Articles & Resources

Please check this page periodically for articles of interest from Dr. Harary, M.D., CAQSM.

Shin Splints, Mark J. Harary, MD CAQSM

What are shin splints?

Shin splints, or medial tibial stress syndrome, is one of the most common and problematic running injuries. It is an overuse injury, which means that it develops gradually over time rather than because of one single event. Shin splints are characterized as exercise-induced pain in the medial part of the lower third of the tibia (the larger of the two shin bones). The muscles attaching to the tibia pull in a way that causes swelling of the muscle and the outer layer of the bone. Most people describe a burning pain on the inner part of the shin that radiates towards the foot.

What causes shin splints?

There are many different factors that can lead to shin splints occurring. We can divide these factors into intrinsic and extrinsic factors. Intrinsic factors are related to the person and their running mechanics. These can include low arches, high arches, being knock-kneed or bow-legged, or a history of injury to the lower leg, hip, or back. Extrinsic factors are those that occur outside the body. These include hard or uneven running surfaces, incorrect shoe wear, not changing shoes often enough, and increasing the frequency or intensity of a training regimen too quickly, not giving your body a chance to adjust to the new level.

How is it diagnosed?

If you are experiencing pain while running, you should avoid the aggravating activity and schedule an appointment with a sports medicine doctor. They will take a detailed history and do a thorough physical exam to make an accurate diagnosis. X-rays will not show shin splints but may be ordered to rule out other, more serious injuries, like a stress fracture.

How are shin splints treated?

Treatment of this condition involves two phases: treat the acute pain symptoms and prevent recurrence.

Acute treatment involves RICE (rest, ice, compression elevation:

Rest means relative rest. Activities should be modified so that they don’t cause pain. This can include lower-impact activities such as bike riding or swimming or simply cutting back on the amount or intensity of running.

Ice packs 15-20 minutes on and off a few times after activity can be helpful, as can ice massage to the painful area.

Compressive calf sleeves can help to alleviate pain while walking or exercising.

Elevate the leg while icing after activity.

Tylenol or Motrin are medications that can be taken as needed for pain.

The key to preventing recurring shin splints is to determine the underlying cause. Intrinsic factors such as arch problems or injuries are typically treated with orthotics and physical therapy, respectively. For serious runners, a running coach can help improve your mechanics to prevent a recurrence. Extrinsic factors need to be addressed as well.

What else could it be?

Pain that does not go away with rest or pain that occurs at night might be a stress fracture. If your pain is in a different part of the leg, than it could be a muscle strain or chronic compartment syndrome.

Your sports medicine doctor will be able to accurately diagnose the problem and get you back to running as quickly as possible.

Concussion Baseline Testing, Mark J. Harary, MD CAQSM

Baseline testing has become an important tool in the management of concussions. Many school districts and sports leagues conduct baseline testing on their athletes. Despite that, there can be a lot of confusion as to what exactly “baseline testing” is and how it can be helpful. A baseline test tries to measure how people perform on certain tasks under normal circumstances. This can then be compared to performance after an injury to see where deficiencies are and to help guide treatment plans.

What makes a good baseline test?

A good baseline test is one that can be administered to large groups of people within a short amount of time and produces valid, reliable, and repeatable results. Several companies have created baseline tests, but the most popular one is the Impact test. Impact is a computer-based test that is typically completed in about 20-25 minutes. Test takers complete several cognitive tasks as quickly and accurately as they can. Based on performance on these tasks, an athlete’s baseline score is determined. After a head injury, this test is repeated to see how post-injury performance compares to the pre-injury baseline.

Who should have a baseline test?

Anyone who participates in a sport with a high risk of concussion should have a baseline test. However, this is not always a possibility. Some tests cannot be performed on certain populations. For example, the Impact test is validated for use between the ages of 11 and 60. Outside of that range, we can’t be sure that the test results accurately measure the test taker’s cognitive abilities. Also, people with learning disabilities or vision problems would possibly have a difficult time taking this type of test even when performing at their best. It is important to get a good night’s sleep prior to taking a baseline test because this can affect performance. It should not be done immediately after practice, games, or during any other potentially stressful or distracting situations.

How is baseline testing used?

While a baseline test is done prior to an injury, the same test is performed after a concussion to look at post-injury performance. We then look at the differences between the two tests. Decreased performance on memory sections of the test may indicate that the athlete needs schoolwork or testing limitations. If reaction time is slowed, that indicates that the athlete should avoid contact sports and possibly driving as well. As healing of the injury occurs, testing can be repeated to ensure a return to baseline performance.

What are the limitations?

Baseline testing has limitations. Impact testing, as mentioned earlier, is not a reliable test for kids younger than 11 years old. Because it is often done in groups, there is the potential for distractions affecting performance. Finally, in rare instances, athletes may try to intentionally do poorly on the test in hopes of getting back on the field sooner.

In conclusion, baseline testing can be a very useful tool in concussion management when applied to the right situation.

Biologic treatments of Elbow Injuries, Mark J. Harary, MD CAQSM

With spring sports season upon us and the weather getting nicer, it’s time to get back outside after winter hibernation. Spring sports bring different types of injuries than we see with football, soccer, and basketball. One of those is elbow injuries, and these can be devastating for those athletes that sustain them. In this article, we will focus on UCL injuries and talk about an innovative way to treat them that can get athletes back on the field quickly and without surgery.

The UCL, or ulnar collateral ligament, of the elbow, is a ligament complex on the medial (inner) side of the elbow. Its goal is to limit valgus stress on the elbow joint. A ligament is a tissue that connects two bones together. The UCL connects the lower medial parts of the humerus and the ulna. An overhead throwing motion creates a tremendous amount of stress on this ligament. Over time, it can weaken and eventually lead to it tearing. The harder someone throws, and the more often they throw, the more stress and damage can happen to the UCL. Most people do not feel pain until there has already been significant damage to the ligament. At that point, it is usually too late for the ligament to heal itself. Continuing to throw, despite pain and injury, can lead to the ligament rupturing and needing what is known as Tommy John surgery. This surgery involves reconstructing a new ligament to make the elbow stable again. Once the ligament completely ruptures, surgery is the only option. But if it can be detected before that happens, then this can be avoided.

If the ligament is only partially torn, it can potentially be healed with an injection of PRP, or platelet rich plasma. This procedure takes healing factors found in your own blood and brings them to an area that can’t heal well on its own. See, when a ligament tears, it doesn’t heal with normal tissue. It heals less flexible scar tissue and more susceptible to further injury. This happens because of the poor blood supply to the ligament, which doesn’t allow those healing factors to reach the injured area. During a PRP procedure, a patient’s own blood gets drawn. That blood gets spun in a centrifuge for about 15 minutes to separate the different parts of the blood and create the PRP. The PRP then gets injected, under ultrasound guidance, into the injured ligament to stimulate healing. The platelets clump onto the injured area just like when you get a scab on your knee. They then release the growth factors that promote healing of the tissue.

So this sounds great! But does it work? A study done of 34 athletes with partial tears of their UCL showed that 88% of them returned to their previous level of activity without complaints after PRP injection. All of these patients had failed at least 2 months of physical therapy and rest. The average return to play was 12 weeks. Compare that to a return to play after Tommy John surgery or at least 12-18 months. If we can catch these ligament injuries in time, PRP has the potential to get athletes back on the field months quicker and avoid a career-changing surgery as well.