Kevin is a 38-year-old male who has taken up running over the last 12 months (3 times per week, 5-10km per run) to improve his health. He ran competitively in his teens (middle distance) but has run consistently since his mid-20’s.
He reports pain in both shins (more so in the right leg) on and off when running but his pain has got worse in the past month and he has had to stop running. Kevin reports his pain starts about 15 minutes into his run. He admits he doesn’t really “warm up” rather just gets into it as soon as he laces his shoes up!
He has already tried switching shoes and adding gel inserts to cushion his feet. He also saw a physiotherapist 3 weeks ago who tried ultrasound therapy as well as some massage and stretching. Nothing reduced his pain, even when he reduced his running distance under advice of the physio.
His general foot position and mechanics were good. His feet were slightly “rolled in” and arch height slightly lower than normal. There was good range of motion (ROM) in the flexibility of the joints in the middle of his foot that would indicate he probably rolls in (or pronates) too much when walking or running.
Once his joints and muscles were measured, Kevin ran on the treadmill in the clinic and footage was transferred into the computer based analysis software for further assessment. A summary of his assessment showed:
- During his running, his feet did in fact roll in excessively as he put load on his foot. Interestingly though, the left foot was actually pronating more than the right. This is because there is more resistance in the tibialis anterior muscle controlling that right foot pronation. It results in a better visual position, but more resistance
- When this happened, the main bone in his lower legs, the tibia or shinbone, internally rotated.
- Because his foot now pushes the entire load along the inside of his foot, when he does lift his heel off the ground, the main joint of the big toe is locked so he cannot push off properly.
The pain that Kevin is experiencing is tendonitis of the tibialis anterior muscle. This muscle runs down the front of the tibia or shin and attaches onto the bones on the inside of the foot, just at the top of the arch. Its job is to slow down the rate at which the foot rolls in or pronates (which is a normal shock absorbing action). In Kevin’s case, however, he is pronating too much too quickly and this muscle is being overworked. The other part of this motion is that the internal rotation of the tibia could actually be “twisting” the bone (yes bone’s have a little bit of flexibility), this torsional force can cause some inflammation of the bone itself can actually lead to a stress fracture.
At this time, we can assume that Kevin doesn’t have a stress fracture as he is not in pain all of the time, only after 15 minutes of running. This means we can shelve any plans for an expensive and time-consuming bone scans at this time.
Treatment for tibialis anterior tendonitis will involve use of an orthotic in his running shoe to improve the position or posture of his foot and slow that rate of pronation, thus reducing the work load on the sore muscle. Whilst a good quality pre-fabricated orthotic would help, we have recommended we go with a custom fitted orthotic in Kevin’s case. Firstly, it allows us to customise the prescription to suitthe needs of his left and right foot as individual structures, remember, Kevin experiences more pain his right leg, so it makes sense that the needs change from left to right. Secondly, the increased pressures that come with running on hard surfaces need to be considered in the design. With custom orthotics, we have great freedom in materials, both their strength and thickness. Modern manufacturing techniques can produce a product which is stronger, lighter and of a much lower profile in shoes than previous orthotic design. A 3D scan of his feet will ensure a perfect fit and the end result is something that will last 3-4 years as opposed to something that may be replaced after 12 months.
This would be combined with massage and stretching of ALL the muscles in the lower leg and foot as everything has been overworking while this problem has been going on, obviously paying close attention to the tibialis anterior muscle during such treatments.
Kevin will be able to resume running very soon after commencing the massage and stretching treatments. With reduced distance and speed initially, he will be able to build back up to his normal pace within a few weeks. While waiting for his orthotics to be manufactured (up to 2 weeks), his feet can be stabilised and supported with sports tape and long term, a strengthening program or even adjustment to his running style using further video analysis gives him the ability to increase his running to a higher level if he chooses.