Shin Splints – “Too Much, Too Soon”
Updated: May 10
“Too Much, Too Soon” may be a great title for a classic movie (Errol Flynn & Dorothy Malone, 1958), but it also describes the reason why most people experience the pain of shin splints. In most cases this is due to increased tissue loading with not enough time for adaptation (increased distance, intensity and duration).
People often think that shin splints only affects runners but in reality, it's a common injury that affects participants of any sport that involves running or jumping. This includes activities such as soccer, rugby, basketball, volleyball, tennis, badminton, lacrosse, and dance. (2)
SYMPTOMS OF SHIN SPLINTS
Most people describe the initial pain caused by shin splints as a dull ache along the inside of the lower leg (tibia).
Shin splint pain is often felt at the beginning of a run and then diminishes as the run continues, only to return near the end of the run.
During this initial stage, the pain from shin splints will often dissipate completely with rest. As the shin splints progress, the pain will often become present during both activity and rest. Once shin splints reach the stage of constant pain, a medical professional should be seen to determine if additional injuries are present (stress fractures or compression syndrome).
Note: The exact location of shin splints is often hard to find, because it is usually a diffuse pain in the soft-tissue (fascia, tendon, muscle) rather than on the bone (tibia) itself.
CAUSES OF SHIN SPLINTS
The most common cause of shin splints is repetitive motion. This is not surprising when we consider the force of impact of each runner’s stride. A runner’s shins are subject to two to three times the runner’s body weight upon foot impact. This high level of force can easily overwhelm the shin muscles (dorsi flexors) if they are not currently strong, elastic and flexible. (3)
Running on uneven or hard surface or in worn out running shoes can also cause significant damage. Certain bio-mechanical factors such as hyper-pronation, foot arch height, and unequal leg length (as seen with pelvic rotation) should also be considered during diagnosis and evaluation.
The shin muscles are called dorsiflexors because of the motion they perform when they contract. On contraction, the dorsiflexors (your shin muscles) pull the foot up towards your shins, or dorsi flexion.
Controlling plantar flexion of the foot is not an exclusively linear motion. As the foot strikes the ground it is subjected to both rotational forces (pronation and supination) and side to side motions. (3,5) During running, through the process of eccentric contraction, the dorsi flexor muscles also control plantar flexion. Eccentric contraction occurs when a muscle elongates while under tension.
DIFFERENTIAL DIAGNOSIS OF SHIN SPLINTS
It is very important when diagnosing shin splints to make sure that you are actually dealing with shin splints and not other conditions such as a stress fracture or compartment syndrome.
What are Stress Fractures?
Stress fractures are one of the most common, and potentially serious, overuse injuries. A stress fracture is an incomplete fracture that is typically caused by repetitive, forceful actions. In contrast, most other types of fractures are caused by a single, direct, traumatic impact. (2,8)
In the initial stage of shin splints, runners often notice that pain reduces in intensity after the first few kilometers. In contrast, the pain from a stress fracture tends to build up gradually during running, often beginning as an annoying irritation and becoming unbearable as the run continues. So, during the early stages of shin splints, there is often a clear differentiation between shin splints and a stress fracture.
The problem during the diagnosis, is that the pain in later stages of shin splints could be so severe and continuous that it would be impossible to determine if a stress fracture is the actual cause of injury. This is why you should seek professional advice as early as possible.
There are several diagnostic procedures that a sports practitioner can perform which will help to differentiate which condition you are dealing with.
Unfortunately, routine X-rays will probably not be one of those tests. X-rays are often of little value in detecting a stress fracture. A much better test is a bone scan (or MRI) which is much more sensitive in detecting these fractures. (8)
The image to the left shows a standard X-ray with no indication of a stress fracture. The image on the right, a bone scan, does immediate show the stress fracture in the tibia. (Image link)
From a symptomatic perspective there are some clues that often present themselves upon physical examination which may indicate you are dealing with a stress fracture. For example, with a stress fracture there is often a specific point of tenderness on the shins (tibia), rather than a more diffuse region of pain as is commonly felt with shin splints.
Note: Female athletes with irregular or absent menstrual cycles are at risk for stress fractures. Athletes who do not consume enough calories create energy imbalances; these imbalances can result in low estrogen levels, which can have a negative effect on bone health. Estrogen imbalances should be considered in any female athlete that develops stress fractures. (11)
WHAT IS COMPARTMENT SYNDROME
Another condition that must be ruled out is compartment syndrome. Compartment Syndrome is a painful disorder that occurs when pressures within the muscle build up to unsafe levels. This pressure can cause a reduction in blood flow, which in turn prevents oxygen and nutrients from reaching nerve and muscle cells. Compartment syndrome can be either acute or chronic. (10)
The compartments of the lower leg are divided into four rigid sections. These compartments are bound by strong fibrous tissue (deep fascia), and bones. The following muscles are found in the anterior, superficial posterior, deep posterior, and lateral compartments. Knowing this anatomy can be of great help when you are treating and will help you achieve a successful resolution of shin splints. (Image Link)
The anterior compartment contains:
Tibialis anterior muscle (dorsi flexes and inverts ankle).
Extensor digitorum longus muscle (extend toes 2 to 5 and assists in eversion).
Extensor hallucis longus muscle (extends the big toe).
Peroneus tertius muscle (assists in eversion).
In a case of anterior compartment syndrome, a runner may experience sharp pain and swelling over the shins. They may also notice a weakness in the dorsi flexors, especially against resistance. Furthermore, there is often a decrease in the pulse of extremities and a decrease in sensation.
The superficial posterior compartment contains:
The deep posterior compartment
Flexor digitorum longus muscle (predominately toe flexor's.
Tibialis posterior muscle (plantar flexes and inverts the foot).
Flexor hallicus longus muscle (predominately toe flexor).
The lateral compartment contains:
Peroneus/fibularis longus and brevis muscles (primarily foot evertors).
Chronic Compartment Syndrome
Chronic Compartment Syndrome (Exertional Compartment Syndrome) is NOT a medical emergency and can often be treated with manual therapy (MSR, FAKTR, ART, Graston etc.). In runners the pain of Exertional Compartment Syndrome usually occurs within the first 15 minutes of running, then subsides within an hour after the run. The pressure of these compartments can be measured by a medical practitioner. (2)
Acute Compartment Syndrome
Acute Compartment Syndrome could be a serious limb-threatening condition. Any delay in treatment could lead to infection, complications and even limb amputation. In most cases an Acute Compartment Syndrome occurs after a traumatic event, traumatic fractures, crush injuries, burns, tight bandaging after surgery to blood vessels, and even extremely intense exercise (particularly eccentric movements – extension under pressure). (2)
Bottom Line: If you suspect a stress fracture or compartment syndrome you need the help of a medical practitioner ASAP.
RUNNING AND DORSIFLEXOR STRENGTH
Next time you are out running, listen to the runners around you. You will be surprised to hear just how many runners are slapping the ground with their feet. Every one of these runners could be susceptible to shin splints.
When a runner has weak dorsiflexors, they will have a tendency to slap the ground with every foot strike. A runner slaps the ground because they are unable to control foot motion as they lower the foot to the ground (eccentric contraction).
Slow Verses Fast Running
Another point to consider is that slow runners have a tendency to slap the ground more than fast runners. This is a very interesting observation since faster/elite runners are hitting the ground with more force, yet the fast runner is not only quieter but less susceptible to injury. This is because most elite runners have strong, elastic dorsiflexor muscles and are better able to control the foot as it comes down. Essentially, they have good shock absorbers that are able to dissipate the impact of each stride.
Some of quietest elite runners you will see (and actually not hear) are the east African marathon runners. Many of these runners have developed extremely strong dorsiflexor muscles from running barefoot throughout their lives. Having strong dorsiflexors may be one of the factors as to why east Africans have dominated major marathons around the world for decades. (Image Link)
For Example, When I ran the Paris Marathon back in 2009, the winner was Tadesse Tola from Ethiopia who finished in a time of 2 hours, 6 minutes and 40 seconds. Seeing runners maintaining such incredible speeds while quietly taking each stride is incredible.
So How Does This Work
Elite runners recycle about half their energy through elastic recoil. This process is very similar to a spring mechanism, where you are loading and releasing the spring with each stride. Part of this amazing spring mechanism is the strength and elasticity of the dorsi flexor muscles.
The amount of impact your legs experience also has to do with stride frequency. Slightly increasing your stride frequency by 10% will substantially decrease the amount of ground impact on your tibia (hence decreasing your chance of getting shin splints). (6)
TREATMENT OF SHIN SPLINTS
Fortunately, the majority of shin splint cases do not require surgery. Conventional treatment recommendations of shins splints can be divided into acute and sub-acute phases.
TREATING THE ACUTE PHASE OF SHIN SPLINTS
Let’s start by looking at the Acute Phase of shin splints. Here are some of the recommendations we give to patients during the Acute Phase of shin splints. Please note, the actual recommendations will vary from case to case. Recommendations:
Rest is essential: This is the recommendation that most athletes hate, especially when I tell them they need to rest for approximately 2 to 6 weeks. But this is critical for effective recovery.
Use Ice during the acute phase: I recommend patients ice for 15- 20 minutes 4-to-6 times per day. They can also do direct ice massage, but that should be for only 7-to-9 minutes 3-or-4 times per day.
Use compression to reduce swelling: A compression sleeve or compression wrap can be very useful in reducing swelling. Just make sure that the sleeve/wrap is not too tight, and allows for proper circulation.
Elevate the legs: This is especially effective at night time. Make sure the legs are elevated above the heart. This will help to reduce both pain and swelling.
Perform a gentle stretching routine: Do not push the end range of your stretching exercise (no pain, all gain).
The Tibialis Anterior Stretch: This specific stretch for the Tibialis Anterior combines dynamic (with movement) and static (no movement) stretching techniques, and can be used for both prevention and treatment of injuries such as shin splints and plantar fasciitis.
Sam's Daily Five Stretches: These stretches will help you deal with the larger kinetic chain that is often involved with shin splints. The five stretches we cover with this video are: calfs, hamstrings, adductors, deep hip rotators, and hip flexors.
BEGIN MANUAL THERAPY - ASAP
We have seen significant improvements in our patients when they receive treatment during the early stages of shins splints. Below is an example of a technique that we commonly use when treating shins splints. Therapy should continue through both the acute and sub-acute stages
4 Point Dorsi Flexion Protocol - Motion Specific Release: Dorsiflexion is the movement at the ankle joint where the toes are brought closer to the shin. The muscles of the shins help your foot to clear the ground during the Swing Phase (concentric contraction) of your stride, and absorb much of the impact shock during running. (This MSR protocol will be available to the public June 10/2020)
THE SUB-ACUTE PHASE - THE RETURN TO RUNNING
Intensity: Reduce previous training by at least 50%. Never push through pain.
Cross Train: Perform low impact activities, such as water running or cycling.
No Hills: Avoid hills and uneven surfaces when returning to running. Hill training is great, but not when you are recovering from shin splints.
Mobility Training: Perform appropriate flexibility and self-myofascial release exercise. below in an example of a myofascial release exercise we often recommend.
Myofascial Release of the Shins: Great Exercise for all runners, or anyone with shin splits. This video covers several ways to release myofascial restrictions in your shin muscles using foam rollers, and a tiger tail or rolling pin.
Perform eccentric calf strengthening (Eccentric Calf Raises). Integrate core stability development programs for the hips, abdominals, and gluteal region.
Calf Strengthening - Eccentric Calf Raises & Pulsations: The Eccentric Calf Raise is a great way to increase calf strength, without causing further injuries. These dynamic calf-pulsations are ideal exercises for improving sports performance and power. This is an advanced exercise, so before attempting this exercise, make sure you can easily perform the standard Eccentric Calf Raises & Pulsations.
Foot & Ankle Strengthening Routine - Using a Theraband: This foot and ankle strengthening routine works the flexor, extensors, internal and external foot rotators using a Theraband.
Core Exercise - Front Plank: In this video, we show you how to perform both the Beginner and the Standard plank. Both are great core exercises that work to stabilize the shoulder and strengthen the muscles of your core. Ensure that you only do this exercise within your pain-free zone.
Mountain Climbers (2 versions) - Great Core Exercise: This is a great core stability exercise. You can also perform this exercise on a Swiss-Ball to make it more challenging.
Integrating balance training is a critical aspect of neuromuscular re-education. This will increase joint and postural stabilization, and decrease the likelihood of further occurrences on injury.
Balance Exercises with the Bosu Ball: Balance Exercises - Here are some great suggestions on how to improve your balance using a Bosu Ball (or wobble board). Balance is essential for both rehabilitation and sports performance.
Do NOT ignore the pain of shin splints, especially if the pain is getting worse and you have it for a while. See a practitioner who is going to take the time examining you to get the right diagnosis. If you are suffer from an acute injury, take the steps you need to recover so that the issue does not become a chronic problem.
If you have shins splints, and you are in Calgary just give us a call at Kinetic Health. We will do our best to get you back on the running paths.
Dr. Brian Abelson DC.
Bennett, J. E.; Reinking, M. F.; Pluemer, B.; Pentel, A.; Seaton, M.; Killian, C., Factors contributing to the development of medial tibial stress syndrome in high school runners. Journal of Orthopaedic & Sports Physical Therapy 2001, 31(9), 504-510.
Brian Abelson, Kamali Abelson, Release Your Pain: 2nd Edition Resolving Soft Tissue Injuries with Exercise and Active Release Techniques Rowan Tree Books Ltd.
Brian Abelson, Kamali Abelson, Resolving Plantar Fasciitis Rowan Tree Books Ltd.
Butler, R. J.; Crowell, H. P.; Davis, I. M., Lower extremity stiffness: implications for performance and injury. Clinical Biomechanics 2003, 18 (6), 511-517.
Galbraith RM, Lavalee ME (2009). 'Medial Tibial Stress Syndrome: Conservative Treatment Options', Current Reviews in Musculoskeletal Medicine, 2(3), pp. 127-133. (Level of Evidence: 3a)
Heiderscheit, B. C.; Chumanov, E. S.; Michalski, M. P.; Wille, C. M.; Ryan, M. B., Effects of Step Rate Manipulation on Joint Mechanics during Running. Medicine & Science in Sports & Exercise 2011, 43 (2), 296-302.
Madeley, L. T.; Munteanu, S. E.; Bonanno, D. R., Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: A case-control study. Journal of Science and Medicine in Sport 2007, 10 (6), 356-362.
Sarwark, John F. Rosemont, Ill.: Essentials of musculoskeletal care. American Academy of Orthopaedic Surgeons. 2010.
Thacker SB, Gilchrist J, Stroup DF, Kimsey CD (2002). 'The prevention of shin splints in sports: a systematic review of literature'. Medicine & Science
Compartment Syndrome-OrthoInfo - AAOS"
Stress Fractures in the Female Athlete https://www.uwhealth.org/sports-medicine/clinic/stress-fractures-in-the-female-athlete/13070
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publications which will be available later this year.
Dr. Abelson is the owner of Kinetic Health, a partner in BKAT Motion Specific Release, and a partner in Rowan Tree Books.
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