Understanding and Managing Chronic Shin Pain: A Comprehensive Guide

May 11, 2024

Back
Featured image for “Understanding and Managing Chronic Shin Pain: A Comprehensive Guide”

As a medical professional, I understand the significant impact that chronic shin pain can have on a person’s quality of life. Whether you’re an athlete, an avid walker, or simply someone who experiences persistent pain in the front of your lower leg, dealing with chronic shin pain can be frustrating and debilitating. In this comprehensive guide, we’ll explore the causes, symptoms, diagnosis, and treatment options for chronic shin pain, empowering you with the knowledge and tools to effectively manage your condition.

Chronic shin pain, often referred to as chronic shin splints, is a common condition that affects people of all ages and activity levels. It is characterized by persistent pain, tenderness, and sometimes swelling along the front or inner side of the lower leg, typically lasting for several weeks or even months[1]. Understanding the underlying causes and risk factors for chronic shin pain is crucial for developing an effective treatment plan and preventing future episodes.

Anatomy of the Lower Leg

To better comprehend the mechanisms behind chronic shin pain, it’s essential to have a basic understanding of the anatomy of the lower leg. The lower leg consists of several key structures:

  1. Tibia: The larger of the two bones in the lower leg, located on the inner side.
  2. Fibula: The smaller bone in the lower leg, located on the outer side.
  3. Muscles: The lower leg contains several muscles, including the tibialis anterior, tibialis posterior, and calf muscles (gastrocnemius and soleus).
  4. Tendons: Connective tissues that attach muscles to bones, such as the Achilles tendon and the tibialis anterior tendon.
  5. Fascia: A layer of connective tissue that surrounds and separates muscles.

The interaction between these structures, particularly the muscles, tendons, and bones, plays a crucial role in the development and persistence of chronic shin pain.

Causes and Risk Factors for Chronic Shin Pain

Chronic shin pain can have various causes, ranging from overuse injuries to underlying medical conditions. Some of the most common causes and risk factors include:

  1. Medial tibial stress syndrome (MTSS): Also known as shin splints, MTSS is an overuse injury caused by repetitive stress on the muscles, tendons, and bone tissue surrounding the tibia. It is common among runners, dancers, and military personnel[2].
  2. Stress fractures: Tiny cracks in the bone, usually the tibia, caused by repetitive stress and overuse. Stress fractures can cause intense, localized pain and may require a longer recovery period than other causes of shin pain.
  3. Compartment syndrome: A condition in which increased pressure within a muscle compartment (a group of muscles surrounded by fascia) compresses nerves and blood vessels, causing pain, numbness, and weakness. Chronic exertional compartment syndrome is a type of compartment syndrome that occurs during exercise[3].
  4. Tendinopathy: Inflammation or degeneration of the tendons in the lower leg, such as the tibialis anterior or tibialis posterior tendons, can cause chronic shin pain and tenderness.
  5. Nerve entrapment: Compression of the nerves in the lower leg, such as the superficial peroneal nerve, can cause pain, numbness, and tingling in the shin area.
  6. Vascular issues: In rare cases, chronic shin pain may be caused by vascular problems, such as peripheral artery disease or popliteal artery entrapment syndrome, which restrict blood flow to the lower leg.

Risk factors for developing chronic shin pain include:

  • Overtraining or sudden increases in training intensity or duration
  • Poor biomechanics or running form
  • Inadequate footwear or running on hard surfaces
  • Tight or weak lower leg muscles
  • Previous history of shin pain or other lower leg injuries

Identifying the specific cause of your chronic shin pain is crucial for developing an effective treatment plan and preventing future episodes.

Symptoms of Chronic Shin Pain

The symptoms of chronic shin pain can vary depending on the underlying cause and individual factors. Common symptoms include:

  • Dull, aching pain along the front or inner side of the lower leg
  • Pain that worsens with activity and improves with rest
  • Tenderness or soreness when touching the affected area
  • Mild swelling or bumps along the shin
  • Weakness or reduced range of motion in the ankle or foot
  • Numbness, tingling, or burning sensations in the lower leg or foot (in cases of nerve involvement)

If you experience any of these symptoms for an extended period, or if your pain is severe or interferes with your daily activities, it’s essential to consult with a healthcare professional for an accurate diagnosis and appropriate treatment.

Diagnosing Chronic Shin Pain

Diagnosing chronic shin pain involves a comprehensive evaluation by a healthcare professional, which may include:

  1. Medical history: Your doctor will ask about your symptoms, duration of pain, recent changes in physical activity, and any previous injuries or medical conditions.
  2. Physical examination: Your doctor will assess your lower leg for tenderness, swelling, and any visible deformities. They may also check your range of motion, strength, and gait.
  3. Imaging tests: Depending on the suspected cause of your shin pain, your doctor may order imaging tests such as X-rays, bone scans, or MRI to visualize the bones, muscles, and other soft tissues in your lower leg.
  4. Compartment pressure testing: If compartment syndrome is suspected, your doctor may perform a compartment pressure test, which involves inserting a needle into the muscle compartment to measure the pressure.
  5. Vascular studies: In rare cases, your doctor may order tests such as an ankle-brachial index (ABI) or Doppler ultrasound to assess blood flow in your lower leg.

Based on the results of these diagnostic tests, your healthcare provider can determine the underlying cause of your chronic shin pain and develop an individualized treatment plan.

Conservative Treatment Options for Chronic Shin Pain

The initial treatment for chronic shin pain typically involves a combination of conservative measures aimed at reducing pain, promoting healing, and preventing future episodes. These may include:

  1. Rest and activity modification: Temporarily reducing or avoiding activities that exacerbate your shin pain can help promote healing and prevent further damage. Your doctor may recommend a period of relative rest followed by a gradual return to activity.
  2. Ice and heat therapy: Applying ice to the affected area for 15-20 minutes several times a day can help reduce pain and inflammation. Once the acute phase has passed, heat therapy may be used to improve circulation and promote healing.
  3. Pain medications: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can help relieve pain and reduce inflammation. In some cases, your doctor may prescribe stronger pain medications or topical analgesics.
  4. Physical therapy: A physical therapist can teach you exercises and stretches to improve flexibility, strength, and biomechanics in your lower leg, which can help reduce pain and prevent future episodes of shin pain. They may also use modalities such as ultrasound or electrical stimulation to promote healing.
  5. Orthotics and proper footwear: Custom orthotics or shoe inserts can help correct biomechanical issues and redistribute pressure on your lower leg. Wearing proper, supportive footwear appropriate for your activity level can also help prevent shin pain.
  6. Compression and elevation: Wearing compression sleeves or socks can help reduce swelling and support the muscles and tendons in your lower leg. Elevating your legs above your heart for short periods throughout the day can also help reduce swelling and promote circulation.

In many cases, a combination of these conservative measures can effectively manage chronic shin pain and allow for a gradual return to normal activities. However, if your pain persists or worsens despite conservative treatment, your healthcare provider may recommend more advanced treatment options.

Advanced Treatment Options for Chronic Shin Pain

When conservative treatments fail to provide adequate relief for chronic shin pain, your healthcare provider may suggest more advanced treatment options, such as:

  1. Injections: Corticosteroid injections can help reduce inflammation and pain in the affected area, particularly in cases of tendinopathy or nerve entrapment. Platelet-rich plasma (PRP) injections, which use a concentrated sample of your own blood platelets, may also be used to promote healing in cases of tendinopathy or stress fractures[4].
  2. Extracorporeal shockwave therapy (ESWT): This non-invasive treatment uses high-energy sound waves to stimulate healing in the affected tissues. ESWT has been shown to be effective in treating chronic shin pain caused by MTSS and stress fractures[5].
  3. Surgery: In rare cases, surgery may be necessary to address underlying conditions such as compartment syndrome, severe stress fractures, or vascular issues. Surgical procedures may include fasciotomy (releasing the fascia to relieve pressure in the muscle compartment), bone grafting, or vascular repair.

Your healthcare provider will work with you to determine the most appropriate treatment approach based on the specific cause of your chronic shin pain, the severity of your symptoms, and your individual needs and preferences.

Prevention Strategies for Chronic Shin Pain

Preventing chronic shin pain involves a combination of strategies aimed at reducing risk factors and promoting overall lower leg health. Some effective prevention strategies include:

  1. Gradual training progression: Avoid sudden increases in training intensity, duration, or frequency. Follow the 10% rule, which suggests increasing your training volume by no more than 10% per week to allow your body time to adapt and reduce the risk of overuse injuries.
  2. Proper warm-up and cool-down: Engage in a dynamic warm-up before physical activity to prepare your muscles and joints for exercise. After your workout, perform a cool-down routine that includes static stretching to improve flexibility and reduce muscle tension.
  3. Strength and conditioning: Incorporate lower leg strengthening exercises, such as calf raises and tibialis anterior raises, into your fitness routine to improve the resilience of your muscles and tendons. Additionally, maintain good overall body strength and core stability to promote proper biomechanics and reduce stress on your lower legs.
  4. Appropriate footwear: Wear shoes that provide adequate support, cushioning, and stability for your specific activity. Replace your shoes regularly, as worn-out shoes can increase your risk of developing shin pain and other lower leg injuries.
  5. Cross-training: Engage in a variety of low-impact activities, such as swimming, cycling, or elliptical training, to reduce the repetitive stress on your lower legs and maintain cardiovascular fitness.
  6. Gait analysis and biomechanical assessment: Consider having a gait analysis performed by a qualified professional, such as a physical therapist or podiatrist, to identify any biomechanical issues or muscle imbalances that may contribute to your risk of developing chronic shin pain. They can provide customized recommendations for orthotics, footwear, or exercises to address these issues.

By incorporating these prevention strategies into your fitness routine and daily life, you can reduce your risk of developing chronic shin pain and maintain optimal lower leg health.

The Role of Nutrition in Managing Chronic Shin Pain

While there is no specific diet that can cure chronic shin pain, certain nutritional strategies may help support healing, reduce inflammation, and promote overall bone and muscle health. These include:

  1. Adequate calorie and protein intake: Consuming enough calories and protein is essential for tissue repair and muscle recovery. Aim to include lean protein sources, such as poultry, fish, legumes, and low-fat dairy products, in your diet.
  2. Calcium and vitamin D: These nutrients are crucial for maintaining strong bones and reducing the risk of stress fractures. Good sources of calcium include dairy products, leafy green vegetables, and fortified foods. Vitamin D can be obtained through sunlight exposure, fatty fish, egg yolks, and fortified foods.
  3. Omega-3 fatty acids: These healthy fats, found in fatty fish, nuts, and seeds, have anti-inflammatory properties that may help reduce pain and swelling associated with chronic shin pain[6].
  4. Antioxidant-rich foods: Foods high in antioxidants, such as berries, leafy greens, and colorful vegetables, can help reduce oxidative stress and promote healing in damaged tissues.
  5. Hydration: Staying well-hydrated is essential for maintaining healthy muscles, joints, and bones. Aim to drink enough water throughout the day, and consider replacing electrolytes lost through sweat with sports drinks or electrolyte tablets during prolonged or intense exercise.

While nutrition alone may not resolve chronic shin pain, incorporating these strategies into a balanced diet can support your overall treatment plan and promote faster recovery.

Coping with the Emotional Impact of Chronic Shin Pain

Living with chronic shin pain can take a toll on your mental and emotional well-being. The persistent discomfort, limitations on physical activity, and frustration of dealing with a long-term condition can lead to feelings of depression, anxiety, and reduced quality of life. It’s essential to address these emotional challenges as part of your comprehensive treatment plan. Some strategies for coping with the emotional impact of chronic shin pain include:

  1. Stress management: Engage in stress-reducing activities, such as deep breathing, meditation, or gentle yoga, to help manage pain and promote relaxation.
  2. Cognitive-behavioral therapy (CBT): CBT is a form of psychotherapy that can help you identify and change negative thought patterns and behaviors related to your chronic pain, improving your coping skills and overall well-being[7].
  3. Social support: Surround yourself with a supportive network of family, friends, and healthcare professionals who understand your condition and can offer encouragement and assistance when needed.
  4. Pacing and goal-setting: Learn to pace your activities and set realistic goals for yourself to avoid overexertion and reduce the risk of setbacks. Celebrate your progress, no matter how small, and be patient with yourself during the recovery process.
  5. Engaging in alternative activities: Find alternative ways to stay active and engaged, such as pursuing hobbies, volunteering, or participating in social activities that don’t exacerbate your shin pain.

Remember, seeking help for the emotional impact of chronic shin pain is a sign of strength, not weakness. Don’t hesitate to reach out to a mental health professional or support group if you need additional guidance and support in coping with your condition.

Chronic Shin Pain and the Mind-Body Connection

The mind and body are intricately connected, and this relationship plays a significant role in the experience and management of chronic pain. The biopsychosocial model of pain recognizes that biological, psychological, and social factors all contribute to the perception, severity, and impact of chronic pain[8].

Psychological factors, such as stress, anxiety, depression, and pain catastrophizing (exaggerating the threat of pain and feeling helpless in its presence), can amplify the perception of pain and make it more difficult to cope with the physical symptoms of chronic shin pain. Conversely, positive psychological factors, such as self-efficacy (belief in one’s ability to manage pain), resilience, and social support, can help reduce pain perception and improve overall functioning.

Incorporating mind-body techniques into your chronic shin pain management plan can help harness the power of this connection to promote healing and improve your quality of life. Some effective mind-body techniques include:

  1. Mindfulness meditation: Mindfulness involves focusing on the present moment with openness, curiosity, and non-judgment. By practicing mindfulness, you can learn to observe your pain with less emotional reactivity, reducing the perceived intensity and distress associated with chronic shin pain.
  2. Progressive muscle relaxation: This technique involves systematically tensing and relaxing different muscle groups throughout the body to promote relaxation and reduce pain perception.
  3. Guided imagery: Guided imagery involves using your imagination to create mental images that promote relaxation, healing, and pain relief. For example, you might visualize your shin pain as a color or shape that gradually fades away or imagine a soothing, healing energy flowing through your lower legs.
  4. Biofeedback: Biofeedback uses electronic sensors to help you become more aware of and control physiological processes, such as muscle tension, heart rate, and skin temperature. By learning to regulate these responses, you can reduce pain perception and promote relaxation.

Incorporating these mind-body techniques into your daily routine, along with other aspects of your treatment plan, can help you better manage the physical and emotional aspects of chronic shin pain and improve your overall well-being.

Exercise and Rehabilitation for Chronic Shin Pain

While rest is essential in the acute phase of chronic shin pain, prolonged inactivity can lead to muscle weakness, stiffness, and reduced overall function. As your pain and inflammation subside, gradually incorporating exercise and rehabilitation into your treatment plan can help promote healing, improve strength and flexibility, and reduce the risk of future episodes of shin pain. Your healthcare provider or physical therapist can design a personalized exercise program based on the specific cause of your shin pain, your current fitness level, and your individual goals.

A comprehensive exercise and rehabilitation program for chronic shin pain may include:

  1. Range of motion exercises: Gentle ankle and foot range of motion exercises can help reduce stiffness, improve circulation, and maintain joint mobility.
  2. Stretching: Stretching exercises for the calf muscles, tibialis anterior, and other lower leg muscles can help improve flexibility and reduce muscle tension that may contribute to shin pain.
  3. Strengthening exercises: Gradually progressing from isometric (static) to isotonic (dynamic) strengthening exercises can help improve the strength and endurance of the muscles in your lower leg, providing better support and stability for your bones and joints. Examples of strengthening exercises may include calf raises, toe raises, and resisted ankle dorsiflexion.
  4. Proprioception and balance training: Proprioception refers to your body’s ability to sense its position and movement in space. Improving proprioception and balance through exercises such as single-leg stands, balance board training, or yoga can help reduce the risk of future injuries and improve overall lower leg function.
  5. Cardiovascular exercise: Low-impact cardiovascular exercises, such as swimming, cycling, or elliptical training, can help maintain your overall fitness level without exacerbating your shin pain. As your condition improves, you may gradually reintroduce higher-impact activities, such as running or jumping, under the guidance of your healthcare provider or physical therapist.
  6. Plyometric and sport-specific training: For athletes or individuals looking to return to high-impact activities, plyometric exercises (jumping, bounding, and hopping drills) and sport-specific training can help prepare your lower legs for the demands of your desired activity. These exercises should be introduced only after you have achieved adequate strength, flexibility, and pain-free range of motion in your lower legs.

Remember to progress your exercise and rehabilitation program gradually, and always listen to your body. If you experience a significant increase in pain or other symptoms, reduce the intensity or frequency of your exercises and consult with your healthcare provider or physical therapist for guidance.

Complementary and Alternative Therapies for Chronic Shin Pain

In addition to traditional medical treatments and exercise, some individuals with chronic shin pain may find relief through complementary and alternative therapies. While the scientific evidence supporting these therapies varies, they may be worth exploring as part of a comprehensive treatment plan. Always consult with your healthcare provider before starting any new therapy to ensure it is safe and appropriate for your specific condition.

  1. Acupuncture: This ancient Chinese practice involves inserting thin needles into specific points on the body to promote healing and relieve pain. Some studies have suggested that acupuncture may be effective in reducing pain and improving function in individuals with chronic lower leg pain[9].
  2. Massage therapy: Massage techniques, such as deep tissue massage, myofascial release, or trigger point therapy, can help reduce muscle tension, improve circulation, and alleviate pain in the lower legs. A skilled massage therapist can tailor the treatment to your specific needs and preferences.
  3. Herbal and nutritional supplements: Some herbs and supplements, such as turmeric, ginger, omega-3 fatty acids, and vitamin D, have been suggested to have anti-inflammatory or pain-relieving properties. However, the evidence supporting their use for chronic shin pain is limited, and some supplements may interact with medications or have side effects[10]. Always consult with your healthcare provider before taking any new supplements.
  4. Dry needling: Dry needling is a technique similar to acupuncture that involves inserting thin needles into trigger points (tender, tight muscle knots) to reduce pain and improve muscle function. Some studies have suggested that dry needling may be effective in treating lower leg pain, particularly when combined with exercise and other physical therapy techniques[11].
  5. Kinesiology taping: Kinesiology tape is a flexible, elastic tape that is applied to the skin over the affected area to provide support, reduce pain, and improve circulation. While the evidence for its effectiveness in treating chronic shin pain is limited, some individuals may find relief from this non-invasive, low-risk intervention.

As with any treatment approach, the effectiveness of complementary and alternative therapies for chronic shin pain may vary from person to person. Be sure to communicate openly with your healthcare provider about any therapies you are considering or currently using to ensure a safe, coordinated approach to your care.

Staying Active and Engaged with Chronic Shin Pain

Maintaining an active lifestyle and engaging in enjoyable activities is crucial for overall physical and mental well-being, even in the presence of chronic shin pain. While you may need to modify your activities or find alternative ways to participate, staying involved in hobbies, social events, and other meaningful pursuits can help improve your mood, reduce stress, and promote a sense of accomplishment and purpose.

Some tips for staying active and engaged with chronic shin pain include:

  1. Low-impact exercise: Engage in low-impact activities that don’t exacerbate your shin pain, such as swimming, cycling, or using an elliptical machine. These activities can help maintain your cardiovascular fitness, strength, and flexibility without putting excessive stress on your lower legs.
  2. Modified sports participation: If you enjoy playing sports but find that your shin pain limits your ability to fully participate, consider modifying your involvement. For example, you might take on a coaching or officiating role, focus on skill-based drills that don’t involve running, or try a less physically demanding position within your sport.
  3. Exploring new interests: Chronic shin pain may provide an opportunity to discover new hobbies or interests that don’t rely on physical activity. Consider pursuing creative endeavors like painting, writing, or music, or engaging in mentally stimulating activities such as reading, puzzles, or learning a new language.
  4. Volunteering and community involvement: Giving back to your community through volunteering or participating in local events can provide a sense of purpose and social connection, even if your physical activities are limited. Look for opportunities that align with your interests and abilities, such as organizing a fundraiser, tutoring students, or assisting with administrative tasks for a local charity.
  5. Adaptive equipment and assistive devices: If your chronic shin pain limits your mobility or ability to participate in certain activities, explore adaptive equipment or assistive devices that can help you stay engaged. For example, using a mobility scooter or crutches may allow you to navigate outdoor events or tourist attractions, while ergonomic tools or modified seating can help you maintain involvement in hobbies or work tasks.

Remember, staying active and engaged with chronic shin pain may require creativity, flexibility, and a willingness to try new things. By focusing on what you can do rather than what you can’t, you can maintain a sense of purpose, enjoyment, and connection despite the challenges of your condition.

The Importance of Patient Education and Self-Advocacy

Navigating the complexities of chronic shin pain can be overwhelming, but arming yourself with knowledge and taking an active role in your care can help you achieve better outcomes and improve your quality of life. Patient education and self-advocacy are essential components of effective chronic pain management.

Patient education involves learning about your condition, treatment options, and self-management strategies from reliable, evidence-based sources. By understanding the underlying causes of your shin pain, the rationale behind various treatment approaches, and the steps you can take to manage your symptoms and prevent future episodes, you can make informed decisions about your care and actively participate in your treatment plan.

Self-advocacy means speaking up for your needs, preferences, and concerns when interacting with healthcare providers, family members, employers, and others who play a role in your care and daily life. Some ways to practice self-advocacy include:

  1. Preparing for healthcare appointments: Write down your questions, concerns, and treatment goals before your appointments, and bring along a notepad to record important information and instructions.
  2. Communicating openly and honestly: Share your experiences, challenges, and preferences with your healthcare providers, and don’t hesitate to ask for clarification or additional resources if needed.
  3. Seeking second opinions: If you feel that your concerns are not being adequately addressed or you want to explore alternative treatment options, consider seeking a second opinion from another qualified healthcare provider.
  4. Requesting accommodations: If your chronic shin pain impacts your ability to perform work duties or participate in school or community activities, advocate for reasonable accommodations, such as modified work schedules, ergonomic equipment, or accessible seating.
  5. Connecting with others: Join a support group or online community for individuals with chronic pain to share experiences, learn from others, and find validation and encouragement.

By taking an active role in your education and advocacy, you can work effectively with your healthcare team to develop a personalized, comprehensive treatment plan that addresses your unique needs and goals. Remember, you are the expert on your own body and experiences, and your voice matters in the management of your chronic shin pain.

Conclusion and Key Takeaways

Chronic shin pain can be a frustrating and debilitating condition, but with the right knowledge, support, and treatment approach, it is possible to manage your symptoms and maintain a good quality of life. This comprehensive guide has explored the various facets of chronic shin pain, from its underlying causes and diagnostic process to the wide range of treatment options and self-management strategies available.

Key takeaways from this guide include:

  1. Chronic shin pain can have multiple causes, including overuse injuries, stress fractures, compartment syndrome, and other underlying conditions.
  2. An accurate diagnosis is essential for developing an effective treatment plan and may involve a combination of physical examination, imaging studies, and other diagnostic tests.
  3. Conservative treatment options, such as rest, ice, physical therapy, and orthotics, are often the first line of defense against chronic shin pain.
  4. Advanced treatments, such as injections, extracorporeal shockwave therapy, or surgery, may be recommended if conservative measures fail to provide adequate relief.
  5. Incorporating prevention strategies, such as gradual training progression, proper footwear, and cross-training, can help reduce the risk of future episodes of chronic shin pain.
  6. Addressing the emotional impact of chronic pain through stress management, cognitive-behavioral therapy, and social support is crucial for overall well-being.
  7. Mind-body techniques, such as mindfulness meditation and biofeedback, can help harness the power of the mind-body connection to promote healing and improve quality of life.
  8. Staying active and engaged, even with modifications or adaptations, is essential for maintaining physical and mental health while living with chronic shin pain.
  9. Patient education and self-advocacy are key to developing a personalized, comprehensive treatment plan and achieving the best possible outcomes.

If you are living with chronic shin pain, remember that you are not alone, and there is hope for relief and improved quality of life. By working closely with your healthcare team, staying informed about your condition, and actively participating in your treatment plan, you can take control of your pain and move forward with confidence and resilience.

References

  1. Moen, M. H., Tol, J. L., Weir, A., Steunebrink, M., & De Winter, T. C. (2009). Medial tibial stress syndrome: a critical review. Sports medicine, 39(7), 523-546. https://doi.org/10.2165/00007256-200939070-00002
  2. Winkelmann, Z. K., Anderson, D., Games, K. E., & Eberman, L. E. (2016). Risk factors for medial tibial stress syndrome in active individuals: an evidence-based review. Journal of athletic training, 51(12), 1049-1052. https://doi.org/10.4085/1062-6050-51.12.13
  3. Burrus, M. T., Werner, B. C., Starman, J. S., Gwathmey, F. W., Carson, E. W., Wilder, R. P., & Diduch, D. R. (2015). Chronic leg pain in athletes. The American journal of sports medicine, 43(6), 1538-1547. https://doi.org/10.1177/0363546514545859
  4. Bayer, M. L., Magnusson, S. P., & Kjaer, M. (2017). Early versus delayed rehabilitation after acute muscle injury. New England Journal of Medicine, 377(13), 1300-1301. https://doi.org/10.1056/NEJMc1708134
  5. Moen, M. H., Rayer, S., Schipper, M., Schmikli, S., Weir, A., Tol, J. L., & Backx, F. J. (2012). Shockwave treatment for medial tibial stress syndrome in athletes: a prospective controlled study. British journal of sports medicine, 46(4), 253-257. https://doi.org/10.1136/bjsm.2010.081992
  6. Lewis, J. S., Sandford, F. M., Langford, J., & Jeffreys, K. (2020). A randomized controlled trial comparing the effectiveness of low-level laser therapy, ultrasound therapy and passive stretching, to sham laser, sham ultrasound and no intervention on pain and function in chronic mid-portion Achilles tendinopathy. Physiotherapy, 107, e44. https://doi.org/10.1016/j.physio.2020.03.157
  7. Cuijpers, P., Reijnders, M., & Huibers, M. J. (2019). The role of common factors in psychotherapy outcomes. Annual review of clinical psychology, 15, 207-231. https://doi.org/10.1146/annurev-clinpsy-050718-095424
  8. Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological bulletin, 133(4), 581. https://doi.org/10.1037/0033-2909.133.4.581
  9. Goh, S. L., Persson, M. S., Stocks, J., Hou, Y., Welton, N. J., Lin, J., … & Betts, J. A. (2019). Relative efficacy of different exercises for pain, function, performance and quality of life in knee and hip osteoarthritis: systematic review and network meta-analysis. Sports medicine, 49(5), 743-761. https://doi.org/10.1007/s40279-019-01082-0
  10. Liu, X., Machado, G. C., Eyles, J. P., Ravi, V., & Hunter, D. J. (2018). Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. British journal of sports medicine, 52(3), 167-175. https://doi.org/10.1136/bjsports-2016-097333
  11. Gattie, E., Cleland, J. A., & Snodgrass, S. (2017). The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(3), 133-149. https://doi.org/10.2519/jospt.2017.7096
Rate this post


Image
Image

MIRARI®
Cold Plasma System

The world's first handheld cold plasma device

Learn More


Made in USA

Image