"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
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 commonly caused by repetitive motion, with the impact force of each runner's stride subjecting the shins to forces amounting to two to three times their body weight. If shin muscles (dorsi flexors) are not currently strong, elastic, and flexible, they can be easily overwhelmed by these high levels of force. Key factors to consider include:
Running on uneven or hard surfaces, or using worn-out running shoes, which can lead to significant damage.
Biomechanical factors during diagnosis and evaluation, such as hyper-pronation, foot arch height, and unequal leg length (which may occur due to pelvic rotation).
The shin muscles, also known as dorsiflexors, perform the motion of dorsiflexion when contracting, pulling the foot up towards the shins.
Managing foot plantar flexion is not limited to linear motion. The foot experiences both rotational forces (pronation and supination) and side-to-side movements during running.
The dorsiflexor muscles also control plantar flexion through a process called eccentric contraction, which occurs when a muscle lengthens while under tension.
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 rank among the most prevalent and potentially severe overuse injuries. They are characterized by an incomplete fracture typically resulting from repetitive, forceful actions, as opposed to most other fractures that are caused by a single, direct, traumatic impact (2,8).
In the early phase of shin splints, runners often observe a decrease in pain intensity after the initial few kilometers. In contrast, pain from a stress fracture tends to escalate gradually during running, starting as a mild irritation and eventually becoming intolerable as the run progresses. Hence, during the initial stages of shin splints, a clear distinction can often be made between the two conditions.
However, the diagnostic challenge arises when pain in the advanced stages of shin splints becomes so severe and persistent that it becomes difficult to ascertain whether a stress fracture is the actual underlying cause. This is why it is essential to seek professional advice at the earliest possible stage.
Several diagnostic procedures can be employed by sports practitioners to help differentiate between various conditions related to shin pain.
Regrettably, routine X-rays are usually not among those tests, as they are often ineffective in detecting stress fractures. A more suitable diagnostic tool would be a bone scan or magnetic resonance imaging (MRI), both of which are significantly more sensitive in identifying these fractures (8).
The left image demonstrates a standard X-ray without any indication of a stress fracture, whereas the right image, a bone scan, prominently displays a stress fracture in the tibia.
From a symptomatic standpoint, certain physical examination findings can hint at the presence of a stress fracture. For instance, a stress fracture often presents with a specific point of tenderness on the tibia, as opposed to the more widespread pain typically associated with shin splints.
It is important to note that female athletes with irregular or absent menstrual cycles are at an increased risk for stress fractures. Insufficient caloric intake can lead to energy imbalances, which in turn can result in low estrogen levels and negatively impact bone health. Estrogen imbalances should be considered in any female athlete who develops stress fractures (11).
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.
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).
In summary: 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 process for shin splints is comprehensive, as it is crucial to accurately diagnose the condition and identify any underlying issues that may contribute to the development of shin splints. During the assessment, healthcare professionals perform a series of orthopedic tests to evaluate the musculoskeletal system, a lower extremity neuro exam to assess the nervous system, and a vascular exam to ensure proper blood flow to the affected area.
If the findings warrant further investigation, imaging studies may be advised to better understand the extent of the injury and eliminate the possibility of other issues, such as stress fractures or compartment syndrome. This comprehensive assessment allows healthcare professionals to formulate a suitable and efficient treatment plan, customized to address each patient's specific requirements. In the following demonstration video, you will see various tests that we commonly employ for shin splints. As demonstrated, our examination extends beyond the shins, encompassing regions above and below the primary area of concern, to ensure 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 relationship between shin muscle strength and shin splints is a crucial factor in understanding the development and prevention of this common running injury. Weakness in the shin muscles, particularly the dorsiflexors, can lead to increased stress on the surrounding tissues and result in shin splints. By examining this correlation, we can better appreciate the importance of strengthening and conditioning exercises in both preventing shin splints and promoting a faster recovery. First let’s consider normal runner verses elite runners.
While running, observe the runners in your vicinity. You might be astonished by the number of runners producing a slapping sound as their feet make contact with the ground. Each of these runners may be prone to shin splints.
Runners with weak dorsiflexors are more likely to slap the ground during each foot strike. This ground-slapping phenomenon occurs due to the runner's inability to control foot motion while lowering the foot to the ground, which is attributed to eccentric contraction.
Slow Verses Fast Running
An additional aspect to take into account is that slower runners tend to slap the ground more frequently compared to faster runners. This observation is intriguing, as faster or elite runners exert greater force on the ground, yet they are not only quieter but also less prone to injury. The reason behind this is that most elite runners possess robust, elastic dorsiflexor muscles, enabling them to better control their foot's movement during landing. In essence, they have efficient shock absorbers capable of dissipating the impact of each stride.
Some of the most silent elite runners are East African marathoners, who are barely audible as they run. A significant number of these runners have developed exceptionally strong dorsiflexor muscles by running barefoot throughout their lives. This strength in dorsiflexors might be one contributing factor to East Africans' domination of major marathons globally for decades.
For instance, in the 2009 Paris Marathon I participated in, the winner was Tadesse Tola from Ethiopia, who finished with a time of 2 hours, 6 minutes, and 40 seconds. Witnessing runners maintain such impressive speeds with each quiet stride is truly remarkable.
So, how does that work?
Elite runners recycle about half their energy through elastic recoil. This process resembles a spring mechanism, where each stride loads and releases the spring. A crucial component of this incredible spring mechanism is the strength and elasticity of the dorsiflexor muscles.
The impact experienced by your legs is also related to stride frequency. By slightly increasing your stride frequency by 10%, you can significantly reduce the ground impact on your tibia, thus decreasing your risk of developing shin splints (6).
Treatment of Shin Splints
The majority of medial tibial stress syndrome (shin splints) cases can typically be managed without surgical intervention. The conventional approaches to treating shin splints are primarily divided into acute and sub-acute phases, with specific interventions tailored to each phase to ensure optimal recovery and prevention of further complications. These interventions may include rest, icing, compression, elevation, stretching, strengthening exercises, and manual therapy, all customized to address the unique needs of each individual patient during the respective phases of recovery.
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.
6-Minute Intermediate Plank Routine
This routine consists of four 90-second sets, with 30 seconds of rest between each set. Before attempting this intermediate core plank exercise, it is recommended to practice the 4-Point Core Plank Stabilization - Beginner Protocol for a few weeks to develop slow-twitch muscle fibers. Once you can comfortably complete 3-4 sets of the intermediate routine, you may progress to the advanced level.
Balance Training
Incorporating balance training is a crucial aspect of neuromuscular re-education, as it contributes to improved joint and postural stabilization while decreasing the likelihood of repeated injuries. The following is an example of an advanced balance routine that we recommend to our patients after they have successfully completed the initial exercise program. This advanced routine aims to further strengthen and refine their neuromuscular control and stability for better injury prevention.
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, accurately diagnosing and treating shin splints requires a comprehensive understanding of the condition, its potential underlying causes, and effective therapeutic approaches. By considering the importance of rest, manual therapy, strengthening exercises, mobility training, and balance training, practitioners can develop customized treatment plans to address shin splints in a targeted and effective manner. Early intervention is crucial for preventing further complications and ensuring a successful recovery. Through proper management and adherence to these strategies, athletes can safely return to their activities while minimizing the risk of recurrent injuries.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
Revolutionize Your Practice with Motion Specific Release (MSR)!
MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.
Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.
Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.
With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!
References
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.
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.
Abelson, B.; Abelson, K. (n.d.). Resolving Plantar Fasciitis. Rowan Tree Books Ltd.
Butler, R. J.; Crowell, H. P.; Davis, I. M. (2003). Lower extremity stiffness: implications for performance and injury. Clinical Biomechanics, 18(6), 511-517.
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)
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.
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.
Sarwark, J. F. (2010). Essentials of musculoskeletal care. American Academy of Orthopaedic Surgeons. Rosemont, Ill.
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.
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.
Disclaimer:
The content on the MSR website, including articles and embedded videos, serves educational and informational purposes only. It is not a substitute for professional medical advice; only certified MSR practitioners should practice these techniques. By accessing this content, you assume full responsibility for your use of the information, acknowledging that the authors and contributors are not liable for any damages or claims that may arise.
This website does not establish a physician-patient relationship. If you have a medical concern, consult an appropriately licensed healthcare provider. Users under the age of 18 are not permitted to use the site. The MSR website may also feature links to third-party sites; however, we bear no responsibility for the content or practices of these external websites.
By using the MSR website, you agree to indemnify and hold the authors and contributors harmless from any claims, including legal fees, arising from your use of the site or violating these terms. This disclaimer constitutes part of the understanding between you and the website's authors regarding the use of the MSR website. For more information, read the full disclaimer and policies in this website.
#ShinSplints #SymptomsofShinSplints #CausesofShinSplints #DifferentialDiagnosisforShinSplints #StressFractures #CompartmentSyndrome #ChronicCompartmentSyndrome #AcuteCompartmentSyndrome #TreatmentShinSplints #KineticHealth #BrianAbelson #MotionSpeciifcRelease #MSR #runninginjury #calgary #chiropractor #nwcalgary #royaloak