By Alex Cross
The world as we know it has changed – working from home, gyms closed, no organised sport, personal training sessions online and most people have a lot more spare time. So how are people getting their fix of exercise – running! Something we often see with a rapid spike in running (in trained and untrained individuals alike), is an increase in shin pain, which is often referred to as ‘shin splints’ (otherwise known as medial tibial stress syndrome - MTSS).
What are ‘shin splints’?
Shin splints are both poorly understood and highly prevalent, accounting for up to 16% of all running related injuries – which is an absurdly high number for one condition1. Furthermore, up to 94% of high-level runners will report experiencing shin-splint pain throughout their running career – demonstrating that it does not discriminate between new and experienced athletes2. The exact definition varies depending who you talk to, but the best and most succinct definition is;
‘Exercise-induced pain along the posteromedial tibial border, which can be provoked on palpation over a length of 5cm or more1’– essentially, pain on the inner aspect of your shin which is 3-5cm in length and is sore upon touching. The area of pain is outlined in figure 1.
Figure 1. Area of pain commonly associated with medial tibial stress syndrome
Obviously, this is quite a broad definition and emphasizes the poor understanding of shin splints and the pathology that causes it. There are multiple theories regarding the pathology, but the three most widely accepted are;
1. Bone overload injury along the medial tibia
2. Muscle and tissue attachments onto the medial aspect of the tibia (tibialis posterior, gastrocnemius, soleus)
3. Bony breakdown due to increased loading (cycle of bone breakdown vs. bone repair begins to favour the bone breakdown)
As, I’m sure you can see, with so many different theories out there, it is only natural that people have their own method of fixing shin-splints. However, their ‘method’ is likely based on anecdotal rather than robust scientific evidence and does not at all mean it is the right actions for your unique presentation. Many people suggest running through the pain, anti-inflammatories, regular icing and stretching – and all these methods, despite working for some people, have very low-level (if any) evidence behind them. Be careful scrolling through Google and following the instruction of various websites and blogs, as they do not know your condition and although they might claim this works all the time, it doesn’t. Despite all this, what we do know regarding shin splints is;
· It is caused by a rapid increase or spike in an individual’s load and is more prevalent in less experienced runners – primarily due to the large level of compressive loads that are transmitted through the tibia during running3.
· There is a strong relationship between calf muscle weakness and shin splints1,4
o Both the soleus and gastrocnemius work very hard during running – absorbing 6.5-8.0 and 2.5-3.0 body weight force respectively during running. Thus, if they are not functioning as well as they should be, there may be more load on the tibia5
· It can be quite a debilitating condition which may take significant time to recover from, largely related to the unique nature of the condition1
I think I have shin-splints, what should I do?
If you have exercise-induced shin pain which hangs around during and after exercise and decreases with relative rest, it is likely that you may have shin-splints. Great – now what? Obviously, the next best step is to reduce your load somewhat and seek the opinion of a medical professional that you know and trust. Now I know it would be great if I could give you a one-size fits all approach, but with shin-splints, as with most conditions, that is not the case. Only after taking a thorough history and conducting an appropriate physical examination can you begin to understand, how and why this pain has developed. Every professional will have their own method of treatment to manage shin pain, and although there is no one ‘gold-standard’ approach, the treatment methods with the most promising results are;
· Education surrounding expectations and prognosis1,6
· Load management1,2,6
· Specific and guided strengthening1,6
· Graduated loading1,2,4,6
That is a pretty thin list which also looks relatively boring; however, it should be the backbone of any treatment and rehabilitation protocol. Along with these principles, it is an important clinical decision to decipher which, if any, additional treatment methods will help progress the course of your rehabilitation (e.g. manual therapy, gait re-training, foot and orthotic assessment).
Take-home message
Medial tibial stress syndrome is a complex injury that is primarily related to the load capacity of both tissues and bones alike. It is likely the result of complex biomechanical and tissue-related stresses occurring through the lower leg in response to aberrant loading or inadequate strength through the lower leg. As a result of the complex nature of this condition, it is imperative you seek out a medical professional to help diagnose and progressively rehabilitate you back to running pain free.
References
1. Winters, M. (2020). The diagnosis and management of medial tibial stress syndrome : An evidence update. Der Unfallchirurg, 123(Suppl 1), 15–19.
2. Newlin, D., & Smith, D. S. (2011). Shin Splints 101: Explaining Shin Splints to Young Runners. Strategies (08924562), 24(3), 10–13.
3. Norman, C. (2005). What causes shin splints? Scientific American, 4, 84.
4. Michael, R. H., & Holders, L. E. (1985). The soleus syndrome: a cause of medial tibial stress (shin splints). American Journal of Sports Medicine, 13(2), 87–94.
5. SCHACHE, A. G., DORN, T. W., WILLIAMS, G. P., BROWN, N. A. T., & PANDY, M. G. (2014). Lower-Limb Muscular Strategies for Increasing Running Speed. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 813–824.
6. Winters M, Eskes M, Weir A, Moen MH, Backx FJ, Bakker EW (2016) The treatment of medial tibial stress syndrome: an extensive summary and update of a systematic literature review. Sport Geneeskd2:44–45