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Tibial Stress Syndromes (Shin Splints) – Callison/Lau



“…we’re from ACU Sport Education and the Sports Medicine Acupuncture Certification Program. Um, we’re going to talk today about tibial stress syndrome.”

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Hello everyone. Welcome to our sports acupuncture webinar. My name is Matt Callison. I am Brian Lau. We want to thank the American Acupuncture Council for sponsoring our, our sport, our sports acupuncture webinar here. Uh, we’re from ACU Sport Education and the Sports Medicine Acupuncture Certification Program. Um, we’re going to talk today about tibial stress syndrome. So let’s go to the first slide please.

So since spring has sprung and we’re quickly approaching summer, we’ll start to see patients that are coming in with a tibial stress syndrome or the layman term for this being shin splints. Uh, people are trying to be able to get in shape. And so this is a common, very common overuse injury. So, uh, Brian, we’re chatting just last week. We, uh, we just published our module three lower extremity online recordings through net of knowledge. And we were talking about what we could actually grab from that since it’s so fresh in our minds and tibial stress syndrome was, was the first thing that we thought about. And so this is actually a, uh, it’s a fun topic because it is something that most of us most acupuncturist to see clinically. And there are some techniques that we have found work extremely well for this. So, uh, before we jump into the first slide there, Brian, do you want to say anything or do you want to go right into medial stress syndrome?

Uh, I’ll say something simple and that is, uh, this particular topic is one that I’ve dealt with, uh, not for a long time, but when I was in high school, I was a wrestler and we used to do a lot of drills on a hard floor running drills and these wrestling shoes that had zero support. Um, they’re not, you know, they’re designed to be on a mat, right? Not on, uh, not for running shoes, but sometimes being young and stupid. We were lazy and just wore the same shoes as we went out and did running drills and exercises and sass. I remember at the high school, this was, uh, something that I didn’t have horribly, or it stopped me that it was quite painful. So I know this one personally, uh, fortunately I haven’t dealt with it for, uh, most of my adult life


Midnight. And then that I’m ready to roll. All right. So should we go to the next slide and Brian, you want to take it away?


As Matt mentioned, that student’s lens is kind of the layman term, uh, for medial and anterior tibial stress syndrome, I’m going to start the discussion talking about medial tibial stress syndrome. So that’ll affect the, the sort of medial side of the tibia, and we’ll look at the anatomy and kind of mechanism of injury for that. Um, and then, uh, I think Matt will take it, uh, from anterior

Tibial stress syndrome, but collectively people refer to these as shin splints. Um, it’s an overuse injury inflammatory condition that involves micro tears and either the myofascial origin. So the tibialis anterior that would be for the anterior tibial stress syndrome or the tibialis posterior for the medial tibial stress syndrome. Uh, those muscles are along the shaft of the tibia. So let’s, uh, go to the next slide and we’ll jump into medial tibial stress syndrome. So immediate tibial stress syndrome, uh, the pain and tenderness is found on the medial really at the posterior medial aspect of the tibia, you know, on the sort of the yin channel side of the leg. Um, so on the medial portion of the tibia, just really on that most posterior aspect. So that would be along the liver channel. Um, and we’ll talk a little bit about the channels on this slide, but, um, it’ll be usually the pain is, is level with the area between spleen eight and spleen six.

That can be a little less than that. It can go beyond those boundaries, but that’s the typical region that it covers. Uh, so that’s the area that people will tend to have pain that they’ll, um, they’ll be complaining about, um, in terms of channels. When we get later in the presentation, we’re going to be looking at a myofascial release technique. We’re gonna be looking at an acupuncture, of course, but then we’ll also look at the myofascia release technique. And in that, uh, particular associated technique, it will be in reference to the spleen, send you a channel. So this injury and the pain is a long that distribution of the liver channel, but the channels, aren’t just a line along the body. You know, they’re not only on the surface, so to speak, you know, we’re taking a needle or we’re penetrating the skin and where that needle goes can be, they’re either more deep or superficial.

So if we were just to glance at this image from mats, a text, a sports medicine acupuncture, um, and look at the arrows, the arrows are pointing to the tibialis posterior muscle, which is what attaches to the posterior surface of the tibia. And that’s, what’s going to pull excessively, or when it does pull excessively on the tibia and you create little micro tears there, that’s going to be what contributes to the medial tibial stress syndrome. But if we look at where those arrowheads sit, not what they’re pointing to, they’re pointing to tibialis posterior, but where do they sit? There’d be another muscle there. Um, that’s not shown in this illustration because it’s, it’s highlighting the relevant anatomy of the tibialis posterior, but that muscle that’s just medial to the tibial. The tibialis posterior would be the flexor digitorum longest. And then if we go lateral on the other side and the lateral side of tibialis posterior, it would have flexor hallucis longest.

But if we come back to that medial side where those arrow had CIT, uh, that would be flexor digitorum longest, that’s actually part of, as we define it in sports medicine, acupuncture, part of liver sinew channel, whereas the tibialis posterior a little bit more anterior, um, and a little bit more in the middle part of the tibia, you know, lateral to the flexor digitorum longest is the tibialis posterior as part of the spleen sinew channel. So depending on the depth that the needle is reaching, uh, we’ll also determine really which at least from a sinew channel perspective, what, uh, uh, channels being, uh, affected. Uh, so we’ll look at, at that aspect as we’re doing the myofascial release technique and we’ll discuss it, um, also, uh, in terms of the channels when we get to the acupuncture portion, but just a heads up, and I’ll re refresh that when we get back to the myofascial release techniques, but this one’s talking about the anatomy and that’s the tibialis posterior, that’s what the arrows are pointing to note that the tibialis posterior comes down, the leg becomes a little bit more medial around spleen six, and then look at how it attaches onto the foot and how much of a support mechanism it creates on the arch of the foot.

It’s really the Keystone muscle for that. Uh, at least from an extrinsic, from the muscles that are in the leg for creating arts apart in the foot. Uh, so I kind of think about the aspect of how the spleen can lift and this a spleen sinew channel muscle is really a prime lifter of the medial arch. And I, I see that as one of the spleen functions to have lifting, you know, in this case of the foot. So if we can go onto the next slide


So a medial tibial stress syndrome, like we said, involves the tibialis posterior muscle commonly occurs, uh, occurs in individuals who are moderately to severely over pronated. Um, because of that line, Nepal, that we were just looking at how much that, um, tibialis posterior influences the lifting of the arch, when you’re going to the weight bearing and the foot hits the ground, there’s a normal pronation, you know, the foot, the arch is going to drop and that tibialis posterior is going to be elongated, but there’s normal. And then there’s, overpronation where it’s just like a flat tire. And that Tim posterior, it gets pulled really excessively long, probably a little bit in a more of a charring standpoint. So it doesn’t have that normal elongation where there’s a little tone there and it kind of checks, it keeps that, that, um, pronation and check, it keeps it from going too far out of the boundaries in this case, it just flattens.

So if you were to look at these images here and just glance at the runners, if we can see from the waist down, uh, notice which one of those, you know, they’re not all hitting, they’re not all in the, in the weight-bearing part of the gate, but some of them are which ones do you notice, or which one do you notice that really highlights that collapse of the medial arch? I’ll give you a second just to glance at that, but you can look at the front person, you know, th the, the weights falling to the medial arch that’s normal probation, but if you look at the person just behind him, right in the middle of the shot, um, it looks like I can’t tell what the number is 71 possibly, uh, with delusional shorts on yeah. Blue shorts. Um, you can see how much farther that person’s going into pronation and imagine that dropping of the medial arch and how accessibly that would be pulling on the tibialis posterior. Um, so people with foot overpronation is going to be a really key thing that you’re going to notice. That’s going to affect things like a medial tibial stress syndrome. Um, it’s very common with runners that accounts for approximately 13 to 17% of all running related injuries. So it’s a pretty big one. You’ll see it as the prime complaint, or at least a secondary complaint in your practice. Um, you know, frequently, if you haven’t already anything you wanted to add to this format.

Yeah. Brian, I just want to reiterate what you’re talking about with the spleen function being, lifting the tibialis posterior, or this is something that we talked about in December webinars through the American acupuncture council. It will be spoken about it has planets and the number of different injuries that can actually occur from that. And we actually spent a bit of time asking practitioners to look for, um, any time of earth signs and symptoms, spleen and stomach that may be actually contributing to some of the musculoskeletal pain, because with any muscle skeletal injury, there’s always going to be some kind of [inaudible] component, either that the organ and the channel has directly effected that or that the organ systems are deficient and not controlling inflammation very well. So there’s always some kind of [inaudible] component for the TCM practitioner to take a look at that. So that was the December, uh, webinars, something that you, you guys may want to check out on PEs planus, uh, Brian talk right now, but the tibialis post here. But if we look at that person with the blue shorts as well with the tibialis anterior, that will also end up being elongated with overpronation. So we’ll talk about the tibialis anterior, just a little bit, Brian, back to you.

Yeah. Yeah. And just the foreshadow that that’s going to be the stomach Cindia channel. So now we’re talking about spleen stomach and, and often how those correlate again, from a Zong Fu perspective, how frequently those, those two organs are so integrated, you know, that compared to other internal, external parents, those two are just like really functioned quite often together. And their disharmonies are often associated, um, both from a musculoskeletal, but even from his own food perspective. So I’m curious Matt, about the, the, um, long food perspective. I feel, you know, doing Chicano practice Tai Chi can be really any physical activity. If you take time to strengthen the arch in my mind, I feel like, and I see this to some extent play out though. It’s a little hard to, to test for, but, um, but I feel like you’re strengthening this lean channel. Sure. You know, at least the component that’s related to the foot, but I feel like that’s, that’s strengthening and calling on extra blood flow to that area, more communication with the nervous that that starts to be, you know, at least a component of, of strengthening tone to find the spleen. So even from his own food perspective, that, that, um, improvement of health for the floods can also have a, um, uh, regulatory effect on the whole system.

Yeah. And that’s through any channel, right? I mean, if you have a, um, excess gallbladder or excess excess liver and deficiency in gallbladder by exercising, the hip AB doctors and 80 doctors, it does help to balance that particular aspect. In fact, you can, you can feel the pulse prior to the exercises and feel maybe a sharp edge to a pulse. Some people would call that a winery recalls and then have the person do hip AB duction, 80, the options, and it softens the pulse. And that’s just one example. We could also talk about subscapularis and Terry’s minor, you know, again, but, but Brian’s point here is that how important it is to be able to prescribe exercises to your patient. And these are more webinars, isn’t it actually, how important is to prescribe exercises to be able to compliment your acupuncture treatment based on your differential diagnosis for TCM differential diagnosis? Sorry, Brian,

That’s good. Yeah, I think we’re ready to jump ahead. Next slide. All right. So some differentiation, because there’s more than one thing, uh, you know, fortunately, or unfortunately, fortunately, because it makes us put our detective hats on and makes life more interesting. Uh, there’s more than one thing that can cause pain in this region. Um, so if anytime, somebody comes in with pain and we just like, ah, medial tibial stress syndrome, uh, we’ll get it sometimes. And we’ll miss it other times because sometimes it’s not medial tibial stress syndrome and a common very, very close. I mean, you know, within probably less than an inch, uh, of, uh, uh, posterior to this where there’s going to be pain would be a solely a strain. So just off, you know, not up against the bone, but just off the, uh, the bone just posterior, um, there’s going to be a, uh, painful when there’s a solely a strain cause the soleus is a pretty wide muscle and it covers a lot more territory, both medial and lateral than the gastrocnemius.

So this would be, again, this is, uh, channels are a little odd in the, in the leg compared to the rest of the body because it’s along the spleen channel, but the soleus, again, as we have it defined and, and a sports medicine acupuncture would be part of the kidneys in new channel, but we’re on, you know, in this case, the pain that often is going to be apparent is really pretty close to that. Um, kind of most medial edge of the solely, as you know, this only has covers that whole posterior portion of the leg. So it’s a big muscle. And, uh, the bulk of that solely is really, it would be the kidney sinew channel, but the distribution of the pain is going to be really along more of this spleen channel, just posterior to the, um, often again in that region of spleen eight, but that through spleen seven, it’s probably not going to go down as low as spleen six. Um, so something to be aware of, you know, if you’re palpating to help confirm the pain and not so painful right up against the bone, but you back off, uh, what would you say Matt, about half an inch, an inch at the most? Yeah, yeah.

A quarter of an inch sometimes.

Yeah. And then that’s where, Oh, you know, that’s where the pain is. That’s you, you have your fingers right on it. That starts indicating more of a soleus, uh, uh, strain. And, um, it’s pretty close, pretty close in terms of their description of where it’s going to be. So something to look for, uh, uh, that can help differentiate the pain and that’s going to be a different channel correspondence. It’s going to be different, uh, uh, treatment. We’re going to stay with medial tibial stress syndrome for today, but it’s good to differentiate. Can I add something to that, right? Absolutely. Please. Yeah.

So we can use, this is something that we’ve talked about in the past before where we talk about it quite a bit actually is, um, acupuncture as an assessment. This would be when you’re in your assessment. Uh, part of the, um, treat of the clinic, uh, patient visits are for the patient visit and you’re trying to figure out, okay, this is a solely extreme, it seems like it’s going to be more painful. And it’s bound up in that mild fascial tissue about a quarter of an inch away from the bone. Um, we’re saying that it’s more of the kidney, mild fascial gene, Jen, but it’s also the spleen primary channel. Okay. So where’s the stagnation. Is it in the primary channel or is it in the soleus, mild fascial tissue? Um, in the kidney, what we could do is maybe needle kidney three, we can needle maybe kidney four as part of the assessment, and then go back to that soleus and feel if it’s quite a bit softer, is there less pain without patient to the patient?

If not, maybe we could needle spleen three and spleen four and see if that moves cheat within this plain channel and go back and out pate. That solely is, um, from my experience, it’s usually going to end up being kidney three, kidney four, and sometimes even kidney five that starts to take pain away from that solely us. But it’s nice to be able to at least put your detective hat on as Brian was saying and figure out actually, where is that stagnation? Is it more in the spleen primary channel or is it in the kidney gene, Jen?

Yeah, maybe we could just throw in an ashy point, uh, or if you’re a little more, have a little more finesse, maybe a motor point if you know the location for the soleus motor point and you’re going to get resolved, but you’re going to increase those results. If you link it with the channel and it start building a comprehensive picture and Madden this image, you can actually kind of see it. You know, we, we highlight this in our cadaver, um, classes, uh, uh, we look at it on a, on a cadaver specimen and you can really see that. Um, but this even just in the image here, you can see it quite well because if you follow the soleus through the Achilles tendon and look at its attachment on the Achilles tendon, um, I can tell you that the solely as partial portion has a much stronger connection into the medial side of the calcaneum attendant onto the calcaneus.

But then, uh, in this particular model, you can see how that links through the fascia of the calcaneus and right into the abductor hallucis, which we dropped straight down from, uh, could be six. There’s a pretty prominent abductor hallucis muscle. That’s, that’s visible, um, here. So, you know, that whole chain is, is really, uh, um, all part of the same myofascial plane of tissue. And, and as Matt was saying, like, give me five, such a strong point. Other other kidney points might be the ones that are really, um, indicated kidney two is the motor point for the abductor hallucis. So there was a lot of pronation that might be willing to consider too. Yeah. A lot of good choices for this, but that’s kind of deviating from the topic of the, of the day. So anything else,

Because we go in a lot more detail on that module three in the anatomy cadaver lab, and talking about that with different slides such and how I’m really how important that is, and trying to be able to balance out that calcaneus with any kind of, of ankle injuries or these technology and such are going to keep moving and we’re going to take all day. Yeah.

Uh, so the second differentiation to, to consider is a tibial stress fracture. It’s it’s, um, often as a gradual onset, it’s a progression of tibial stress syndrome. So, um, uh, the, the, um, when the tibia is excessively pulling and you’re getting these micro tears, especially if the person’s really powering through it and controlling it with then sets is, uh, um, is that a common dynamic, um, to kind of deal with the pain and they keep on working with it that can progress into a tibial stress syndrome where there’s a lot of, uh, starting with a lot of extra osteoblast, the plastic cellular activity, um, that can sometimes show up on a x-ray, uh, frequently can show up on an x-ray. And, um, you can kind of see that little cloudy area where the arrows are pointing to, and that can progress into a tibial stress fracture.

So with that, there’s going to be a really exquisite tenderness at a point specific region on the tibia. So if it’s not responding to treatment there, that that area is, um, exquisitely tender, where you’re palpating, um, even sometimes a very light pressure. This is something to consider and getting some imaging would be the way to go. And I think the next slide shows a little bit more on this map, but if you want to add anything here before we move on, maybe after the next slide. Yeah. Okay. So the next slide. Yep. So that doesn’t always show up on the x-ray because some of that osteoblastic activity is maybe a relatively new, and it hasn’t reached the level where it’s going to show up on an x-ray. So you can’t really rule it out with a negative x-ray MRI will show a little bit more. Um, but, uh, it, again, it’s really, I, I, we, I see it as if it’s not responding and there’s that, you know, points specific exquisite tenderness, that’s the indications that I’d be looking for, uh, that you would want to consider this to be real, uh, stress fracture method. You are going to add something. I think, uh, the GDV, but I think is another good one. Yeah, go ahead. Yep.

Both of these x-rays were from a patients of mine. Um, and when you are suspecting an osteopath increase osteoblastic activity, or even as it progresses into even a cortical stress fracture, um, like Brian was saying, it is exquisitely tender as you’re palpating along the tibia, and you find that spot, there’ll be a fluid within the tissue. We call that chia DEMA. Um, and it just the gentlest of pressure for the patient. It hurts quite a bit. Um, so just know this is trying to go and get some imaging. If it doesn’t show up on an x-ray, then you want to request a bone scan or even an MRI, but a bone scan is usually the gold standard for that kind of thing. If it’s not going to show up on an x-ray, you want to catch that you want to be the acupuncturist that catches this. Um, and, and because this will come into an acupuncturist office, if you are treating musculoskeletal injuries, uh, it’s just something to be able to make sure that you’re aware of anything else be. Nope. All right.

Okay. So now we’re going into a anterior tibial stress syndrome. So this is going to be affecting the tibialis anterior, which is responsible for 80% of dorsi flection. And it’s an incredibly strong decelerator for plantar flection. So you can see this runner, who’s running down an incline, he’s got heel strike. And so his foot is going into plantar flection. So that tibialis anterior is slowing down the ankle and the foot. So it’s, ecentric CLI lengthening. It’s a contraction. So therefore with overused, just like the tibialis posterior, it can have micro tearing some of the fascial attachments or the muscle fibers microscopically can start to tear away a little bit from that bone thing causing pain. Now the pain just like tibials poster syndrome is going to be on the bone. So you want to palpate medial to the stomach channel on the aspect of where the tibialis anterior attaches to the tibia bone.

That area will be tender if it’s going to end up being a shin splints of involving the tibialis anterior. So let’s go to the next slide and you’ll see the common areas to pop it for. This is usually around stomach 37, generally speaking. I don’t think I’ve ever seen it go all the way up to stomach 36 reasons. It’s usually more toward the muscle belly of it. Um, uh, stomach 37 and even just below stomach 39. So again, I just want to reiterate, it’s not on the stomach channel. That’s a different injury. That would be a tibialis anterior strain. So if you palpated on the stomach channel and you feel a fast cycle of tissue, that’s really quite hardened and that’s causing more pain than when you palpate on the edge of the bone where the tibialis anterior, it comes close to, right? So then therefore it’s going to be more of a tibialis, anterior strain.

Why is it important? It’s going to be different needle techniques, same channel that you’re working with, same channel correspondences that you can work with. But yet if it’s the tibialis anterior strain, we’re going to be needling the motor points. Um, and not necessarily the, um, the technique that we’re going to be showing you for shin splints. Now there’s something that we should all be aware of. And maybe you already know about this, but if not, make sure that if the person is talk is, is complaining about anterior pain when running it gets worse during activity, and then starts to go away. When you look at the front of the leg, that anterior, there may be a certain shine to the tissue, let’s go to the next slide.

It could be chronic exertional compartment syndrome. Now this is a pretty serious condition that often requires surgery. Um, I’ve seen this quite a few times at UCS D the treatments that we applied helped with the person, but as soon as they actually started going back into activity, it came right back. Surgery is in my mind, the better way of going with this, uh, chronic exertional compartment syndrome is usually occurring with people that are increasing their training or they’re changing their running terrain. Something of that nature could also usually be brand new shoes, but they’re starting to develop shin splints, anterior shin splints, but yet the pain is going to be more in the tibialis. Anterior is going to be a long, the bone. It’s going to be a accompany, usually with a burning or an aching or a pressure sensation. And a big note here, it’s often bilateral 70 to 80% of the time you’ll have this as bilateral.

So remember that one, that’s a key. All right. And then also with this burning aching and pressure and possible numbness as well, is that it usually will start to go away 30 minutes, 15 minutes or 30 minutes after they actually stopped their activity. What happens is that the muscle tissue starts to hypertrophy from the increased training or from changing the random terrain and at a very rapid rate. And so the fascia tightens quite a bit, and with that increased pressure within that answer your compartment. And now this kind of chronic exertional compartment syndrome can happen to any compartment of the lower leg, but it’s most common in the anterior compartment. So this is why I can kind of mimic this tibialis anterior stress syndrome or the shins anterior shin splints. Is that the, so like I was saying is that muscle will start to hypertrophy.

You’ll get the fascia starting to type, it starts to compress. You’ll have a decrease of the venous return. So therefore there’ll be increase of the interstitial fluid. That’s going to put pressure on the neurovascular structures. Um, it starts to get a lot of compression within that region. Again, you’re going to start pressing against the anterior tibial nerve and the deep peroneal nerve, um, getting the signs and symptoms of burning aching pressure numbness. If you do have a patient with that, you want to refer them out, continue to treat them because you’re going to, you can still help them, but refer them out for further diagnostics with this. Now it can be a very serious condition if you’re going to be decreasing the amount of blood to the area, uh, let’s go to the next slide. This is something that I think is really quite viable valuables to feel the dorsal Punal pulse, which is right next to stomach 42, right?

So this is going to be a collateral branch off of the anterior tibial artery. So if you go just lateral to the extensor, hallucis longus tendon, and just medial to the extensor, digitorum, longus tendon, you want to feel for that pulse, right? So it’s pretty common. Make sure you compare sides, even if you feel the pulse on the same side of the possible exertional syndrome, if it is decreased compared to the opposite side, we think of that as being a symptom, right? So as a pop, sorry, as a possible sign here. So, um, feel the dorsal pudo pulse in these kinds of cases, it’s going to be pretty valuable information for you. All right. So what else do we have? Let’s go next.

Can I say something real quickly about that? Matt is, um, some people, some folks are aware of both of these, uh, situation, uh, conditions, but, um, uh, maybe not. So it’s worth mentioning, you know, compartment syndrome, uh, for those who might be aware of like more of an, uh, traumatic compartment syndrome, where you have something call on your legs, some kind of a weight or something like that, you know, an earthquakes and stuff like that. You’ll see these with people. That’s a much more trauma-based, uh, uh, condition where you get that swelling and that can be an emergency, a really severe emergency condition. Um, this is like that it has the same components in that it’s, it’s, um, it’s, uh, restricting and putting pressure on those neurovascular bundles, but it’s not from, you know, impact like a trauma, like something falling on the leg or something like that. But a lot of people are aware of, of compartment syndrome, and this is notice the difference of chronic exertional compartment syndrome. So just that,

Well, there won’t be blood vessel rupturing or bruising with case. Cool. All right. Thanks, Pete. All right. So let’s, um, start to get into the treatment techniques with this. Um, at UCS, I started an externship for Pacific college of Oriental medicine, which is now called Pacific college of health sciences. Um, this was, gosh, I’ve been doing this for 20 years now and it still is ongoing. So we take the interns from Pacific college and we treat the UCF athletes and, uh, shin splints is extremely common, um, there, so we have plenty of experience, uh, to, to practice a number of different techniques to see what works and what actually doesn’t work. And so, um, I developed the study and it’s, again, it was just a very small study. It was only a three week study. We only had 45 people in the pool. Um, there was three groups in the study.

One was an acupuncture, only study. One was a sports medicine only group. And then there was also a group that was a combination between acupuncture and sports medicine. Now, the protocols for sports medicine was ice stretching and strengthening, and also ultrasound. They were using actually both ultrasound and ice in this case, depending on the patient. So they were doing it using those four things. Then the sports medicine group, um, with the acupuncture sports medicine, we applied the techniques that were about to go over the accuracy techniques in addition to the sports medicine protocols. And then we also had the acupuncture group of suggest acupuncture in that sense. Um, so what we found was that at the end of the three weeks, Oh, there’s one important note is that almost each one of these athletes were taking a lot of assets and they’re taking it, um, during and before, and also after the events, because they really need to be able to compete or they’re going to lose their position on that team.

So, um, and says was, was gobbled down like candy. And so one of the questions that we had with this particular study was that they could go ahead and decrease the amount of end sets if they wanted to voluntary voluntarily. So, um, this was something that we found in the study that, that in the acupuncture group, people were actually not taking the sets and just coming in twice a week for the acupuncture, which was not statistically significant in the other two groups. Uh, so in this article, uh, printed in the journal, Chinese medicine, 2002, so way back when, um, it does show that the acupuncture group was actually far superior and the other two groups, um, really didn’t match up very well as far as getting results. Now, again, this was only a three week study. There was only 45 participants in this. If we made it an eight or a 10 week study, I would think that the other two groups would actually start coming up. But I think there was actually enough evidence to show that these needle techniques that we’re about to get into, um, actually work pretty darn well. Um, and this is something that, um, I continue to use and have been teaching in the SPAC program Ford smack program for a good 20 years now. And, um, so we’re getting a lot of good results with it. So let’s take a look at the next slide.

All right. So the key with this with medial tibial stress syndrome is to palpate where the top of the pain is on the tibia. And then also where’s the lower range, the lower end on the tibia. So you’re going to start your needling at the top, just above the painful area. And you’re going to thread a number of different needles could be eight, could be 12. It could be more depending on how long the area of pain is. So each needle will


And we’ll go in and the other one we’ll actually go right on top of it. So there’ll be continuous needles all along that edge. Now it’s going to be shallow needling, right? And that’s going to be very important. You don’t want to go deep when we did go deep. It actually aggravated the condition. So it’s a transverse needle technique, no more than 15 degrees, right? You want to thread that needle right along the edge of the tip yet, as if it is scraping the tibia, you don’t want it to go too much into the soft tissue. You want it in the crevice, just off of the edge and on that edge of that bone, right along that liver channel, just like on liver five, how we try to be able to scrape the bone fat, think about that with these particular needles, uh, you don’t want the needle at 30 degrees.

You wanted at 15 degrees, 10 to 15 degrees, and then thread that. So they overlap all the way down to low the area of pain. Now match this needle technique with your constitutional treatment. You can also go ahead and treat other points with this. For example, we were talking, um, spleen points because the tibialis posterior is associated with the spleen gene, Jen. So we want to treat spleen points in this case, of course, we want to probably treat stomach 36 for the patient, which is also nice. Cause that’s the motor point, one of the motor points for the tibialis anterior. So to reiterate this needle technique is not the only thing that we do, but this is a successful needle technique for helping to decrease pain. When you are helping to treat this patient now for the anterior tibial stress syndrome, which is the next slide.

It’s the same type of needle technique is the exact same idea. And, but you’re threading in different areas, obviously. So it’s right on the edge of that tibia and medial to the tibialis anterior in this case. So again, this is going to be something that you want to go ahead and treat the person constitutionally with it. And also you want to apply the myofascial techniques that we’re going to be getting into just next, I believe. Um, one important note, if the patient does have foot overpronation that this, these needle techniques will help decrease the pain, but the foot overpronation will need to be corrected or helped. And one way or another through exercises treatment, maybe, maybe the foot is prone is so much that you actually need to be able to get inserts. And that’s something that we actually talked about in that webinar in December. So the foot overpronation does need to be addressed for long-term clinical success. Brian was saying, um, no, I think it’s good. All right. You want to get into the mob passionate techniques? Yeah, sure.

So, um, I guess we go to the next slide. So we have, uh, one, one slide and a video for, um, demand terrier. And for tip posterior, we’ll start with tip posterior. Uh, we have videos for these because as Matt mentioned, um, we pick the subjects that we’ve recently presented on it, and it’s now live on the Neta knowledge, uh, for some of our classes, for the sports medicine acupuncture program. Um, and we recorded, uh, some acupuncture, more distal points for treatment of things in the assessment and treatment of the sinew channel class. But we have a lot of myofascial release techniques in those classes. So we have videos for them, for presenting at the webinars, um, uh, just cause we had better camera angles. We can, we can plan it a little bit better. Unfortunately, we don’t have videos for the acupuncture part cause we we’re, we’re reserving those classes for live classes, just so there’s more oversight.

Um, especially certain techniques require a little bit more oversight where there might be. Um, it might cause damage if people aren’t doing them correctly, we’ve, we’ve reserved those for post COVID, um, to do a in-person. Um, but some of the other classes, we were able to do a online webinar form during this time of COVID. So unfortunately that videos for them, it’s not to say that these are more important than the acupuncture. It just happens that we have videos for them. So let’s use them. Um, so this one, uh, we’re going to be working just sinking deep, uh, behind the tibia. And the goal is to kind of move the tissue posterior to soften those connections of the tibialis posterior, uh, from the tibia, uh, with the caveat that if there’s extreme discomfort for this, you have to use less pressure or maybe start using this technique as the, um, a few sessions in, as the acupuncture starts improving the condition.

So if the person is retreating from you on the table, either soften the pressure or uh, hold this one in reserve for down the road, but it’s usually, uh, able, you’re usually able to do it. It’s a slow technique you’re giving the time, uh, the tissue time to sort of soften and melt a little bit and connected tissue to sort of, um, become a little bit more soluble to go from that more gelatinous, hard state to a more soluble state. So it’s, it’s often applicable, but, um, you might have to modify pressure, especially on this medial surface that could be quite tender. So you’re going be sinking, a soft fingers sink in, take your time. And then slowly moving the tissue posterior as the person does a range of motion with the foot, if it’s too much of a range of motion that can push you out. So, so it has to be a small plantar flection, dorsal flection, very slowly. You’ll see that on the video. So let’s go ahead and look at the video and it’ll highlight that

This is a compliment to the tibialis, anterior myofascial release the technique. Again, it could be one that’s done along with that one, or it can be done separately. There’s various clinical reasons why you might do one or the other. Um, but the same idea exists is I want to move the tissue from the deep posterior compartment from lower down around spleen six in particular, it’ll be over tibialis posterior. I want to move that tissue away from the tibia. And I want to angle my direction down into that deep posterior compartment, multiple muscles there. But my goal is thinking about influencing the tibialis posterior and moving that most anterior most muscle away from the bone and giving more space along the spleen channel and spleen send you a channel. So I’m going to enter in just posterior to the tibia. Spleen six would be a really good starting point to consider.

So we’ll go in the region of spleen six, angling posterior, I’m going to have the patient’s door selection and plantar flection. This one, especially as I get higher up, it might be a smaller if I can get away with a little bit more, well, that might get to the point where it feels like his musculature is pushing you out out of that little Valley, which has all minimize the movement. Reposition slightly superior, six strays towards the table, and then ankle dorsiflexion thinkers. It could be the flat of the failings, same thing. As I dropped behind the tibia, I sink down towards the table and a slide traction, posterior, they’re going to do it ankle doors to flection. That’s almost pushing me out, but I’m going to do it to see if I can open up that tissue a little bit and relax, good up singing down traction, posterior slightly, just enough to give a drag on the tissue call for movement. Could you even consider using the flat on my elbow, but I’d have to be very mindful of depth because this tissue can be very sensitive.

One more

Sink down, traction, posterior call for movement. That’s enough right there. Yep. Too much. And we’ll push you out. So you might have to minimize the movement. Let’s do one final pass. Might be a little bit more on the solely as two, but that’s okay. It’s still opening up that same space behind the tibia. All right. An excellent technique for tibialis posterior syndrome. As the other technique on the stomach channel would be for tibialis anterior syndrome. It’s excellent to open up the ankle dorsi, flection and working on any condition that would be affecting the foot, uh, especially PEs planus. And we can look at a modified technique for past planters specifically.

I think we can probably move on, uh, to the next slide. Uh, that one I think was most relevant for tibialis posterior stress syndrome. Um, and I know we have not unlimited time. So, uh, this is a similar technique and we’re on the stomach. I send you a channel on the tibialis, anterior, very similar idea. I’m going to sink into the tissue. There’s a little bit more meat of the tissue to sink into. We have such a narrow space for tip posterior. You’re buying the tibia to get to that deep posterior compartment, but the anterior compartment we’re really having a little bit more direct access to. And another difference with this one is the tin posterior. I’m just kind of angling and stretching away, but I’m not gliding through the tissue so much because then I would just be gliding through the soleus. So it’s, it’s more of a traction. Whereas this one I’m going to actually glide through the tip anterior, but at the same goal to help soften those connections to the tibia. So let’s go ahead and look at this one.

We’re looking at a specific myofascial release technique for the tibialis anterior muscle and especially cases and especially useful in cases where it feels like the tibialis anterior. Is it here to the tibia and another condition where you might feel a little bit of a loss of a ballet dance, rigid, tibialis, anterior, and glued and stuck to the tibia. So we’re going to come in with a fist loose fist. My knuckles are going to be right up against the tibia and not driving into the tibia tibial crest, but right up against the tibia as close as I can get to it, I’m going to angle directly down. I’m going to go planning through the muscle, but I don’t want to think about it as a round technique where it pulls the leg into external rotation. I want to think that I’m going straight down to the table and it’ll actually squeeze the leg, push it a little bit into medial rotation, or at least it will influence it towards medial direction.

So again, this way around the leg will pull it into lateral rotation this way, straight down into the table, we’ll push it into medial rotation. So I’m going to contact sync perpendicular into the tissue, ask the patient to do some divorce, deflection toe extension plantar, flection to reflection. Sometimes it’s a little bit faster of a technique, but this tissue feels very stuck here. So I’m going to take my time and let it soften and melt and back out. It’s not uncommon to see some little tracks where your fingers, where it’s a little finger tracks. I can move down a fist length. I can sing stray towards the table, ask for movement and falling at that flood into dorsiflexion and plantar reflection. Again, even if I take my hand away, it actually pushes the leg more into medial rotation because my intention is just straight down. One more pass. You don’t want to go too far down because it can get a little nervy at about mid leg is good. It’s a one Margo plantar flection, and I’m going to do one more pass on the coming back up. You don’t have to do it this way every time, but this tissue felt particularly congested, uh, ankle, Doris deflection, total extension, and then down.

All right, that’s great. So, um, just to reiterate on some of the first technique for the medial side, if the patient is experiencing what you are thinking of osteoblastic activity, where there’s a dime-sized spot that is exquisitely tender, you can perform the technique above and below. It just let pain be your guide. I mean, these techniques are actually very, very useful after the acupuncture technique, um, to help free up that area and increase the circulation. Uh, Brian, anything you want to say before we jump into the exercise now, I think, uh, we’re ready for that. So with the exercise, this is ankle rotation. This is coming from our postural assessment and corrective exercise class in module three. This is a go-to exercise for shin splints. This is something that’s always going to be in. The protocol will be the only exercise. It all depends on the patient’s posture.

Like for example, if they do have food, overpronation, there’ll be a number of different exercises that we teach to be able to, um, use with that. But this would be one exercise we would throw into that protocol because it does exercise all of this in new channels, the yin and the yang sinew new channels with the lower leg. Um, this is an exercise that actually requires quite a bit of concentration. Those because people start to kind of have it, their mind is wandering or the dog comes and licks the patient’s face because they’re on the floor. You know, you have to really concentrate with this exercise. Now in this photo, what you’re seeing is the model, bring the hip into 90 degrees of hip flection, and then supporting that leg so that the tib and the fib are going to pair be parallel with the table.

I’m parallel with the floor. Then you go into ankle dorsi, flection from ankle dorsi flection. You’re going to ask the person to make a full range of motion as if you’re drawing. And Oh, you do that 10 or 15 times in one direction. And then you do 10 or 15 times in the opposite direction. Now to work the opposite side, you’ll notice that the model has Dorsey flection. So this is going to be an exercise that you want to work on both sides. You know, the person’s going to be having shin splints on one side exercise, both sides because there is going to be a crossover neurologically and also with the channels. So this is a really great exercise to really, um, before running and also after running helps really loosen up that lower leg quite a bit, um, before the run. And it helps to, uh, loosen up the leg quite a bit after the run as well. Brian, anything you want to add to that? Yeah.

Yeah. You know, when they’re doing the exercise, I know this is my hand. So you just have to use a little imagination here, but if the person has e-version and they’re already, you know, you can look at the, the video, uh, the webinar we did on PEs planus, we go into it a little bit more than I have time here, but if there are any version of their ankle and foot position is such that it’s going to encourage that, that turning out, um, whether they’re pointing the foot down in the planet reflection or up into door selection, and they have a much harder time going up and in or down and in, which is going to engage, tip anterior and tip posterior. Um, when they do this, they sometimes cheat a little bit, or they’re like a little, uh, a little iffy on the both, uh, down and in and up and end portion of it. But they’re very strong on the up and out, down and out portion of it. You really have to coach them to make sure they’re there fully getting that foot turned in, in both directions, whether they’re going clockwise or counterclockwise. So don’t let them just kind of like, you know, bully it into one direction. It kind of like, eh, not quite there at the other direction, you have to give them a little bit of incentive or kind of bring that to their attention

At least. Yeah. That’s a good point watching your patient, perform the exercise before they go home and do it. And a lot of concentration each time, making sure they’re going into the complete range of motion. If the mind starts to wander, it’s going to be really easy just to kind of flap it around a little bit, which is not really doing very much. It’s not really exercising this. Um, this is also called shin burners. And after doing it 10 or 15 times yourself, you’ll understand why it’s also called shin burners. It’s a difficult exercise. It’s a fantastic exercise, especially for shin splints. Anything else there, Brian? No, I think we are good. All right. So here’s some contact information. You guys, um, uh, thank you so much for attending. It looks like we really went over time with this. And so for you guys that hung out the whole time, thank you very much. Uh, we wanted to thank the American Acupuncture Council again for having us with this sports acupuncture webinar. Um, Brian, it’s always a pleasure hanging out with you and we should say, Oh yes, next week, make sure that you are back for Lorne Brown. He’s going to be discussing some topics, whatever Lorne is going to be talking about. It’s always excellent. He’s got that unique ability to be an amazing clinician and a real, quite an academic as well. So, um, Lauren is a great guy and somebody to be able to listen to.

All right. Thanks. You guys very much. Appreciate it. Yeah. Thank you.