Does strengthening the tibialis anterior muscle during an active strain worsen or improve the condition?

Strengthening the Tibialis Anterior During Active Muscle Strain

Strengthening the tibialis anterior muscle during an active strain should begin after a brief 3-5 day rest period, not during the acute injury phase, and early functional strengthening is essential for optimal recovery and should not be delayed beyond this initial rest period. 1

Critical Timing: When to Start Strengthening

Acute Phase (First 3-5 Days)

• Limit complete rest to 3-5 days maximum to avoid the detrimental effects of prolonged immobilization, which results in less optimal outcomes compared to functional treatment strategies 1
• During this brief period, use ice, compression, and elevation for symptom management 1
• Complete immobilization beyond 5 days delays recovery and return to function 1

Early Functional Phase (Days 3-5 Onward)

• Begin strengthening exercises as soon as the initial 3-5 day period ends to recover muscle functionality 1
• Start with range-of-motion exercises first, then progress to strengthening as pain allows 1
• Research demonstrates that injured muscle begins functional recovery by 48 hours despite ongoing inflammation, suggesting that early mobilization is physiologically appropriate 2

Why Early Strengthening Helps Rather Than Harms

Physiological Recovery Timeline

• Muscle contractile ability after strain injury follows a predictable pattern: 70.5% of normal immediately after injury, dropping to 51.1% at 24 hours, then improving to 74.5% at 48 hours and 92.5% at 7 days 2
• The temporary decrease in function between 24-48 hours results from pain due to inflammation, not worsening structural damage 2
• Functional treatment allows return to activities 7.1 days sooner than immobilization approaches 1

Mechanism-Based Rationale

• Recovery mechanisms differ based on injury severity: single large strains heal without requiring myogenesis (new muscle fiber formation), while multiple small strains require myogenic cell proliferation for full recovery 3
• Inhibiting muscle regeneration through prolonged rest prevents recovery of contractile function after repetitive strain injuries 3
• Reduced lower extremity muscle size and strength are associated with higher risk of bone stress injuries, indicating that maintaining muscle strength provides a protective mechanism by attenuating shock and reducing loads 4

Comprehensive Strengthening Protocol

Tibialis Anterior-Specific Exercises

• Include direct tibialis anterior strengthening along with calf muscle strengthening to address muscle imbalances that may have contributed to the initial injury 1, 4
• Focus on proprioception, strength, coordination, and function as core rehabilitation elements 1

Proximal Strengthening

• Address core and pelvic muscle strength to optimize lower extremity biomechanics and reduce excessive hip adduction, which increases tibial loading 1, 4
• Hip strengthening may improve eccentric control and could be beneficial, particularly in female athletes who demonstrate greater hip adduction angles 4

Progressive Loading

• Progress to plyometric strengthening and running drills once basic strength is restored 1, 4
• High-impact training such as jumping or hopping can be highly osteogenic and should be included in advanced stages, with zig-zag hopping being optimal for tibial bone strengthening 4

Biomechanical Corrections During Rehabilitation

Assessment Requirements

• Screen for lower extremity biomechanical abnormalities including excessive hip adduction, rearfoot eversion, or knee valgus that may have contributed to the injury 1, 4
• Greater than 5° of internal knee rotation or knee valgus during loading increases stress fracture rates 2-4 fold, indicating the need for proximal strengthening to control these variables 4

Flexibility Components

• Address muscle flexibility, particularly calf and hamstring flexibility, as tight muscles increase tibial loading 1, 4

Critical Pitfalls to Avoid

Do Not Prolong Rest

• Avoid relying solely on RICE protocol as evidence for its long-term efficacy is limited; functional treatment must follow the initial 3-5 day period 1
• Prolonged immobilization beyond 5 days delays recovery and increases the risk of recurrent injuries 1

Do Not Neglect Exercise Therapy

• Exercise therapy is crucial for recovery and preventing recurrent injuries 1
• Scarring and fibrosis that develop by 7 days post-injury may explain frequent recurrence of injury to strained muscles if proper rehabilitation is not performed 2

Progression Monitoring

• Monitor for any increase in local muscle tenderness throughout the progression 1
• Pain during and after exercise should guide progression; if pain occurs, rest until symptoms resolve, then resume at a lower level 5

Return to Activity Guidelines

Walking Progression First

• Begin with pain-free walking as the first milestone before advancing to running activities 1
• Progress walking duration to 30-45 minutes of continuous pain-free ambulation 5

Running Reintroduction

• Start with 30-60 second running increments interspersed with 60-second walking periods 5
• Progress distance before increasing speed, building to 50% of pre-injury distance before introducing speed work 5
• Use the "10% rule" to guide progression of running load (increase by no more than 10% per week) 1
• Start on level surfaces and avoid hills, hard surfaces, and uneven terrain initially 1, 5