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Shin Splints: Too Much, Too Soon


Track Athletes Competing

Old Classic Movie "Too Much, Too Soon"

"Too Much, Too Soon" might be a fitting title for a classic film (starring Errol Flynn and Dorothy Malone, 1958), but it also aptly explains the primary reason behind the onset of shin splints for most people. Generally, shin splints occur when the tissue experiences increased stress without adequate time for adaptation, such as when distance, intensity, or duration are suddenly increased.


Article Index:


Introduction


Examination & Diagnosis


Treatment


Conclusion & References

 


Group of Runners

Symptoms of Shin Splints

The initial discomfort of shin splints can often be described as a vague ache along the inner part of the lower leg, specifically the tibia. Key characteristics of shin splint pain include:


  • Pain experienced at the start of a run, which lessens as the run progresses, and then reappears towards the end of the run.

  • In the early stages, pain typically subsides completely with rest. However, as the condition worsens, pain may be felt during both activity and rest.

  • When the pain becomes constant, it is essential to consult a medical professional to rule out other injuries, such as stress fractures or compartment syndrome.

  • Pinpointing the precise location of shin splints can be challenging, as the pain is generally spread across the soft tissue (including fascia, tendon, and muscle) rather than focused on the bone (tibia) itself.


 

Causes of Shin Splints

Shin splints are often caused by repetitive motion and the impact force of running, which subjects the shins to forces two to three times a runner's body weight. If the shin muscles (dorsi flexors) lack strength, elasticity, and flexibility, they can be overwhelmed by these forces. Key factors include:


  • Running on uneven or hard surfaces and using worn-out shoes, which can cause damage.

  • Biomechanical issues like hyper-pronation, foot arch height, and unequal leg length (often due to pelvic rotation).


The dorsiflexor muscles contract to pull the foot up towards the shins (dorsiflexion) and control plantar flexion through eccentric contraction, which involves lengthening under tension. Foot movement during running also includes rotational forces (pronation and supination) and side-to-side movements.


 


Runner

Are You Actually Dealing With Shin Splints?


When diagnosing medial tibial stress syndrome, commonly known as shin splints, it is crucial to accurately identify the condition and rule out other potential issues such as stress fractures or compartment syndrome.


STRESS FRACTURES


Stress fractures are common and potentially serious overuse injuries, characterized by incomplete fractures from repetitive forceful actions, unlike other fractures caused by direct trauma.


Early in shin splints, pain often decreases after a few kilometers, while stress fracture pain worsens during running, starting mild and becoming intolerable. This distinction helps in the early stages.


However, as shin splints progress, severe, persistent pain can make it hard to differentiate from a stress fracture. Therefore, seeking professional advice early is crucial.

Bone Scan

Sports practitioners use various diagnostic procedures to differentiate conditions related to shin pain. Routine X-rays are often ineffective for detecting stress fractures. Instead, bone scans or MRIs are more sensitive and effective.


For example, a standard X-ray may not show a stress fracture, while a bone scan clearly indicates a fracture in the tibia.


Symptomatically, a stress fracture typically presents with a specific point of tenderness on the tibia, unlike the widespread pain of shin splints. Female athletes with irregular or absent menstrual cycles are at higher risk for stress fractures due to energy imbalances leading to low estrogen levels, which negatively impact bone health. Estrogen levels should be considered in female athletes with stress fractures.


COMPARTMENT SYNDROME

Another condition that must be excluded during diagnosis is compartment syndrome. Compartment syndrome is a painful disorder characterized by pressure buildup within the muscle compartments to dangerous levels. This increased pressure can lead to reduced blood flow, subsequently depriving nerve and muscle cells of essential oxygen and nutrients. Compartment syndrome can present as either acute or chronic (10).


The lower leg compartments are divided into four rigid sections, bound by robust fibrous tissue (deep fascia) and bones. These compartments contain the following muscle groups: anterior, superficial posterior, deep posterior, and lateral. Familiarity with this anatomy can greatly assist in the treatment process and facilitate the successful resolution of shin splints.


Sprinters

Chronic Compartment Syndrome


Chronic Compartment Syndrome, also known as Exertional Compartment Syndrome, is not a medical emergency and can often be managed with manual therapy techniques (MSR, FAKTR, ART, Graston, etc.). In runners, the pain associated with Exertional Compartment Syndrome typically arises within the first 15 minutes of running and subsides within an hour post-run. A medical practitioner can measure the pressure within these compartments (2).


Acute Compartment Syndrome


Acute Compartment Syndrome is a potentially severe, limb-threatening condition. Any delay in treatment can result in complications, infection, and even limb amputation. Acute Compartment Syndrome typically occurs following a traumatic event, such as traumatic fractures, crush injuries, burns, tight bandaging after surgery on blood vessels, or even extremely intense exercise (particularly eccentric movements – extension under pressure) (2).


Note: If you suspect a stress fracture or compartment syndrome, it is crucial to seek the assistance of a medical practitioner as soon as possible.


 

Examination Process


The examination for shin splints is thorough to ensure accurate diagnosis and identify underlying issues. Healthcare professionals conduct orthopedic tests to evaluate the musculoskeletal system, a lower extremity neuro exam for the nervous system, and a vascular exam to ensure proper blood flow. If needed, imaging studies like X-rays, bone scans, or MRIs may be recommended to further assess the injury and rule out conditions like stress fractures or compartment syndrome. This comprehensive assessment helps in creating an effective, customized treatment plan.


The following demonstration video shows various tests used for shin splints, covering areas above and below the shins for a holistic evaluation.


Knee Examination


Effective Orthopedic Assessment Procedures - This video provides an overview of the frequent causes of knee pain and demonstrates how to identify them through orthopedic examination techniques.




Ankle and Foot Examination


This video employs orthopedic tests to assess several prevalent ankle and foot conditions encountered in clinical practice. These conditions encompass Ankle Sprains (inversion sprain), Cuboid Syndrome, Talar Dome Lesions, 5th Metatarsal Fracture, Syndesmosis injury, Achilles Tendon Tendinopathy, Morton's Neuroma, 2nd Metatarsal Stress Fracture, Plantar Fasciitis, and Bunions.


Peripheral Vascular Examination - Key Points


A peripheral vascular examination serves as an important method for identifying indications of vascular-related pathologies. Recognizing and addressing PVD may help prevent cardiovascular and cerebrovascular complications. This video covers several standard procedures routinely performed in clinical practice.


 

Shin Muscle Strength & Shin Splints

The strength of shin muscles, especially the dorsiflexors, plays a key role in preventing and managing shin splints. Weak dorsiflexors increase stress on surrounding tissues, leading to shin splints. Strengthening these muscles is essential for both prevention and faster recovery.


Observe runners around you. Notice how many produce a slapping sound as their feet hit the ground. This sound often indicates weak dorsiflexors, which prevent proper foot control during running, increasing the risk of shin splints. Incorporating conditioning exercises to strengthen these muscles can help prevent this common running injury and promote quicker recovery.

Slow Verses Fast Running

An interesting observation is that slower runners tend to slap the ground more often than faster runners. Despite exerting greater force, elite runners are quieter and less prone to injury. This is because elite runners have strong, elastic dorsiflexor muscles, allowing better control of foot movement during landing. Essentially, their efficient shock absorbers dissipate the impact of each stride effectively.

Group of Marathon Runners

Some of the quietest elite runners are East African marathoners, known for their almost silent strides. Many of these runners have developed exceptionally strong dorsiflexor muscles by running barefoot throughout their lives, which may contribute to their dominance in major marathons worldwide.


For example, in the 2009 Paris Marathon, the winner was Tadesse Tola from Ethiopia, finishing in 2 hours, 6 minutes, and 40 seconds. It's truly remarkable to see runners maintain such impressive speeds with each quiet stride.


So, how does that work?


Elite runners recycle about half their energy through elastic recoil, similar to a spring mechanism that loads and releases with each stride. The strength and elasticity of the dorsiflexor muscles are key to this process.


Impact on your legs is also linked to stride frequency. Increasing your stride frequency by just 10% can significantly reduce the ground impact on your tibia, thereby decreasing the risk of developing shin splints.

 

Woman Stretching

Treatment of Shin Splints


Most cases of medial tibial stress syndrome (shin splints) can be managed without surgery. Treatment is typically divided into acute and sub-acute phases, with specific interventions for each phase to ensure optimal recovery and prevent complications. These interventions include rest, icing, compression, elevation, stretching, strengthening exercises, and manual therapy, all tailored to the individual needs of each patient.



ACUTE PHASE OF SHIN SPLINTS


Let's begin by examining the Acute Phase of shin splints. The following are some recommendations provided to patients during the Acute Phase of shin splints. Please note that specific recommendations may vary from case to case:


  • Rest is essential: Athletes often dislike this recommendation, especially when informed that they need to rest for approximately 2 to 6 weeks. However, rest is crucial for effective recovery.

  • Use ice during the acute phase: Patients are advised to apply ice for 15 to 20 minutes, 4 to 6 times per day. Direct ice massage can also be performed but should be limited to 7 to 9 minutes, 3 or 4 times per day.

  • Employ compression to reduce swelling: A compression sleeve or wrap can be highly effective in minimizing swelling. Ensure that the sleeve or wrap is not overly tight and permits proper circulation.

  • Elevate the legs: This is particularly beneficial at night. Ensure that the legs are elevated above the heart level, helping to alleviate both pain and swelling.

  • Conduct a gentle stretching routine: Avoid pushing the end range of your stretching exercises (no pain, all gain).


Examples of effective stretching exercises: Tibialis Anterior Stretch and Sam's Daily 5 (stretch a larger kinetic chain).


Tibialis Anterior Stretch

This particular stretch for the Tibialis Anterior incorporates both dynamic (with movement) and static (no movement) stretching techniques. It is useful for both the prevention and treatment of injuries, including shin splints and plantar fasciitis.




Sam's Daily Five Stretches

These stretches address the broader kinetic chain frequently associated with shin splints. The five stretches covered in this video target the following muscle groups: calves, hamstrings, adductors, deep hip rotators, and hip flexors.





 

MANUAL THERAPY


Substantial improvements have been observed in patients who undergo treatment during the early stages of shin splints. The following is an example of a technique frequently employed in the treatment of shin splints, which should be continued throughout both the acute and sub-acute phases.

Increasing Ankle Mobility - 4 Point Dorsi Flexion Protocol (MSR)

Dorsiflexion refers to the motion at the ankle joint in which the toes are drawn closer to the shin. The shin muscles assist in lifting the foot off the ground during the Swing Phase (concentric contraction) of a stride and absorb a significant portion of the impact shock during running.


 

Sub-Acute Phase - Return to Running

  • Intensity: Decrease prior training intensity by a minimum of 50%. Refrain from pushing through pain. Cross-Training: Engage in low-impact exercises, such as aquatic running or cycling.

  • Terrain: Steer clear of hills and uneven surfaces during the recovery period. While hill training can be beneficial, it is not advised while recovering from shin splints.

  • Mobility Training: Implement suitable flexibility and self-myofascial release exercises. The following is an example of a myofascial release exercise commonly recommended.


Releasing the Shins - Tibialis Anterior, Peroneus Longus/Brevis

An excellent exercise for runners or individuals with shin splints. This video demonstrates multiple methods for alleviating myofascial restrictions in the shin muscles using foam rollers and a tiger tail or rolling pin.




STRENGTHENING


Incorporate eccentric calf strengthening exercises, such as Eccentric Calf Raises, into your routine. Additionally, integrate core stability development programs targeting the hips, abdominals, and gluteal region to enhance overall muscle balance and support.


Calf Strengthening - Eccentric Calf Raises & Pulsations

The Eccentric Calf Raise is an effective method for enhancing calf strength while minimizing the risk of further injuries. Dynamic calf pulsations serve as an optimal exercise for augmenting sports performance and power. This is an advanced exercise; thus, ensure that you can effortlessly execute standard Eccentric Calf Raises & Pulsations before attempting this variation.


Foot & Ankle Strengthening Routine - Theraband This exercise routine targets the flexors, extensors, as well as the internal and external foot rotators, utilizing a Theraband for resistance.







 

Balance Training


Incorporating balance training is crucial for neuromuscular re-education, improving joint and postural stabilization while reducing the risk of repeated injuries like shin splints. Below is an advanced balance routine recommended for patients after completing the initial exercise program. This routine aims to further strengthen and refine neuromuscular control and stability to prevent injuries.


Improve Your Balance - Advanced

Balance exercises can be of great benefit to people of any age. Balance exercises improve your ability to control and stabilize your body's position. Balance exercises are great at reducing injury risk, rehabilitating current injuries, or increasing your sports performance.



 

Conclusion


In conclusion, preventing and managing shin splints requires a holistic approach that includes proper diagnosis, treatment, and strength conditioning. Recognizing the symptoms early and differentiating between shin splints and more severe conditions like stress fractures or compartment syndrome is crucial. Employing a combination of rest, icing, compression, elevation, and customized exercise routines can effectively address both the acute and sub-acute phases of shin splints. Strengthening the dorsiflexor muscles and incorporating balance training are essential strategies for reducing the impact on the shins and promoting faster recovery.


Furthermore, observing and emulating the running techniques of elite athletes, who often exhibit strong dorsiflexor muscles and efficient energy recycling, can provide valuable insights into injury prevention. The combination of targeted muscle strengthening, proper biomechanical evaluation, and adaptive training routines plays a significant role in minimizing the risk of shin splints and enhancing overall running performance. By integrating these practices, runners can achieve better stability, reduce injury recurrence, and enjoy a healthier, more sustainable running experience.


 

References

  1. Bennett, J. E.; Reinking, M. F.; Pluemer, B.; Pentel, A.; Seaton, M.; Killian, C. (2001). Factors contributing to the development of medial tibial stress syndrome in high school runners. Journal of Orthopaedic & Sports Physical Therapy, 31(9), 504-510.

  2. Abelson, B.; Abelson, K. (n.d.). Release Your Pain: 2nd Edition Resolving Soft Tissue Injuries with Exercise and Active Release Techniques. Rowan Tree Books Ltd.

  3. Abelson, B.; Abelson, K. (n.d.). Resolving Plantar Fasciitis. Rowan Tree Books Ltd.

  4. Butler, R. J.; Crowell, H. P.; Davis, I. M. (2003). Lower extremity stiffness: implications for performance and injury. Clinical Biomechanics, 18(6), 511-517.

  5. Galbraith, R. M.; Lavalee, M. E. (2009). Medial Tibial Stress Syndrome: Conservative Treatment Options. Current Reviews in Musculoskeletal Medicine, 2(3), 127-133. (Level of Evidence: 3a)

  6. Heiderscheit, B. C.; Chumanov, E. S.; Michalski, M. P.; Wille, C. M.; Ryan, M. B. (2011). Effects of Step Rate Manipulation on Joint Mechanics during Running. Medicine & Science in Sports & Exercise, 43(2), 296-302.

  7. Madeley, L. T.; Munteanu, S. E.; Bonanno, D. R. (2007). 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, 10(6), 356-362.

  8. Sarwark, J. F. (2010). Essentials of musculoskeletal care. American Academy of Orthopaedic Surgeons. Rosemont, Ill.

  9. Thacker, S. B.; Gilchrist, J.; Stroup, D. F.; Kimsey, C. D. (2002). The prevention of shin splints in sports: a systematic review of literature. Medicine & Science.

  10. Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioners Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.


 
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DR. BRIAN ABELSON, DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.



 


MSR Instructor Mike Burton Smiling

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