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Shin Splints wants to run marathon

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mandyt, Mar 17, 2010.

  1. mandyt

    mandyt Active Member

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    I have had a patient refd to me (original Pod on hols) he has shin splints and wants to run a marathon in 3 weeks time,

    The previous Podiatrist casted him and then wasn't there for the fit of the orthoses, this was 3 weeks ago.
    Patient is still complaining of pain, not eased what so ever, he is also complaining that orthoses rock inside his trainers so don't fir properly also that they are incredibly hard compaired to his last pair.

    From the info I have gathered the patient requested orthoses as he has has shin splints in the past and they have worked.

    I am seeing this patient on Friday for the first time, are there any suggestions as to what I can do.

    Should I recast with a softer 3/4 insole also has a 4 degree varus post in them.

    Any help will be appreciated, in respects to education for him etc.

    Not dealt with many shin splints !!!!

  2. Griff

    Griff Moderator

  3. B. Englund

    B. Englund Active Member


    Why a 3/4?

    I think a full length do better in running shoes since trainers (almost) always allow you to replace the existing sole. My experience tells me the full length orthotics stay in place much better and eliminate the risk of that rocking motion.

  4. Firstly, it depends on what we mean by "shin splints", this is an umbrella term that could include a number of pathologies.

    I agree with my colleague, I very, very rarely make 3/4 length devices for running shoes.

    What are his current orthoses made from? For marathoners I will often use a high density plastazoate to reduce weight, with a 3mm eva full length top-cover. In the case of medial tibial stress syndrome (MTSS) I'll usually have a high arched device with medial heel skive of 8-15 degrees and often a forefoot varus post on the forefoot extension.

    If the patient had success with his previous devices, why not ask him to bring them along so you can take a look at them? Although you won't have the exact prescription (unless they are pre-fabs), you should be able to glean plenty of information from them. What shoes is he running in?

    P.S> if he wants to run a marathon in 3 weeks time, we need to know his pain levels, i.e. at rest? or only when running etc. as he runs the risk (if he hasn't already got them) of stress fracture- like I said "shin splints is an umbrella term.

    Compression supports may help, but not in compartment syndrome.

    NEED A DIAGNOSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
  5. Timm

    Timm Active Member

    Hi Simon, and others.
    How do you decide how aggressive to make the forefoot varus posts in these patients?
    And what would be the most aggressive forfoot varus post you have prescribed in millimetres at the medial edge of the varus post?
  6. Up to about 5mm
  7. mandyt

    mandyt Active Member

    Hi Everyone

    Thanks for the great replies, I am seeing the patient tomorrow afternoon, so i will give a better diagnosis then. unfortunately I will also have to write out the orthotics prescription when I see him.

    The previous orthotics are the ones that he says are uncomfortable, hhhmmm !

    Can anyone suggest what material I order the orthotics in he currently has them in Rigid Carbon fibre with a 4 degree rearfoot varus post. This is the info I have gathered from his previous prescription.

    Thanks again, I know this is a difficult one, but I have been landed with prescribing orthotics !!!! not my first love, but I don't think I can do any worse than the expert that has left the patient in pain and me in turmoil !!!!

  8. Shane Toohey

    Shane Toohey Active Member

    Dear Mandy,

    At the usual risk of being well left of centre and probably being late to have input I just feklt the need to write something in the hope of stopping the shuddering I've experienced since reading this thread.

    Your story really exemplifies the arrogance that exists in our profession where someone will take casts for orthoses that they will not fit nor manage a few weeks before an important event and presumably advised or given the impression that they 'know' what needs to be done to achieve the result required. They were wrong!!!!!!!!
    There is no evidence whatsoever I think to support such an approach.
    I'm afraid that the process is going to be repeated with the poor punter only having a very short time to respond to new devices which have a reasonable chance of not being perfectly tolerated by the time of their event. The punter will hate podiatrists very soon. I also hear this sort of story quite often.

    If the devices were incredibly hard and uncomfortable, we are most likely talking about aspects of the medial arch, generally the height as the main problem (very common).

    Now as a heretic, I'd only fit a full length shelf device such as an X-Line with wedging rearfoot and forefoot as required in whatever configuration seemed apropriate for the feet being presented and which appeared to improve any obvious dysfunction. So the threapy would start immediately with 3 weeks to get settled in and with time to tweak if needed. I'd also be seeing him twice a week providing local treatment for his overused tissue and mobilising joints as required.
    I may make casted functional devices later on with the information found out by trail and error for this particular case helping me get really close to the mark straight away.

    Sorry to be a wet blanket.

  9. I agree with much of what you have written Shane. With 3 weeks, you should probably be counselling him not to run the marathon, let alone trying to get the devices made and him habituated to them in that time. I'm not sure the modified simple insole will be habituated to any quicker than any other type of device though. I have my own lab, so can turn devices around in less than 24 hours. So wouldn't really lose time when compared to using chairside devices.
  10. Shane Toohey

    Shane Toohey Active Member

    Thanks Simon,

    Also have my own lab Simon.
    At the risk of taking this thread on a tangent I'll explain my approach which has been ridiculed in the past.
    I work with a sports physician. The arrangement is that he only sends me the complicated cases as I can only take very limited numbers of new patients and provide the service that I want to provide. He sends the bulk of pateints to our other pod.
    These folk I see often have a few pairs of devices and on questioning admit that their overall musculoskeletal symptoms have increased over the time that they have been using orthoses, despite changes and often despite the cessation of the original symptoms. Whilst trying to keep the "baby" I have to admit that whatever theories, or parts therof, of biomechanics and the translation into the practical that I use, I am working with a highly flawed model, that at best gives my direction for trial rather than anything near something that I could honestly and confidently claim to be true.
    I treat every case as a single case study and don't mess with these folk like they have been messed with before. So despite owning a lab, I always trial modified insoles and only go onto casted devices when we are winning. Sometimes the hard part is getting the same result as with the insoles.
    Originally it was surprising, but often the punters also related to me how their overall symptoms had also reduced dramatically, particularly in the upper body.
    I do have concerns about the damage being done with orthoses that is never realized. I am concerned about the watered down theories and repetitive practical
    protocols that I see. I expect and often get outstanding results very quickly with the insoles as mentioned by working with the forefoot and the rearfoot and not by trying to get the foot into 'neutral' by holding up the medial arch, but am not surprised about having to make changes in the wedging. This wedging in the long run indicates to me not only the direction of the segmental interventions but also helps with the quantity.
    Another concern I have is that with only one 'tool' in the belt being orthotic therapy pods only see one possible solution for most problems and so jump into orthotic therapy for multifactorial problems that require far more than orthoses. I could go on.
    So, thanks for your time, Simon,appreciated.

  11. mandyt

    mandyt Active Member

    If you were in front of me I would HUG you, and say THANK YOU as everything you have said is everything I believe about being a good Podiatrist.
    I do not specialise or even enjoy biomechanics, give me Diabetes in any stage or form in a patient anyday and I will show you a proud and professional Podiatrist.

    I am dreading seeing this man tomorrow, and I have no idea what mood he will be in although the receptionist says he has given many angry phone calls !!!
    I Know he wants a miracle cure like most athletes when they have an event so close by, but we are not magicians !!!and as we all know there is nothing like rest and time to cure most things...
    I know this is not what he wants to hear...

    I worked in Podiatry for 3 years full time in Australia and in that time I never once fitted or advised orthoses when other treatments could hel.

    A massive thank you, to you and you are definately not a wet blanket, just a very honest and decent Podiatrist

  12. And there lies the problem. The concept of the "trial" insole is flawed. Simple insole with wedge = apple, casted device = orange; both fruit but different. A simple insole with wedging is not a simulation of a casted orthosis.

    I use wedges stuck onto insoles a lot, if they work I rarely replace them with a casted foot orthosis- why would I try to fix something that isn't broken?

    Mandy, I'm still not sure why it is you that is seeing this patient? Why has there not been continuity in this patients care?

    At the end of the day, it's not your fault, you didn't give him shin-splints; he did that himself :bash:. In this situation I usually simulate straining, tell them that it's no good, I've tried, but I can't sh!t miracles. ;)
  13. Brilliant.:D
  14. Mandy:

    In reading your posts, I can see you are in a difficult situation. First of all, as Simon said, "shin splints" is not a diagnosis any more than "foot pain" is a diagnosis. You must first take a history, examine the patient and then come up with a differential diagnosis for this patient for their exercise-induced leg pain. Differential diagnoses may include include tibial or fibular stress fracture, chronic exertional compartment syndrome, muscle strains or tears, focal nerve entrapment, fascial herniation, lumbosacral radiculopathy, vascular claudication and popliteal artery entrapment syndrome. However, the most common injury seen in the legs of runners is medial tibial stress syndrome (MTSS).

    As Shane mentioned, your best bet, if you determine this to be MTSS, is to try getting him into an over-the-counter insole initially with a varus heel wedge, increased medial longitudinal arch height and varus forefoot extensions which will decrease the valgus bending moments on the tibia and decrease the tensile forces on the soft tissue structures attaching to the medial tibial border. If he has pain with walking in the tibia also, think medial tibial stress fracture. Making an orthosis at this point is risky since the patient may not have time to accommodate to the orthosis in a week or two before the marathon. I would cast the patient for the orthosis after the marathon.

    You must also warn the patient that running a marathon with MTSS that his medial tibial pain may develop into a medial tibial stress fracture which will then prevent him from running for 3-4 month while he is healing. You should document what you told him in your chart so, in case he says you didn't warn him about tibial stress fracture possibilities, you are covered.

    I gave a lecture on MTSS at the national sports conference in Australia about five years ago which I have posted on Podiatry Arena.


    I also will have a feature article published on medial tibial stress syndrome in Podiatry Today magazine next month which I will post on Podiatry Arena when it is published.

    No podiatrist starts their career as a sports medicine expert. However, many of these experts begin their climb toward greater knowledge on this fascinating subject when treating their first injured athletic patient that is desperate to compete in the sport they love and have placed their trust in you to help them achieve that goal.

    Good luck.:drinks
  15. Griff

    Griff Moderator


    You really have no reason to be dreading this chap coming in. Nor does he have any right to be angry with you. The facts are simple:

    • He has MTSS (to be confirmed on assessment of course)
    • He wants to run a marathon in 3 weeks
    • He has orthoses which sound as if they have not been beneficial
    • He has never seen you before

    Don't have a restless night tonight worrying about this! Simply assess him tomorrow morning - explain what you think the problem is - and then discuss the options (adding the caveat of a relalistic timeline based on his no doubt unrealistic expectations). Nothing that has happened before you see him is your responsibility - just treat him like any new patient.
  16. mandyt

    mandyt Active Member

    This has made me laugh, I will look in the mirror and repeat 20 times before I see him,
    ha ha!
  17. mandyt

    mandyt Active Member

    Hi Ian

    Thank you very much, for your kind and true words, I am a very confident Podiatrist in all areas except picking up someone elses pieces !!
    You were right though, I have lost sleep over this for a couple of nights and it is not worth it.
    I just hate it when the patients says well you are supposed to be the specialist why has this not worked !! and being professional you act professional.

    What I want to say is
    You asked the other Podiatrist for casted orthotics as they have helped when you had MTSS before.

    I have no idea why the last Podiatrist gave you this type of orthotic and why they are not working this time.

    Maybe the stress fracture is more serious this time
    Maybe you are pushing yourself too hard.
    Maybe you will stop blaming us as a profession and take some responsibility

    Maybe I will win the lotto and sit on a beach bare foot sipping BIG cocktails !!!

    Thanks for all your help
    I feel more confident (I think ha ha)

  18. JB1973

    JB1973 Active Member

    morning all
    in terms of the marathon ( as lets face it, thats all the boy is worried about!) with only 3 weeks to go he should probably be tapering down and reducing the amount of running he's doing anyway so it should be easy to rest the legs. suggest cross training, cycling, swimming along with your other advice. if he's trained properly then 3 weeks gentle/no running but subsituting it with other things he should be ok for the marathon.

    the professional in me agrees with others that you should really be talking him out of it though! however i know runners and i'm training for one myself so he's probably gony do it whatever you say.
    good luck
  19. How did you get on Mandy ?
  20. mandyt

    mandyt Active Member

    Hi Simon

    Well I turned up to the clinic armed with all the very valuable information given to me on this thread.
    I sat and waited at 4 o'clock and no patient !! the receptionist then came up and said she had rang him and he thought he would just come at 5 o'clock instead because that was more convenient for him !!
    I had a 4.30 patient so I said to the receptionist
    "I am leaving at 5pm as I am driving up to Scotland for the weekend"

    The receptionist looked horrified ,, but he had all week to change his time and I am sorry but I don't run a drop in clinic...

    I hope no one thinks I am heartless because I am not I have treated patients at all times of the day and night and often driven miles out of my way at no extra charge to help a patient.

    This man however had caused me sleepless nights and then thought he could just turn up when it suited him with no phone call prior to the 4pm appt.

    I had already driven for an hour and a half to this clinic and was only seeing him and one other person..

    Can I just thank you all very very much for the kind and honest replies.
    I love being a Podiatrist and having support like you all on this forum, makes me think we all do a great job.

  21. Shane Toohey

    Shane Toohey Active Member

    Have a good weekend in Scotland Mandy
    Sometimes there are people who iyou are better off not to be dealing with and he was one of them. He be telling you what to do!
  22. thank you for interesting thread, it is a shame it appears that we will not be getting an out come for the pt.

    If His marathon is in 3/52 then i presume that he is due to do the London marathon. Places are difficult to come by and often people try several times before gaining an entry. Also, there may be a lot of sponsorship money at stake for their successful compleation, so you can understand reluctance to pull out. London marathon do do a referral scheme, so if runners let them know soon enough their entry can be carried over to the next years event, which may soften the blow.

  23. Griff

    Griff Moderator


    Its unlikey to be London as it is still 1 month (and 2 days) away and this chaps marathon is in about 2 weeks time. Maybe its Paris on the 11th? (in which case much much easier to get entry)

  24. thanks, was thinking of a pt that i have seen that is doing a marathon next month that i assumed was london, but come to think of it, i believe that they are doing the brighton marathon which i believe is two weeks before london. It is a new one on me, so may have facts wrong also. I was really makeing the point regarding defered entry as many will offer garentied entry to next years event at no extra charge, if you are unable to do this years race.

  25. Griff

    Griff Moderator

    Yep you're right could be Brighton (the week before London on 18th), or Blackpool on the 11th...

    C'mon Mandy put us out of our misery - what marathon is this chap doing?
  26. mandyt

    mandyt Active Member

    Thanks for all the replies and all the interest.
    So the story you all know so far, patient booked in for the Monday 5pm appt.
    I rush back from Scotland still armed with all the great info received on this forum
    (again biomech NOT my first love).
    Patient decided to say his appt was for Tuesday 5pm !!!!!!
    The Physio who owns the clinic and is aware of all this and was the one who made both the Friday (wrong time) and Monday (decided to change day to Tuesday) appointments. looked at me and said WE were giving an unprofessional service........

    The physio then asked if I could come in on Tuesday at 5pm just to see this patient. I said NO I have wasted two appointments which I don't get paid for, traveling costs etc..

    He said it was the Podiatrists responsibility to arrange the correct orthotics,
    I said why as a physio did you not give him exercises or discuss this with him.

    This is the reply that came !

    The gentleman rang up and asked for orthotics he has had them before but they no longer work and his shin splints are worse than ever.
    The gentleman has asked for a new pair of orthotics so he can run his marathon.

    I said " has anyone diagnosed shin splints as there are no notes in the clinic?"

    The physio said "well the man wants orthotics and it is our job to give them to him"..

    Seriously!!! I said "If I wanted antidepressants do you think my doctor would just write me a prescription because I was paying"
    A bit overboard but god almighty .....

    Hence to say I have said I won't be working there anymore.
    Sorry.. didn't go into Podiatry to have the patient tell me what they want and to make a Physio clinic rich.
    I went into it to give a good service and sleep at night knowing I did a good job.

    Sorry :eek: I can't answer the marathon question but the man sounds like a plonker who couldn't even remember when his appts were so god help him trying to remember which marathon to turn up to..

    Thanks agin to you all
  27. Shane Toohey

    Shane Toohey Active Member

    Great that you stood up to that rubbish, Mandy
    Life's too sshort, hey?

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