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27/10/2014

Shin splints, taking out the tension | noijam

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Shin splints, taking out the tension


By NOI Group (http://noijam.com/author/noinotes/), October 22, 2014

(https://noijamdotcom. les.wordpress.com/2014/10/ nal_oct_2014.jpg)

Shin splints are a real problem out there common, painful, activity limiting and often treatment resistant. A bit
of research on shin splints (or the more recent, awkward, and I am not sure helpful term, medial tibial stress
syndrome) in the medical databases, wont provide much clarity in aetiology or agreement in treatment and you
will nd there are probably many different kinds of shin splints. If you Google shin splints, in-line with the
growing trend, youll get lots of diagrams with multiple strips of brightly coloured tape applied in complex patterns.
Sometimes you need to be aware of the science, and move on. Move on to what you see in front of you clinical
scientists are often years in front of desk scientists.
Here is a clinical pattern I have seen many times over the last 30 years.
The history
I recently caught up with an old friend while teaching a course in Brisbane, Australia. She is a keen golfer, mid 40s,
and had a left tibial fracture 3 years ago it healed well and she was back to good quality golf within months. Six
months ago she began to experience medial tibial pain radiating to the posterior medial malleolus in her left leg
during and after golf. She had a medical check up there was nothing sinister and no complications from the
fracture. She also saw a number of therapists who proposed muscle imbalances in the leg, switched off glutes,
trigger points and biomechanical issues in her feet she had been told that both her feet were at. Various
therapies had been diligently applied and adhered to, including strengthening, stretching, suctioning, needling
even a bit of core stability (perhaps this last one was thrown in as a just in case).
The end result for my friend was that she was avoiding golf and if she did play, used a cart to minimise the amount
of walking. Especially, as she had been warned, on uneven ground.
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(https://noijamdotcom. les.wordpress.com/2014/10/shinsplints.jpg)

Reported area of pain for shin splints


The examination
I checked her out. There was nothing exceptional in the leg at the time of examination nothing surprising at all
for a 40 year old, active woman who had been fully functional for a number of years post fracture.
However, there was a clear neurodynamic nding which had not been examined in the past. In the slump position,
with left ankle dorsi exion/eversion and knee extension, the tibial area pain was recreated. Releasing knee
extension released the tibial symptoms, as did releasing neck exion. The same test on the right side revealed
hamstring tugging and a better range of knee extension. I reasoned these to be relevant ndings.
Post examination thoughts
I thought that there were two critical elements in the clinical presentation of the person in front of me. Firstly, and
most importantly, an avoidance behaviour based on the (erroneous) fear that playing golf or exercising and
experiencing any pain meant that there was further damage occurring and things were getting worse. One comment
from my friend went something like If I keep playing golf with my muscles all out of balance, the trigger points will
come back and Ill just make it worse. Secondly, there was the relevant neurodynamic nding. If I was trying to be a
bit smart, I might suggest that a third clinical element was a positive feedback loop between these rst two, with
the fear-based though viruses helping to drive a sensitive nervous system which in turn provided erroneous
evidence for the thought viruses to be maintained.
The treatment
We treated it. First I suggested not calling it shin splints this metaphorical diagnosis suggests that the problem
needs support or outside help aching shin, even just sore shin is better.
Secondly we moved her nervous system around a bit with the idea of restoring its sliding and gliding function and
maybe ossing and ushing out some areas that had been a bit sticky for some time.
We have recreated the assessment and treatment in the video below:

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Thirdly, we chatted. I suggested that there may be a bit of an increased ache for a day or so post stretching as this
sometimes happens but not to worry about it Its your body adjusting to the treatment. I suggested that the problem
now was a bit of nerve and soft tissue irritation, it sometimes happens, even a few years after an injury as the brain holds
memories of serious injuries and can react over time* almost trying to heal it again so it puts a bit of useful swelling
there which can irritate things. It gets a bit compounded when treatments dont work or make sense and you start to
worry worry can make things more sensitive too. But this is all good it will go. Go back to golf theres nothing that
can be damaged play 18 holes a few aches and pains are ne and normal, continue the post game gin and tonic
She played 18 holes of golf 2 days later no problems. Its now 3 weeks later, and with much golf and regular
stretching there are no reported problems.
My thinking
Not all shin splints are the same of course some acute presentations may be serious medical emergencies** and
should be treated as such. But my example is a common and repeated scenario and I believe that this problem is not
often treated in this way.
This is not intended to be some crowing about a miracle there was no miracle cure, no quick- x, no tricks, no
secret technique performed by magical hands. There was just some basic clinical reasoning powered up by a
modern, neuroimmune understanding of how pain works or at least the best understanding available to us right
now.
The kind of pattern reported above is common and will usually ease with the simple principles showed in the video.
If I had to have a go at the pathology, I would suggest some tibial nerve irritation, perhaps even a minor
compartment syndrome in the posterior compartment which houses the tibial nerve. How simple it would be to
suggest that the nerve and its connective tissue sheath were sticky, perhaps with limited oxygenation, some local
immune inspired in ammation perhaps also related to slightly altered anatomy post fracture. But more than that
I suggest that the persons perception of the problem has also added to the sensitivity both locally and in
neuroimmune territory representing the meaning and the function of the leg.
I rang my friend today and asked how she was going I am doing ne. Golf is no problem at all. Its good to know I
couldnt hurt this paying golf and its good to have some stretches that I know are getting at it.
Sometimes our game can be deceptively simple?
David Butler,
www.noigroup.com (http://www.noigroup.com)
*We are talking here about a temporal brain glial response microglia and astrocytes have a danger surveillance function
which may last for many years. If activated they may encourage responses in other systems such as the endocrine and
sympathetic systems leading to swelling and increased local sensitivity.
**If you ever see or experience lower leg pain that commences suddenly, is associated with rapid and signi cant swelling
of the lower leg, changes in blood ow, tingling and or loss of sensation dont hesitate, seek appropriate medical
assistance immediately.

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2 1 R E S P O N S E S TO S H I N S P L I N TS , TA K I N G O U T T H E T E N S I O N

Efwef Gwerb (https://www.facebook.com/efwef.gwerb) October 22, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1081)
Pro at work.
Dave, Id really be keen to see more case studies on video because theres so much to absorb. Now you
say there was no magic, but there were certainly some good positive suggestions thrown in:
1) Can you feel how it goes instantly? (this sentence has now been internalized and may well re-emerge
later when she performs the exercise at home).
2) Great, youre in control (sense of control reduces anxiety).
3) Feel the pull, enjoy it (dont resist pain, move into it without fear).
4) Cant hurt anything there (more anxiety reduction).
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5) Theres something you can do a er to make things really settle (Compare with say: this exercise
*should* help you, or worse this exercise *might* help you. Theres just no question it will help).
And the voice is very non-threatening in tone.
Given all this, I cant help thinking if your friend would have had just as good an outcome without the
nerve exercises.
EG.
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1081#respond)

Efwef Gwerb (https://www.facebook.com/efwef.gwerb) October 22, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1083)
Just to clarify my last sentence no nerve exercises but still incorporating all the excellent therapeutic
alliance and suggestion stu . Could it still have worked?
Sometimes I like to just do interferential (IFT) on its own nothing else. I do this because I know that IFT
has no long term e ect and so it gives me a good idea about how e ective my rapport/suggestion work is.
I had an elderly lady this week with a sore knee and she couldnt walk too well. So I did 3 treatments of
just IFT on its own. Sounds insane doesnt it?! But I sit and chat with her while the machine is on (she
talks, I listen) and LOTS of things are going on in that time. LOTS! Shes fine now.
Im at the point of thinking its quite possible to just give everyone 10 minutes of IFT and still get excellent
results. But Ive got some more experiments to do and plenty of skills to master yet.
EG.
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1083#respond)

davidbutler0noi October 23, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1086)

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Hi Cam,
I am really open to the idea that the nerve exercise may not have been needed and that the critical
elements included the examination and the you cant damage yourself story. Maybe deep massage may
have had a similar e ect? In this case it is about reasoning, selecting an appropriate intervention and
basing the narrative around it. In another clinical situation the intervention could be around weak and
tight muscles or electrotherapy.
Cheers and thanks
David
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1086#respond)

John Barbis (https://www.facebook.com/john.barbis.3) October 22, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1084)
YO Dave,
What are you doing with such droll clothes!!!! I loved the orange shirts and electric green ties. Are you
getting old?
By the way, great video. Videos are great, but people need to know that there is much more here than
meets the eye. You make it look simple, as all great clinicians do. Clinicians need to take the courses, be
mentored, and study. There is a lot of work that went into to making that treatment look simple, straight
forward, and valuable. In fact it is if you understand all of the big and little clinical wisdom facts that went
into deciding what to do and how to explain it. There is a tremendous amount of devil in the details
here that should not but anyone o but spur them to learn more.
As I get older, I really appreciate watching masters, no matter what the discipline, at work. I applaud not
only your technique, but all of the years of mastery that went into that performance. Thank you for
sharing that.
JohnB
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
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davidbutler0noi October 23, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1087)


Many thanks John,
As you know, my attempts to contribute to the profession have also included enhancing professional
fashion consciousness. I have always enjoyed being polychromatic.! You should have seen the socks and
undies that I had on during that clip!. And you are so right there is a lot of work that goes into making
something look simple in the clinic. But digressing back to colour it is also a small part of the clinical
magic. I have always held the notion that a patient (and student) must come back curious. And if what
will he be wearing next time? is part of that then so be it.!
Very best wishes
David
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1087#respond)

chisholmalex October 23, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1085)


I really did enjoy the endorphin rush of the typo on the original post! A great example of a belly laugh to
reduce pain perception. It was really funny! A great example of the holistic approach.
That being said, I agree that all those positive suggestions help make the treatment more e ective.
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1085#respond)

Andrew Imrie (https://www.facebook.com/andrew.imrie.37) October 23, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1088)
As always, I enjoy reading your thought provoking posts David.

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This really makes me wonder about the clinical reasoning and that goes onFollow
to support the interventions
that you mentioned that your friend had trialed.
Follow

noijam

every
new post
delivered
From a bio-mechanics perspective, these are, IGet
assume,
probably
rationalized
in terms of reducing torsion
to your Inbox.

or forces that may have detrimental e ects on tissues, presumably contributing to inflammation and
other
followers this sort of makes sense, but I
peripheral sensitization. In the current medialJoin
tibial479
stress
syndrome,

VERY MUCH WONDER what those same interventions


may have
within a di erent language
Enter your
emailachieved
address
context with the therapists being mindful of what their patient was cognizant of during and a er Rx
sessions.

Sign me up

I would propose that reassurance to move, reduction of cognitive error and thought virus taking home
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and rumination (by way of asking the patient to paraphrase


their understanding of the therapist
(https://wordpress.com/?ref=lof)
educational/cognitive input), in combination with some distracting (yet perhaps biomechanically helpful
and mechanically risk mitigating) exercise homework might have resulted in quite a di erent outcome
possibly without needing peripheral nerve mobes to desensitise?
I also wonder if (cat amongst pigeons, not being a current disciple of and still a sceptic of) kinesio taping
may play a role in non-threatening, distractional, non-noxious sensory cortex stimulation, reducing threat
value, improving confidence to move, all with the polychromatic, possibly individualised and favourite
happy healing colour scheme of the patient???
Andrew
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1088#respond)

davidbutler0noi October 24, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1100)


Hi Andrew, Thats all fair enough. A lot of people have got better in the past from therapies that did not
even contemplate neural structures. In this situation, trying to be uncorrupt in my clinical reasoning as I
contemplated the periphery/health of tissues area , I found more support for peripheral neuropathic
contributions than anything else. I can conceive of some scar in connective tissues, a local immune
response, a little bit of acicidy, bit of oxygen starved tissue, some sluggish gelling axoplasm etc all
needing a bit of a wring out and flush (how scientific is that? !!).
Coloured kinesiotape??. Its just like when you make an appointment to see the doctor your pain eases
you have done something about it, added some safety same as sticking a bit of tape on add a bit of
colour and you have done something special. Lets hope its not all the therapists do!.
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I remember taping up football teams ankles in my youth. I am sure my saying I will put a heel lock in as
well helped more than the sticky stu .
David
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bobnotrob October 23, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1089)


Dont know if it was ironic or cosmic, but I had a professional ballet dancer last week with similar
symptomatology and history (long term shin splints problem that morphed into intermittent medial
shin pain with distinct avoidance behaviors). I had a feeling that none of her previous clinicians looked at
the neurophysiology of her case, so I proceeded (literally with your work in hand) to assess the LQ nerves.
Lo and behold, clear signs of tibial, sural and femoral nerve involvement. She had more going on than just
her lower leg issue, but that was the chief complaint. I look forward to reporting how this weekends
performance went for her, which was a big thing as she is casted in a principal role. Thank you, NOI!
Bob
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davidbutler0noi October 24, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1099)


Thanks Bob let us know. This also links into Frdrics question
below.
David
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
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Ian Stevens (https://www.facebook.com/ian.stevens.944) October 23, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1090)
really enjoyed this and the reasoning what i particularly homed in (apart from lack of polynesian/dame
edna inspired fashion) was this *We are talking here about a temporal brain glial response microglia and
astrocytes have a danger surveillance function which may last for many years. If activated they may
encourage responses in other systems such as the endocrine and sympathetic systems leading to swelling
and increased local sensitivity.
can you send links or expand on this?? so relevant clinically esp to the stressed /confused person with
lots of explanations .I have had complex pts who have been labelled as all sorts of obscure Rh
conditons and when you hear the narrative that led up to their bodily dysfunction simple measures like
reducing loadbearing /education/graded exposure +- minus analgesics have really helped reverse the
situation .
ian
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1090#respond)

davidbutler0noi October 24, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1095)


Hi Ian,
The notion of microglia and astrocytes as surveillance cells on the look out for danger to the
representation they are associated with, plus their ability to remain activated, experienced or alert over
time helps us understand a lot of clinical scenarios.
A good read on the experimental data is Austin PJ & Moalem-Taylor 2010 J Neuroimmunology 229:26-50
here the data showing local and remote glial responses months a er an injury is detailed. An older classic
article by Banati R ( Neuroreport 2001, 12: 349-3442) provides evidence of brain glial activation years a er
peripheral nerve injury. In one case (amputation), brain glia was still active 23 years a er. Any by the way,
while you are feeling glially Yirmiya and Goshens Normal Cousins lecture Immune Modulation of
Learning, Memory, Neural plasticity and Neurogenesis (Brain, Behaviour and Immunity (2011) 25: 181-213
is a great review .
A person holding the language and image that their shin splints are torn muscle attachments or
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periosteum pulled away from the bone has created something dangerous for glial cells to respond to,
essentially resulting in an alteration of immune balance (see Austin and Moalem-Taylor for discussion on
immune balance). And as you suggest Ian , confusion, and stress and multiple labels adds to the danger. It
all help us understand the problem that always comes back.
And even just asking someone how are you rather than the how is that torn muscle seems to be a
biologically better place to start.
David
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1095#respond)

John Barbis (https://www.facebook.com/john.barbis.3) October 23, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1091)
Yo Dave,
I am very pleased to learn that you have not lost your keen fashion sense. the profession needs more of
that. Please keep the undies underwears, my nervous system isnt ready for that. Great work. TGD
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1091#respond)

davidbutler0noi October 24, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1098)


You are not the only person who has suggested that John!
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1098#respond)

John Barbis (https://www.facebook.com/john.barbis.3) October 23, 2014


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(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1092)
that should be undies under wraps!!!!!
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1092#respond)

Frdric Wellens (@PhysioAxis) (http://twitter.com/PhysioAxis) October 24, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1093)
Hi David, I enjoyed your blogpost very much, as obviously, my cognitive biases are along the same lines as
yours! Although I too find that shin splints patient have altered tibial nerve neurodynamic I o en also find
some small hypoesthesia on the skin overlying the painful area on the picture. Wouldnt that be a
cutaneus spahenous nerve territory? How to reconcile this finding and the abnormal tibial nerve
neurodynamics?
These and other findings across di erent condition o en have me wondering on the meaning of altered
neurodynamic findings. Are the altered findings suggestive there is an issue with the nerve tested per se?
Or rather, is the finding simply suggestive there is an increased sensitivity of the nerve secondary to
peripheral sensibilisation secondary to inflammation in a neurologicaly related msk tissue?
In other words, is the increased nerve sensitivity related to the nerve itself or rather to a parent tissue?
Could it be both? (rather likely I would say).
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1093#respond)

davidbutler0noi October 24, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1096)


Hi Frdric,
I would probably reconcile such saphenous changes by the likelihood of multilevel changes in lumbar
DRGs and cord, set up by an original nerve issue perhaps tibial in the posterior compartment . Other
possibilities could include excessive deep tissue massage of the saphenous nerve!
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I think you have nicely answered the last question yourself. My feeling is that it is rare that the test
suggests a singular issue with the nerve tested per se. The moment a nerve is injured remote glial and
neural changes occur. Sticky nerves needing a bit of a wriggle and a wring out occur of course but much
more, I think neurodynamic tests expose specific sensitive movement constructed by peripheral and
central responses and pathophysiologies rather than a sensitive nerve. I like the term parent issue
David
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Efwef Gwerb (https://www.facebook.com/efwef.gwerb) October 24, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1094)
I was thinking today how the word Physiotherapy gives the wrong impression about how the body-mind
works. It gives the wrong impression to students and the client population.
Isnt it time we changed the degree course and called it something new? I propose: Psycho-somatics.
The body is still clearly represented, but the emphasis has definitely changed to reflect new science. Even
if Psychosomatics was a degree course for the treatment of chronic pain only, that would be a start. Not a
weekend course. Teaching this stu as a weekend course puts it alongside Rok taping certificate courses.
I feel confident this sort of education will appear formally somewhere in the world soon. How can it not
with the ground swell of new information appearing? Uni of SA could be the leader.
EG.
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
replytocom=1094#respond)

davidbutler0noi October 24, 2014 (http://noijam.com/2014/10/22/shin-splints-taking-out-thetension/comment-page-1/#comment-1097)


Ah Cam things change ever so slowly!!!. But it MUST happen. Most OT courses are still psychologically
based with minimal neuroscience. Very few PT courses include more than a few hours pain science or the
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pain stu goes with electrotherapy. Pain is till almost absent in medical courses. The University of South
Australia, to their credit took on semester long (180 hours e ort) courses in clinical pain sciences a
decade ago but I am not aware of any other institution doing it. (And of course pain is just the default
term for the other perturbed brain outputs which are taught in such a course.
Not sure about the term psychosomatics. And while on the topic I would love a better word than the
mouthful that is biopsychosocial.
David
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Efwef Gwerb (https://www.facebook.com/efwef.gwerb) October 24, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1101)
Neuro-somatic therapy? Neuromatrix therapy? Its time
Instead of Biopsychosocial what about holistic?!! Hehe.
Maybe a cute acronym like PAEP pain as emergence phenomenon. It brings the listeners attention to the
model, and the model can change. Therefore we dont get locked in to something obsolete.
EG.
Reply (/2014/10/22/shin-splints-taking-out-the-tension/?
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davidboltononoi (http://davidboltononoi.wordpress.com) October 25, 2014


(http://noijam.com/2014/10/22/shin-splints-taking-out-the-tension/comment-page-1/#comment-1104)
Dear NOI family and friends,
Ive followed this post with great interest, fascinating. All that I can add is that up until 25 years ago I
regularly examined diagnosed and treated individuals with Shin splints. Since joining NOI and applying
their knowledge and experiences i have yet to see one true case!!!!!!!!!
However a true case can be a medical emergency therefore, through solid clinical reasoning I always set
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Shin splints, taking out the tension | noijam

out to prove myself wrong.


For me this largely applies to the whole range of peripheral pathologies..
Beautiful demonstration David, the master at work x
DB
On location
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