Riley Smith L.Ac., DACM, C.SMA

Dr. Riley Smith LAc, DACM, C.SMA shares a case study on medial tibial stress syndrome (shin splints) | SPORTSMEDICINEACUPUNCTURE.COMRiley Smith, L.Ac., DACM, C.SMA completed the SMAC Program in July 2021, and is a practicing sports acupuncturist in San Diego, California.

“I can say with confidence that, an acupuncturist living here in San Diego, enhancing my skills in treating musculoskeletal pain and injury is imperative. The year-round outdoor weather results in an endless number of weekend warrior athletes desperate for a new and innovative way to treat both their chronic and acute injuries.

I have always been fascinated by the interplay between Western anatomy and Chinese Medicine. The SMAC program does a fantastic job of respecting both disciplines, while simultaneously making the interplay between the two easy to understand and implement in practice.

Such is the case with my patient, Daniel (not his real name). This patient is a 33 year-old male who is an avid athlete with a history of competitive CrossFit®.  Today, he primarily engages in Olympic weightlifting and running 1-3 miles 2-3 times per week along the harbor in San Diego.

He had stopped running for the past six months when he came to see me for bilateral Medial Tibial Stress Syndrome (AKA “shin splints”). Running is his “mental reset,” so the absence of this therapeutic exercise is having an effect on mood and mental health.

This patient had been to his medical doctor, physical therapist, chiropractor, massage therapist, etc., and was getting very discouraged about the process of trial and error with no alleviation of his shin splints symptoms. Pain is excruciating enough to force him to stop running about 15 minutes into his normal run. Patient also complains of low back pain.

Daniel’s condition is bilateral, which is not as common for “shin splints” making me initially think to begin looking bilaterally at hips, knees and feet thanks to my SMAC training.

Western Assessments:

Palpation:

Tender upon palpation medial border of tibia at conjunction of posterior tibialis.  Mild edema and warm to the touch.

Hips and pelvis:
  • Bilateral anterior tilt
  • Right side ilium elevation
  • Pelvic rotation nominal
  • Lower crossed syndrome
Knees:

Bilateral valgus

Feet:

Bilateral pes planus and foot pronation

Orthopedic Assessments:

  • Positive Helbing sign bilateral
  • Navicular drop 7mm left, 5 mm right
  • Overhead squat anterior view right foot turns out
  • Overhead squat lateral view excessive forward lean and arms fall forward
  • Overhead squat posterior view asymmetrical hip shift to the right

MMT:

  • Bilateral hamstring weakness
  • Gluteus minimus weak on right
  • Tibialis anterior weak bilaterally
  • Soleus bilateral did not induce pain
  • Adductor magnus weak on left

TCM Assessment:

Pulse: wiry
Tongue: thick yellow coat

Complains of GERD, “weak digestion” and irritability

Liver qi stagnation with stomach qi ascending (wood overacting on earth) and weakening spleen causing spleen qi deficiency.

Treatment:

Series of 12 treatments over 3 months. 2 twice per week for 2 weeks, once per week for 4 weeks and every other week after that.  Patient now comes once every 3 weeks for maintenance.

Prone:
  • L4-UB 32
  • Semimembranosus and biceps femoris long head bilaterally
  • Gastrocnemius bilaterally
  • Upper trapezius and Rhomboid Major bilaterally
  • Glute Minimus motor point right
  • Adductor Magnus motor point right
  • Glute Minimus motor point left
  • UB 18 sedate, UB 23 neutral, UB 20 sedate, UB 19 tonify, P 6 neutral
Supine:
  • Bilateral MTSS treatment a shi around spleen 6-8 bilaterally with TDP lamp while needles are in place and/or castor oil pack with hydroculator after withdrawing needles.
  • Bilateral Rectus Femoris, VMO and peroneus longus to complete Hau Tuo Arc
  • Tibialis Anterior (both ST 36 and lanweixue)
  • Pectoralis major bilateral
  • Ren 17 neutral, Ren 8 neutral, Liver 3 neutral
  • Tibialis Posterior

Myofasical:

  • Lengthen Rectus Femoris bilaterally
  • Descend Stomach Qi
  • Spleen JinJing along Tibialis Posterior to reduce adhesions

Corrective Exercise*:

I organized them in a way that eliminates as much up and down off the floor as possible and also hits musculature in a way that makes sense anatomically.  The “*” corrective exercises are “must do” for days in which Daniel might be short on time.  The entire protocol 3-4 days per week in the order below.  Foam roll and stretch everyday.

1.     Foam roll
  • Left side glute min/medius (lacrosse)
  • Right side adductors
  • Bilateral rectus femoris (lacrosse)
  • Bilateral TFL
  • Bilateral Peroneals
  • Bilateral lateral gastric
2.     Corrective Exercise
  • Monster Walks
  • Supine Pelvic Tilts
  • Figure 4 Spinal Rotations
  • Inchworm and Foot Curls
  • Heel-Toe Inversion
  • Heel Raise
3.     Stretch
  • Glute Medius/Minimus Left side only
  • Double Knee to Chest
  • Bird Dog

* This is significantly more corrective exercise than I would normally give a patient, however this recommendation matches patient’s constitution, compliance and desire for improvement and knowledge of exercise science.

Daniel reported less pain upon palpation midway through Week 2 of treatment. I encouraged him to avoid running for 8 weeks while the area had time to heal and postural irregularities could be corrected.

After 6 weeks of steady improvement, I encouraged him to walk 10-20 minutes on a flat surface. He reported no pain.

After 8 weeks, he began running for 5 minute increments until he got up to 20 minutes per session by the end of one week. At that time, it was Week 10 and at the end of Week 12 he reported no pain with his prior running distances of 1-3 miles 2-3 times per week.

Daniel is currently pain-free and has stated to me that this was the type of holistic treatment he had been looking for all along. He could not find anyone who would really take the time and explain what was happening from a physiological and structural issue and then offer a realistic roadmap to recovery.

I am currently working on more follow up with Daniel in order to prevent the reoccurrence of the medial tibial stress syndrome (“shin splints”):

  1. I have referred him to a podiatrist for custom inserts
  2. I have referred him to a running store for new shoes that match his gate
  3. I have referred him to a lifting coach for personalized coaching on his lifting stance and posture to correct deviations found in overhead squat
  4. I am also a functional medicine practitioner and am running a GI MAP stool test to assess for H Pylori, which would account for GERD and ascending stomach qi. Daniel is also taking testosterone supplementation as per an MD. Given his family history of estrogenic cancer, I want to run a DUTCH hormone test to determine whether or not his low serum testosterone level is truly a verified low or mimicking low due to excess estrogen shunting testosterone aromatization to the 4-OH pathway. Unbalanced hormones and/or genetic predispositions to favor one pathway over the other can have an effect on musculoskeletal pain and inflammation, all of which can be resolved though pharmaceutical-grade supplementation and lifestyle modifications.

The confidence I gained with SMAC would have been impossible to find anywhere else. I feel that I can effectively communicate to patients in a way that makes sense to them, can communicate with physicians and also serve as a bridge between patient and physician.”

To connect with Riley, visit his C.SMA Directory Listing.