Although often an initial difficult diagnosis, soleus syndrome is a common running injury that if addressed early, can have a quick recovery without significant loss in training. The following clinical presentation helps to illustrate that early intervention and specific therapy can effectively recover this injured tissue and return the athlete to full sport participation. A brief discussion on differential diagnosis and clinical implications will be included.
A 24-year-old fit soccer player presented in the clinic after one week of worsening bilateral medial tibial pain and calf muscle tension. She was unable to identify a clear mechanism of injury although described that training had recently included regular 6km runs prior to practice and that these were now the times of most pain. Historically she did not typically run or train outside of her 4-times/week soccer days. Although pain lingered during the rest of her practice, she participated fully. The following day to a practice she would complain of deep and achy soreness that was initially mild but was now becoming significantly worse. This patient was concerned that she was soon not going to be able to participate further in practice and thus potentially lose her spot on the team.
Specific point tenderness along the superior medial tibial borders and also deep and lateral to the gastocnemius muscle were noted. A functional squat movement could not be achieved without the heels raising. With the patient sitting, and the feet dangling over the edge of the table, dorsiflexion was measured to be 0 degrees bilateral. In the same position, resisted soleus contraction was painful. Although slightly “stiff feeling”, dorsiflexion was measured at 6 degrees with the knee extended and with no pain upon resisted plantar flexion. Examination included a gait analysis both walking and running which showed a noticeable shortened stride length when running.
Differential testing was also performed to test for possible compartment syndrome, stress fractures, neurological causes, or vascular blockage. These special tests (Hertling & Kessler, 1996) included functional tests (hops and jumps) to test for stress fractures as well as tapping percussion along the tibia , Homan’s sign to test for vascular insufficiencies, neural tension test (Slump test), examination of the feet weight bearing and non-weight bearing, and full palpation of the gastrocnemius, soleus, anterior compartment, posterior knee, and tibiofibular joint.
It was my clinical impression after examination that due to her running history and her palpable hypertoned soleus muscle combined with deficient dorsiflexion, that she was suffering from a form of shin splints known as soleus syndrome. I also felt that periostitis or fasciitis was suspect due to point tenderness at the soleus origins, although likely moderate to mild for lacking significant signs of inflammation. Her running history indicates that she began with too much distance too soon. Although she can fully participate with the sprinting aspects of her sport (gastrocnemius), she did not progressively condition to perform 6km slow jogs (soleus).
Treatment consisted of two 30-minute massage treatments per week for the course of four weeks. Techniques included PNF stretching of the soleus, muscle-belly stripping and release to the soleus and lower leg compensating tissue, cross-fibre frictions to myofascial adhesions between soleus and gastrocnemius, passive Achilles tendon stretching, and myofascial trigger point release of the gastrocnemius and soleus muscles.
The patient was advised to initially stop running prior to practice and instead walk and focus on prescribed stretches for soleus, gastrocnemius, hamstrings, gluteals, and the peroneus muscle group. She was allowed to otherwise participate fully in practices as long as nothing else provoked pain. Immediately after practices and on days-off she was to again focus on sustained stretching, ice therapy, and rest (R.I.C.E). The patient was educated on mechanism and nature of injury, the significance of training through pain, stretching theories, and how to control inflammation.
Running was modified and progressed as follows: During the second week of therapy she began three 30-minute shallow water pool runs in which she began at 20% weight bearing (chest deep) and progressed to 50% weight bearing (waist deep) by the third week. Pool running was performed in a backward direction and in shallow water so as to gently maintain and promote dorsiflexion and flexibility. During the fourth week of therapy she performed three runs of 3, 4, and 5km.
Upon completion of treatment, pain had gradually and steadily resolved and she was able to return to full sport participation. She was to continue her stretches on a regular basis, especially before and after training and game days.
It is important to understand that “shin splints” is a catch phrase for anterior medial tibial pain that may arise from a number of causes. With an athlete, some of the most common causes for this pain are anterior compartment syndrome, tibial stress fractures, and soleus syndrome (Brunker, 2001). Often diagnosing may include bone scans and x-rays. Differential diagnosing is key before progressing with a well thought-out therapy program.
In regards to soleus syndrome, patient history often reveals running at a slower pace (jog) but to a distance that is much greater than what they are accustom. With repeating this activity, the soleus muscle becomes hypertonic and will begin to inflame the periostium in extreme cases. Grays Anatomy confirms that the soleus muscle origin attaches along the superior posterior tibia as well as the superior posterior fibula including the posterior fibular head. These are often sites of elevated pain upon palpation. Based upon this anatomy, the bent-knee soleus stretch becomes very effective in restoring flexibility (Brunker, 2001). Reduced dorsiflexion with a bent knee and resistive muscle testing are two of the greatest indicators for soleus syndrome (Reid, 1992). Gait analysis and posture exams are also useful tools in understanding possible biomechanical stresses. For example, subtalar pronation may overload the soleus and gastocnemius muscles as they supinate and plantarflex the foot for propulsion (Hertling & Kessler, 1996).
This case study helps massage therapists recognise that proper assessment and differential diagnosing is often a critical step before proceeding in actual treatment. Notably the above case study underscores the essential role of the soleus muscle as related to anterior medial tibial pain. With more awareness of anatomy and biomechanics, perhaps therapists will be able to more accurately assess and differentiate between the multifactorial nature of this running dysfunction.
Brunker, Peter 2001 Clinical Sports Medicine. Second Ed, McGraw-Hall Austrailia Pty Ltd, Roseville Austrailia.
Gray’s Anatomy, Thirty-fifth Ed, Longman Group Ltd. 1973.
Hertling & Kessler 1996 Management of Common Muskuloskeletal Disorders. Third Ed, Lippincott-Raven Publishers, Pennsylvania USA.
Reid, David 1992 Sports Injury Assessment and Rehabilitation. Churchill Livingstone Inc., New York USA.