically focusing on abnormalities present in Marfan syndrome
• transthoracic echocardiograms.

What was found in the 37 male and 33 female US National Team members?

• Three male athletes (8%) had an aortic sinus diameter greater than or equal to 4 cm, one of whom also had an ascending aorta greater than 4 cm.
• Two female athletes (6%) had aortic sinus diameter greater than or equal to 3.4 cm, and another had an ascending aorta of 3.4 cm.
• There were no other intracardiac or arterial abnormalities. 
• Individual musculoskeletal characteristics of Marfan Syndrome were common among the athletes but not more frequent or numerous in those with aortic dilation.

Paul and his colleagues concluded that the prevalence of aortic root dilation in this population of athletes was higher than what has previously been reported in other similar populations. He also recommended long-term follow-up of these athletes as essential to better determine the potential contribution of high-level volleyball training versus individual aorta characteristics as the cause of the aortic dilation to better identify the risk of further dilation and dissection.

These findings and recommendations apply most directly to adult, elite volleyball players, but should be of interest to a wider population that includes younger volleyball players, non-elite adult volleyball players, and other taller, thinner elite athlete groups such as basketball players, crew rowers, and track and field jumpers.

Perhaps future efforts will provide more specific screening and evaluation recommendations for a wider group of volleyball players, namely junior level/collegiate athletes and non-elite level adults.

Very grateful to Paul and his group for his diligence and insight, and eager to have the opportunity to share our expanding volleyball medicine knowledge with the entire volleyball community.

Should Indoor Volleyball Players Wear Ankle Braces?

Ankle sprains are the most common acute injury in indoor volleyball, and very few things spark intense debate in the volleyball community more than the question about using ankle braces to prevent these type of injuries. 

Photo courtesy of USAVolleyball

I'm going to review this subject by not only listing some studies about ankle braces, but more importantly tapping the awesome collective wisdom of my USA Volleyball Sports Medicine colleagues Aaron Brock, ATC and Jill Wosmek, ATC who work with Men's and Women's National Teams respectively.  I am not going to review ankle taping, since many athletes do not have access to proper ankle tape applications by athletic trainers, and even when done well, tape looses most of the protective effect within 30 minutes of application.

The majority of ankle sprains are when the ankle inverts (rolls in) and this most often occurs with play at the net where athletes make contact with another players foot when landing from a jump during hitting or blocking. The theory behind bracing is to reduce abnormal ankle motion, but some fear that depending on bracing might make lower leg supporting muscles weaker and maybe even increase the risk of knee injuries.

I do not endorse or have any investment in particular types of braces, and will only list particular brands and makers if they were mentioned in studies and all opinions are our own and do not represent official policy of USA Volleyball or any other group or employer.

What does the medical literature say about this?

• A prospective study of high school players made the conclusion that two types of braces (Active Ankle Trainer II and Aircast Sports Strirrup) protected players who never had a previous ankle sprain, but did not prevent subsequent sprains in players with a past history of sprain.
• Moving up to the collegiate ranks, prophylactic use of double-upright padded ankle braces significantly reduced the ankle injury rate compared to national statistics studying ankle injuries.
• Focusing more on female volleyball players, technical and proprioceptive training were effective methods on preventing ankle sprains in athletes with four or more ankle sprains, while bracing was more effective in only those with less than four past injuries
•  Elite volleyball players with recurrent sprain who underwent injury awareness training, technical training (emphasized proper take-off and landing technique for blocking and attacking) and balance board work enjoyed a twofold reduction in incidence of new ankle injury
• Limited evidence suggests that ankle braces do not increase the risk of knee injuries. The same review found that addressing the strength of the leg muscles (evertors, invertors, dorsiflexors, and plantar flexors), hip extensors and abductors  and ankle dorsiflexion limitations may be an ankle injury-prevention strategy.

What do my expert volleyball medicine colleagues have to add?

In his experience working as the Director of Sports Medicine and Performance and the Head Men's Athletic Trainer for USA Volleyball, Aaron Brock has the following insight:

• The great majority of ankle sprains seen with the US Men's National Team have been to the unprotected ankle. 
• No conclusive evidence exists that ankle braces adversely affect on court performance
• It is still possible to sprain an ankle while wearing ankle braces but the risk is significantly diminished. Also, ankle sprains while wearing braces usually result in a less severe sprain.  
• In his opinion, the best way to prevent ankle injuries is the use of ankle braces

As the Head Athletic Trainer for the USA Women's National Team and formerly the athletic trainer for Penn State Men's and Women's Volleyball Teams, Jill Wosmek offers her professional recommendations:

• Type of shoe is also important for proper heel position that isn't "too high" and thus having more side to side motion
• For younger players, she recommends braces as the type of volleyball play is a bit more chaotic and the athletes are not as strong
• Many college teams have bracing/taping as team rules that influence decisions
• On the US Women's National Team, the majority do not tape or brace but must heed disclaimer that level of play is higher, there are not a lot of under the net collisions, and the team spends a lot of time with strength and proprioceptive training

Does this information make you more or less apt to use ankle bracing and strengthening programs to reduce the risk of ankle sprains?

Watch this Video on How to Prevent the Six Most Common Volleyball Injuries