This is an area that has become quite prevalent within the running community, particularly over the last 5 years. I feel this is largely to do with the fact that (wonderfully) more people are getting into running, and runners are doing more kilometres and faster workouts. This has meant the number of “repetitive overload” injuries of the lower limb has skyrocketed.
If you’re not a runner but have just started you may have launched into it all guns blazing, and if you are already a runner, you may have spiked your mileage to stay sane in iso and just as a general fun challenge…. either way, the impact load has increased and this may present in the form of shin pain (medial tibial stress syndrome) AKA Shin Splints.
The pain often starts humble enough, and may even warm up as you start to jog. You may be able to run through it for a while....
BUT, the reality is:
Unless measures are taken, shin splints are a persistent injury that needs to be respected and (in my clinical experience) cannot just be “run out” or ignored.
Firstly, let us define what MEDIAL TIBIAL STRESS SYNDROME, or as it is colloquially known as SHIN SPLINTS.
MTSS/Shin Splints is an inflammation of the muscles, tendons, and bone tissue around your tibia. Pain typically occurs along the inner border of the shin bone (tibia), where muscles attach to the bone. Shin splint pain most often occurs on the inside edge on the lower two-thirds of your tibia.
The pain is non-focal but extends over “at least 5 cm”, which is different to a tibial stress response/fracture which is a pin-pointed small area of pain directly over the bone. Shin splints are often bilateral (but not always) and can be felt on direct palpation of the affected area and on impact activities such as impacting the ground when running.
Shin splints are an overload injury most commonly seen in sports where there is repetitive lower limb impact such as running or dancing.
It typically gets worse when you run or perform any impact activities and improves when you stop, but can reappear after cooling down due to the inflammatory component of this condition. When shin splints get worse the pain can remain during exercise and also could be present for hours or days after cessation of the activity.
Important to note:
*What to look out for:
The most common complication of shin-splints is a stress fracture, which shows itself by tenderness of the tibia in a very focal spot, and may even have a small lump on the bony surface.
The pain is worse when you stand up or exercise, and it takes a while to improve afterwards. It is caused by muscle pulling on the shinbone and eventually causing the bone to crack. This can be diagnosed with a scan after getting an assessment from your doctor/physio.
*Other conditions such as tendonitis and compartment syndrome can also cause symptoms like shin splints
It's important to get a handle on your specific diagnosis so you can start a treatment plan to get back on track!
How did we end up here?
There can be several causes of shin splints, and all of them vary slightly from person to person, but one thing that shin splints are certain of is that they occur from OVERLOAD.
Your lower limb is not tolerating the impact dosage. The running has overloaded your lower leg muscles, tendons and the attachments at the tibia and micro-trauma has occurred and accumulated.
Internally a chronic inflammation of the muscular attachment along the posterior medial tibia and bony changes are considered to be the most likely cause of the medial tibial stress syndrome.
Here are some likely causes: (it’s likely at least 2-3 of these are relevant)
OVERLOAD: a sudden increase in the amount or intensity of impact exercise eg: a spike in running volume.
OVER PRONATION of the foot (when the ankle joint rolls inwards too far as the foot hits the ground— often seen in people with fallen arches or flat feet.)
TIGHT MUSCULATURE of the lower leg muscles (anterior/ posterior/ lateral and medial tissue surrounding the tibia)– all of the surrounding tissue may be tight causing excess traction on the tibial surface.)
ENVIRONMENTAL: change of running terrain, eg: running on sloping, uneven or hard surfaces.
FOOTWEAR: unsupportive or old footwear which does not have the arch support or cushioning required for running shock absorption.
MUSCULAR WEAKNESS: lacking the required calf and foot muscle strength can lead to a mechanical disadvantage when running resulting in less impact load tolerance.
MECHANICS: over striding when running is a very common factor in injuries that occur below the knee. Over-reaching with each stride can lead to higher ground reaction forces at the shin, and lead to more ‘ impact trauma’.
Once we have confirmed that shin splints are the cause of our pain and discomfort when running, the golden question is HOW DO WE FIX THEM? Also: how do we keep them under wraps and keep them from coming back!?
The first thing to note is: GETTING ONTO SHIN SPLINTS EARLY IS KEY IN A QUICK RECOVERY!
The longer they linger, the more embedded they can become. Inflammation and mechanical compensatory issues can start to occur. It’s important not to ignore them.
DE-LOAD: The most crucial factor in reducing inflammation in shin splints is addressing the provocative activity. It may not have to be for long but I advise at least one week off all impact activity when the shins are inflamed and then a gradual re-load program back to running. This largely depends on how progressed the symptoms are and how the individual responds to de-load.
MANUAL THERAPY: massage, ice massage, dry needling, and foam rolling are all great ways to help release tension in the soft tissue around the tibia to reduce the muscular traction along the bony surface.
STRENGTH: Calf and foot strength exercises are important for building strength in the muscles surrounding the shins. In addition, higher up the chain should be looked at: glute/pelvic stability and hip strength should be addressed in a well-rounded shin splint strength program to address the lower limb holistically. (see example plan below)
STRETCH: Less important than strength, BUT stretching can give symptomatic relief as well. This includes your calves, the arches of your feet, the hips, hamstrings and quads to make sure your whole lower limb is loose.
RUNNING MECHANICS: Over striding can be a large factor in causing shin splints. Getting your technique assessed by a professional is a great way of ensuring you are minimizing the impact of the lower limb while running. This can be done outside or on a treadmill and can work wonders for the prevention of reoccurrence.
FOOTWEAR: Research would lead us to note that slightly more cushioned shoes can help reduce the impact load of shin splints. The most important thing I believe is comfortable shoes that have some arch support to help with reducing over-pronation and subsequently overloading the medial calf muscles.
TAPE: Arch support taping and Kinesio tape for the medial calf compartment can work wonders in helping to aid symptoms of shin splints. I highly recommend taping up the arches of the feet to help reduce traction along the tibial surface and also to give extra support when you start to re-load the lower limb.
ICE: cryotherapy can work wonders for helping with localized inflammation to help ease symptoms. Ice massage (with a small amount of cream- run the ice up and down the length of the tibia for 5-10mins daily- this can help reduce localised inflammation and reduce pain.
If you have been bitten by shin splints, it’s crucial to formulate a strategy for the prevention of their reoccurrence. Looking at implementing a solid weekly strength regime (1-2 whole body Pilates classes or a functional strength regime) can be a great way to address whole body weaknesses/imbalances.
It is widely proven that core/pelvic strength and trunk stability have a great impact on what happens further ‘down the chain’. It can be easy to address the symptoms around the feet/ankles due to this being the pain location, but getting strength further up the body can give your lower limb a great preventative mechanical advantage.
Strength: Example program for a MTSS/shin splint client:
Bent and straight knee calf raises: double leg and then single leg calf raises (ensuring that pressure is being placed through the big toe to utilise the inner portion of the calf.) Once you can perform 3x20 double leg, you can progress to working towards 1x10-15 single leg straight leg, and 2x10-15 bent knee.
Intrinsic foot muscle strength: some of the muscles along the tibia go into the foot to support the arch. Working on the muscles of the feet can help stop pronation and excess load being placed on the inner calf muscles when running. My favourite is the “towel scrunch”. Using a tissue at first (progress to a sock then a towel once you get stronger and more dexterous with your feet) doing daily 1x20 each foot: using your toes to scrunch up the towel, hold for 3 seconds, place it down and repeat 20 times. You should feel fatigue int the foot muscles doing this.
Pelvic/Trunk stability is crucial to runners. (Clams, arabesques, bridges, planks, side planks, dead bugs to name a few). A variety of these should always be incorporated into any lower limb strength exercise work when dealing with an injury. If we can strengthen higher up the chain, we can reduce the impact load further down the limb. *2x Pilates sessions per week can address this easily.
Dynamic Strength (once symptoms have settled) and you can tolerate some impact load. Skipping, pogo jumps, (both double leg) progressing to hops and bounds (single leg) as part of a regular running routine to make sure you are challenging the muscles and tendons in a functional, explosive and dynamic manner helps keep the strength work specific to the sport of running.
When can I return to Running?
This question will vary from person to person and will take into account your own running and injury history, your current symptoms (and length of time of symptoms), and how you respond to the treatment outlined above. This is a good checklist to see when you are ready for impact load activities:
1) You have a full range of motion in the injured leg compared to the uninjured leg.
2) You have full strength of the injured leg compared to the uninjured leg.
3) You can walk without pain or limping, (at least 30mins comfortably without aching.)
4) You can hop with less than 2/10 pain on x10 single-leg hops
This is when a walk-jog program can commence. *see my previous blog post on returning to running after injury for a walk-jog program.
Shin Splints can literally stop you in your tracks, and, if left untreated can drag on for months and even develop into a bone stress injury.
If you pull them up quickly and treat them early, you can recover quickly and get back on the trails. There is lots you can do to TREAT medial tibial stress syndrome and (even better) PREVENT them altogether.
One of the most common ways to strengthen the whole body in a functional and specific way to stay robust is through home mat Pilates. If you think your body could do well with this, I can help you out. I am now offering live and on-demand Running Specific Pilates Sessions online weekly. It’s a surefire way to get your whole body conditioned within the comfort of your own living room.
If you are still battling with Shin splints after trying all of the aforementioned treatment techniques, or you would like more information in regards to Pilates, please refer to our lower limb rehab on forrunners.app.
About Alice Baquie
Alice has been a physio for fourteen years and specialises in injury prevention and management for runners. Alice has represented Australia in distance running and gymnastics so has sound knowledge of athletic performance and understands the importance of strength conditioning and mobility to help keep the body moving effectively to mitigate injuries.
Alice, otherwise known to her wonderful pilates community as AB is a fun loving inclusive person always ready to chat and have a laugh and has hosted 1000’s of online classes which attract people from all around the world, including 25 Aussie Olympians.