A 42-year-old male runner came to the Sports Injury Centre; he presented with a one-year history of chronic anterior shin pain when running. He had managed his condition with relative rest and anti-inflammatory cream when acute, and usually returned to running within a few weeks, but was never pain-free. Over the past six weeks his symptoms had deteriorated and he was now unable to run for more than five minutes before he experienced severe discomfort. It did not affect his daily routine.

Biomechanically, he presented with a hind foot varus, and in standing his right-foot arch was flat. When analysing his running style on the treadmill, it was noted that he had no heel strike and landed in mid-stance, heavily pronating and with a delayed push-off. Active foot movements showed reduced dorsiflexion, but passively full range of motion, It was noted that dorsiflexion was initiated by the toe extensors (Extensor Hallucis Longus and Extensor Digitorum Longus) and that Tibialis Anterior was slow to contract. On testing its ability to invert the foot (its other function along with Tibialis Anterior), it was found to be weak, and with the foot flat on the floor the two muscles showed poor control in their ability to increase the medial foot arch. On palpating Tibialis Anterior, there were mild inflammatory signs, local tenderness and also Talo Crural (ankle joint) and Sub Talar joint stiffness. On testing muscle length, only Extensor Hallucis Longus and Extensor Digitorum were right.

The aim was to improve the foot biomechanics, regain control of weak and lengthened Tibialis Anterior and Tibialis Posterior, encourage heel strike, and prevent over-pronation when running.

Treatment consisted of providing him initially with some temporary orthotics, and a series of exercises to strengthen and shorten Tibialis Anterior, using a biofeedback machine. This unit enables the patient to identify the specific muscle to be stimulated and thus actively control the firing of this muscle. Once able to dorsiflex the foot just by using Tibialis Anterior (with the other toe extensors relaxed), the exercises were progressed by using theraband to increase the load and speed, to improve muscle control. This was progressed to weightbearing, with Tibialis Posterior control, to maintain the foot arch and thus avoid pronation on functional exercises such as stepping, lunging and squats. Eccentric calf exercises and stretches for the toe extensors were practised to encourage heel strike. Soft-tissue work and joint mobilisation techniques were also used.

When returned to the treadmill, heel strike was normal and pronation was significantly reduced.

The athlete was then given a home-exercise programme concentrating on the above regime. He was told to avoid hill work, hard surfaces where possible, and to run for only 15 minutes at a time until reviewed.

After two or three more treatments, symptoms had abated; he had started to regain control of Tibialis Anterior and Posterior, was able to maintain good arch control on functional exercises, and maintain heel strike when running. He had gently increased his mileage and began hill work with no adverse effects.

Peter Pope


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