Usually the onset from sporting activities or running long distances, when a patient comes in with pain in one or both tibias, we have tools we can use to manage these painful conditions.
December 21, 2021 By Mike Dixon
What I see as a groundbreaking technique in treating certain tibial leg pains is called tibial bending or end-range loading of osseous tissue. Yes – it’s bending a bone to decrease or eliminate certain types of chronic pain associated with runners, athletes or weekend warriors.
Here is the hypothesis as to why this works: Pain and dysfunction associated with chronic shin splints, periostalgia, periostitis, and compartment syndrome are likely caused by an increased interstitial pressure (edema) in the cortex of the bone, the periosteum, associated tendons, ligaments, and/or other important soft tissues, like nerves, blood vessels, and even muscles. This increase in the tissue pressure restricts blood flow, which results in tissue hypoxia.
When increased demands for oxygen during activity are met with a lack of blood flow and tissue hypoxia, the result is pain and dysfunction.
End-range loading techniques (ERLT) of these tissues, including, but not limited to bone, can markedly, if not completely, eliminate pain in as little as one session. (However, it may take few treatment sessions.) This is accomplished by restoring blood flow, reducing tissue hypoxia, and reducing the interstitial pressure created by chronically stressed or injured tissues.
How does ERLT work?
When tissues are stressed beyond their normal capacity, they produce long chain sugar bound proteins called proteoglycans. Proteoglycans are hydrophilic, which means they absorb water like a sponge. Water molecules get drawn into the tissue and thereby increase the interstitial pressure. This pressure restricts blood flow and causes tissue hypoxia. So as therapists we must affect the interstitial pressure, causing it to drop, so that blood flow is restored, and subsequently a reduction in tissue hypoxia.
Here is where we can apply end range loading techniques such as tibial bending and end range loading of the deep posterior compartment of the lower leg.
Fluid and gases only move if there is a pressure difference, therefore in order to move edema out of the area, the pressure within the tissue has to be increased. This bone bending and loading procedure creates an even greater pressure in the involved area, thus causing the edema to flow away from the area. Both the convex and concave sides of the bend will have a higher pressure gradiant, during the procedure, which squeezes out the water molecules. To use an analogy it is like wringing out a sponge.
The ERLT create positive pressures within the tissues and vessels, which is what is needed to allow presssure to subsequently drop within the injured or stressed tissues. Oxygenated blood enters into the tissue so that it can not only heal from the original injury, but it can also allow for instant pain relief.
A case study
To shine some light on this hypothesis, let me tell you about my patient Andrea.
Andrea is an RMT and in 2011, was attending one of my courses, in Red Deer, Alberta. Andrea was suffering from severe sensitivity bilaterally on her tibias at the time – to the point where she did not allow anyone to touch her lower legs.
She had suffered from a misdiagnosis of shin splints as a young girl in elementary school. When she was 18-years old she enlisted into the army. Her basic training was excruciatingly painful for her and she took a lot of ibuprofen and iced her legs every day.
Six weeks into her eight-week training, she went on a 16-kilometre rucksack march. (The cadence is somewhere between a quick march and a jog.) Her legs went well past the point of pain, to complete numbness from her knees down. Eventually, her knees buckled. She was then buddied between two platoon mates for the remainder of the march. At the end of the march, she passed out from the pain. When she awoke, four people where holding her down and another were removing her boots to view her legs. Her legs where bruised black and blue from the knees to the ankles. The base surgeon wrote her an immediate release from the military.
Three years later, she still could not hop down from sitting on the kitchen counter without shockwaves of pain flashing up her shins. She was then referred to Dr. Kelly Brett in Calgary, who diagnosed her with compartment syndrome. Shortly after she was given a bilateral, anterior and posterior fasciotomy of the lower legs by surgeon Dr. Mohtadi.
When I was introducing end range loading techniques during the course I was looking for a participant to show the tibial end range loading technique*. She volunteered at the assistance of her friend, Janet. I performed the ERL technique to her tibias.
“When you asked if anyone had any concerns or conditions affecting the calves, my friend Janet almost yelled my name,” Andrea remembers.
“We ran through my story and then [Mike] double strapped my leg to the table – above and below the knee to stabilize and isolate the movement – and then proceeded to ‘bend’ the tibia. Immediately when [my foot was released], I could feel heat along my shin, and when I was unstrapped, the flush of blood flow was visible. Janet ran her thumb up my shin with good pressure and it didn’t hurt. I cried. It was overwhelming. We strapped my other leg down and repeated the procedure with the same results.”
Andea says she was pain free for about three months before everything “tightened up again.”
“[This is] my ‘normal,’ which means that applied pressure is painful and approximately 30 per cent of my days have tingling and/or tenderness from nerve stimulation from wearing socks. Wearing certain sandals – primarily flip-flops – overstimulates the nerves affected in my feet and it alternates between numbness and tingling, and tingling and pain,” Andrea says.
I offered to see her again in early January 2019, to see what more I could do for her. (See Youtube “Mike Dixon Shin Splints” for a real interview, assessment, treatment, and treatment results.)
Andrea was still having pain in both tibias, especially on the medial aspect. (Andrea says the pain was hard to describe, but intense – at times fuffy socks were too much pressure to bear.)
I repeated the procedure I did in 2011 and she had immediate pain relief, with a change in skin colour from pasty to pink. There was some tenderness where the strap placement was. She broke down in tears explaining the relief she was experiencing.
The next day she posted this on our “Arthrokinetic Therapy Group” FaceBook page: Thank you so much Mike Dixon!! I am incredibly thankful for you and your gift of bodywork. My legs feel AWESOME and I didn’t even notice my socks today!! All the tenderness from the strap compression is completely gone and I am happy. Grateful for you.
Normal treatment protocols for these conditions are to decrease the activity, ice the shins, rest, and take anti-inflammatories. Based on my experience, these protocols generally only provide short-term relief of symptoms. Here’s why.
As mentioned at the beginning of the article, shin splints, periostalgia, and periostitis are basically all the same condition: They develop from overloading the muscles, tendons and bones, causing tibial pain.
It’s a misnomer to say the periosteum is inflamed. It may be inflamed with the onset of the condition, however the inflammation period lasts for only a few days and certainly not for months or years. Just like plantar fasciitis, it is not generally an inflammatory condition. It is a chronic non-inflammatory condition of the plantar fascia, which causes pain while weight bearing, especially in the morning. The real cause of the pain is non-inflammatory edema that was left over from the original injury. It makes no sense to take anti-inflammatories and apply ice for non-inflammatory conditions.
Lets also look at the role of the tibialis posterior muscle in the deep posterior compartment. The tibialis posterior muscle is vitally important for maintaining stability, control, pronation and arch support of the foot during ambulation or weight bearing. Failure of this muscle to maintain the motion control and arch support during a run can lead to over medial rotation of the tibia as the foot arches collapse. This over medial rotation can lead to over stressing the tibia, as the lower leg is placed in a biomechanical disadvantage. This disadvantage could very well lead to shin splints
and many other painful conditions of the feet and lower extremities.
Consider the lateral tracking dysfunction of the patellae: The culprit might very well be the tibialis posterior weakness or dysfunction. I have tested thousands of runners and athletes alike and the majority have a failing grade in the strength of the tibialis posterior.
I have run many tests on this muscle pre- and post-treatment with end range loading techniques (ERLT) to the tibia and deep posterior compartment. In most cases the tibialis posterior regains its strength with no delay. I believe this muscle just needs an adequate blood supply and oxygen needed to function properly. ERLT decreases pressure in tissue, so perhaps the deep posterior compartment has too much pressure in it to allow for proper circulation. Don’t get me wrong, I am not stating a fact, however, it just makes sense to me why muscle strength is regained within minutes of the ERLT.
I encourage the reader to test this muscle on a regular basis to see how this muscle is functioning, and see if there is a connection to other back, hip, knee, leg or foot complaints.
After more than 10 years of practicing ERLT, I am convinced that the principles around these techniques are a great beneficial tool, whether you are a massage therapist, chiropractor, or physiotherapist. There is science behind these techniques and evidence (although anecdotal) to support using these techniques in our treatment sessions. In some cases, but not all, we can see some very favourable and positive results, with a reduction or complete elimination of pain, plus an increase in function.
Please keep in mind that not all techniques work for all patients. Some patients may experience negative effects. You should always make sure you follow informed consent protocols before proceeding with these manual techniques. Make sure there are no contraindications present. For example, osteopenia, osteoporosis, internal fixations etc.
* The scope of this article does not permit me to go into the precise description of the techniques covered.
Mike would like to express his gratitude to Dr. David De’Camillis for teaching this technique as well as his research into ERLT. He was a contributor to this article and provided the various research materials. View the full story on our website.
Mike Dixon has practised massage therapy for more than 30 years. He graduated from the West Coast College of Massage Therapy in 1986, and has self-published two treatment books in joint mobilization and muscle energy techniques. Mike invites all like-minded individuals to join the “Arthrokinetic Therapy Group” on Facebook, and subscribe to his YouTube channel.
This article was originally published in the Spring 2019 edition of Massage Therapy Canada, and published online May 2019.
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