Shin splints. You’ve just shuddered, right? Not two words that any runner wants to hear. So when someone at work had to abandon a run this week due to excruciating shin pain, I thought I’d try and come up with something more helpful than the advice of one of our GP colleagues: ‘unless your foot goes blue or numb then I wouldn’t worry about it!’. He was joking, obviously, but I thought I’d dig out an article I wrote for a local running club magazine whilst I was still working as a physiotherapist two years ago. So Tim, this one’s for you!
What are shin splints?
Your guess is as good as mine. No, seriously. Shin splints is not a medical diagnosis. It’s an umbrella term for for any one of a number of problems that manifest themselves as shin pain. Everything from compartment syndrome and muscle strains to stress fractures and nerve irritation. Although this might sound picky, it matters, because the treatment is likely to be different.
What’s causing my shin pain?
Shin pain can generally be divided into four main areas. Muscular, bony, neural and vascular. In reality these four options look a little more like a venn diagram with a degree of overlap possible. A good place to start is to try and identify the predominant category. You really need a specialist assessment to differentiate here, but as a generalised rule, the following symptoms are what characterise each.
Bony pain- Usually felt on the inside of the lower third of the shin bone itself. Tenderness when the area is pressed. As it worsens will often become more focal to a specific pinpoint-able area.
Muscular pain- Pain either side of the shin one. Pain on resisted movements and when pressing into the muscle.
Vascular pain- Aching, burning and cramping in the lower leg. A sensation of tightness in the affected area. Numbness or tingling and sometimes weakness in specific parts of the foot. Occasional colour changes within the foot.
Nerve pain- Not particularly common, but will usually include some sort of sensory changes as well as burning pain. Often takes longer to settle once activity has stopped.
One of the most common medical diagnosis is medial tibial stress syndrome (MTSS). Although the exact aetiology is still a bit fuzzy, there is general consensus that a stress reaction occurs along the inside edge of the shin bone where the tibialis anterior muscle attaches. As you can see, there is already some overlap here between muscular and bony pain. Even an X-ray will often fail to differentiate the two, which is why a repeat X-ray is often performed four weeks later to look for signs of bony healing. A stress fracture can then be diagnosed in hindsight. An MRI is often a better indicator. In reality MTSS is somewhat of a continuum, although progression to a stress fracture is not guaranteed. Sometimes you end up with a constant state of healing which results in a more chronic problem.
As MTSS is probably the most frequent diagnosis in runners, I’m going to exclude vascular and nerve pain for the remainder of this article as the treatments/causes for these would likely be different.
Why me? What have I done to deserve shins of fire??
Firstly, you’re definitely not alone. Not that that’s much comfort! A recent survey in runners world ranked shin pain amongst the top three injuries. Interestingly, the incidence decreases with running experience. So what do newer runners do differently?
Increasing miles too quickly, or too sporadically and not allowing your body time to accommodate is a cardinal sin. The old school advice of adding no more than 10% of your weekly mileage is a good rule of thumb. In addition to this, having one week in every four where you reduce your training load is sensible. In reality though, some runners can get away with more than this, whist others need to be even more conservative. Knowing your own body is critical when programming your training plan.
Fact: My favourite thing about the human body is it adapts to whatever you ask it to do. But you have to give it the time to respond. It doesn’t happen in a day, or even a month. We’re all guilty of missing a run and then trying to cram it in later in the week, but that’s not how the human body works.
Muscle weakness/poor control
Okay, so we all know that one (really annoying) runner who just runs, does no strength training and is NEVER injured. In the same mould, I had a great aunt who smoked 40 a day and lived pretty healthily to the ripe of age of 93. My point is, that is not the norm. Depending on what literature you read, when you’re running anything between 3-8 times your body weight is transmitted through your lower limb with every stride. If you don’t have sufficient muscle strength and probably more importantly, control, to deal with that, then you have already set yourself up to fail.
Whilst it’s really important that strengthening exercises are tailored to your exact areas of weakness, particularly when you have an injury, a core set would usually include things like single leg squats, weighted squats, bridging, calf raises, lunges and hundreds (maybe even thousands!!) more.
One of the most common mistakes I see, is that people don’t do strengthening exercises that are challenging enough for the demands of running. A few double leg calf raises probably isn’t enough if you’re planning to increase your mileage consistently. You might might need to step up to jumping lunges, or add some weighted curtsey lunges to strengthen some of your lateral muscles, for example. Again, there are almost unlimited options here and the key is to keep your body guessing so that you are always encouraging it to adapt.
This is a tough one. When you watch Paula Radcliffe run, she doesn’t have the silky, effortless style of some marathoners, and yet she is still the fastest female of all time over 26.2 miles. I suppose what that adds up too is that biomechanics are only relevant in context. Here’s a classic example. It has long been reported that runners who habitually over stride and therefore heel strike (land with their heel first) are more prone to injury than runners who land more towards the middle of their foot. Equally though, there are certainly some runners who if you increase their cadence and encourage them to forefoot strike just become more prone to achilles problems. You have to look at an individual.
Generally speaking though, and from experience in clinic, the majority of runners who present with MTSS have recently either increased their mileage, or tried to get faster. Or, both. I’m not convinced that over striding is a guaranteed precursor to MTSS, but the majority of runners I’ve seen with MTSS over stride. Make of that what you will!
Whilst they are not the quick or magic fix that people wish they were, trainers do matter. Running in old trainers, that have lost their shape is unlikely to do much for you. The difficulty, is that finding the right trainer is like searching for a needle in a haystack. Where do you start? The pronation argument is too big to go into here. We all pronate. It’s normal. I’d be worried if you didn’t. But it makes a bit of a mockery of the existing system of putting pronators in a stability shoe etc. Trial and error is undoubtedly the best approach. If you’re lucky enough to find something that works for you, buy 10 pairs now before the shoe company discontinue your beloved find.
I don’t have all the answer here, and to be honest shoes aren’t my area of expertise. A good podiatrist would be better placed to point you in the right direction, not your average salesman who puts you on a treadmill in a shoe shop. Controversial?
Some runners have a medical condition, or genetic traits that pre-dispose them to certain problems. For example, runners with a low BMI, often females, may be more at risk of developing a stress fracture due to a hormonal reduction in bone density. On the opposite end of the spectrum, if 3-8 times your body weight is transmitted through your legs when you run, then clearly body mass matters.
People talk about shin pain as an overuse injury, but I’d be inclined to argue the opposite. Surely not adequately preparing your body for the activity you are asking it to do, makes it an underuse injury? Mind blown!
Anyway, enough waffle, how do I fix the problem?
I’m guessing that since you’re reading this, you’ve already found that burying your head in the sand doesn’t work. If you try and run through shin pain, 9 times out of 10 it’s not going to end well. So, what do you do? You rest, obviously. The problem gets better, maybe even goes away. Then you start running again. And low and behold the pain comes back. You repeat this cycle anywhere from 3 to 103 times getting more and more demoralised each time. Sound familiar?
You have to do something to force some change. So yes, you probably do have to stop running, or at least severely cut back. But doing nothing isn’t the answer either. Firstly, find something lower impact. If you were running three times a week, get on your bike, or dig out your swimsuit and get to the pool. Anything that maintains your cardiovascular fitness.
Next, you have to address the reason for the problem, and this is where you may need more than just an online article to make it specific to you. Introduce some strength training. Remember, resistance and control work is like a ladder. You can’t jump straight onto rung 10, equally staying on rung 1 isn’t the answer either. Make it progressive. You can do this by adding weight, doing an exercise on an unstable surface, making it more explosive, or any combination of these things. It needs to be tough.
Add some stretching. Make sure you have good mobility, particularly in your ankles and calfs. Consider seeing a podiatrist to discuss your footwear options. Remember that taping, dry needling, massage or any other ‘passive’ treatment technique is only ever an adjunct to the hard work you have to do to make a permanent change. They might offer temporary relief, but unless you’re incredibly lucky, that is likely to be all.
Finally, and most importantly, when your pain subsides, re-introduce running so gradually that you wonder whether it’s even worth doing. Like, think snail pace, and then slow down. At this stage, it’s rehab, NOT training. You are expecting this to take anywhere from three to six months depending on the severity of your problems at the beginning. That’s the bit that people struggle to grasp. Weirdly, they’d rather spend those 6 months bouncing between training and resting and still have shin splints at the end of it! I get it. Human beings are all about instant gratification. We’re not very good at the long game. But if you’ve gained nothing else from this article, take away the fact that there is no quick fix. Patience is king, and rehab is queen.
One final piece of advice
All of this relies on the assumption that your shin pain is muscular or bony in nature. As we talked about earlier on, the number of diagnoses for shin pain mean that I cannot recommend highly enough, getting a professional, Chartered Physiotherapists opinion to point you in the right direction. You need to know the beast to tame it. Be wary of anyone who offers you a quick fix, or tells you that you need masses of ‘passive’/hands on treatment. That’s probably more for their own benefit than yours. But, having a specialist to accurately diagnose, pinpoint all of your flaws (let’s be honest you don’t go to physio to feel good about yourself!) check you are hitting the milestones correctly and progress you in the appropriate timeframes can be worth its weight in gold. Or miles!