Runners vs Shin Splints
A poor training structure is going to get you … mediocre results
What are shin splints?
Medial tibial stress syndrome (aka shin splints) is an overuse injury or repetitive load injury of the shin area that leads to persistent dull pain in the front of the leg.
2 examples of getting shin splints for runners:
The weather is starting to get nicer, someone with 0 background of running, or hasn’t run for a while starts running for a week -> signs up for a marathon-> as they go through the marathon the shins start hurting
Summer of doing nothing, wants to do a cross country run when school starts-> first week of school, does running training for 5 days a week.
Both scenarios have one thing in common: A significant change in load within a short period of time.
Risk Factors of shin splints
Newer runners
Big changes in activity levels
Aggressively swinging either the intensity of your workouts. Ie. Going from no work outs to 2 hard workouts a week. Or, Ie. going from running 15 miles a week to 45 miles a week
Different locations of shin splints:
Most common: medial tibia pain; Many other tissues can also be affected such as the front or outer part of the leg (anterior tibialis); Or the outer part of leg (peroneal muscles); Or inner lower leg pain (posterior tibialis)
Differential Diagnosis
Shin splints vs Exertional compartment syndrome:
Exertional compartment syndrome is an increase in pressure in the compartment of the lower limb, occurring when it feels a deep achy sensation as you do more endurance running -> swelling and sometimes changes in skin integrity, shiny, super tight and taught -> usually all over the lower leg area.
Requires to see a doctor and is more uncommon compared to shin splints.
Shin splints vs Stress fractures:
Generally speaking with stress fractures, it’ll be very pinpoint specific localised pain. Eg. sharp localised pain that doesn't go away with running
Sometimes with shin splints you feel it in the beginning of the run, and it goes away, and you feel it towards the end
If you have a stress fracture then you will feel it all through the run, and you might wake up at night time from the pain
If indicated a hop test conducted by a physiotherapist would help differentiate between shin splits or a potential stress fracture:
If there is a potential stress fracture you would need to get it checked out. You only need to stop running if you get a stress fracture, until further investigations by a specialist.
Stress fracture of the tibia shown on X-ray
Shin Splint Running Rehab
Generally, there’s 6 steps to running rehab that your Physiotherapist should touch up on throughout your rehab.
Education
Strength training
Running plan
Nutrition
Recovery
Competing
For the competitive or recreational runners, your FIRST step would be: Getting into the proper mindset
“Adjust short term running goals for the long term goals that you want to obtain”
Modifying intensity and frequency
Realising that things would need to be modified: We really don't want to go through the drastic “no running for 3-4 days and then go running for 4-5 days straight, and expect that the shin pain doesn't come back”
You're going to have to be okay with modifying your plan that you and/or your coach is working on and actually turn down the intensity of the run. So if you're doing speed work, perhaps doing some more interval work on the track, and taking it down a notch, substituting to some threshold and tempo training.
Higher speed -> more force from foot to shin bone -> increased pain in people that have shin splints
If you decide to ignore symptoms, you are risking dis-progressing and irritating the periosteum…Research shows that a lot of the inner bone that have this repeated inflammation of the outer periosteum, the bone density is actually less -> so you’re more at risk of getting an actual stress fracture.
Shin Splint Management
Old OUTDATED Model
Drumroll…. It’s the RICE protocol which is the promotion of resting, trying some ice, and the usage of anti inflammatories.
The usage of RICE protocol is common information a lot of runners are given from many health care providers. Unfortunately it tends to lead to a constant injury cycle.
Updated Model Of Management
In 2020, an article from the British Medical Journal has proposed the management structure called PEACE & LOVE as opposed to RICE.
P - Protection: Avoiding activities and movements that increase the pain during the first 3 days (Ie. change terrains, runs)
E - Elevation: May be beneficial in shin splints if there is inflammation
A - Avoiding Long term usage of anti-inflammatories: our body does need some inflammation to stimulate the next healing process. If someone that has shin splints chronically for weeks and is just taking NSAIDs, not allowing the body to get to the next phase of healing where the body actually starts to remodel is not a good idea.
C - Compression: Compression socks are a great thing for the short and long term wise, and may help to reduce swelling and discomfort.
E - Education: Gaining a good understanding of shin splints.
LOVE: After the first few days has passed, we need LOVE.
L- Load: Strengthening muscles, adding mechanical load to stimulate collagen formation to aid healing. Allowing pain to guide your gradual return to activities.
O - Optimism: Conditioning your brain for optimal recovery by being confident and positive
V - Vascularisation: Promoting exercise, even using the elliptical instead of running can help improve blood flow. At this time, manual therapy, cupping, and dry needling can help as well.
E - Exercise: Restore strength, mobility and proprioception by adopting an active approach to recovery
If you are experiencing shin splints the general approach is to reduce training load and inject as much variety in your training load. So, what external factors work well?
Running shoes: Have at least 2 or 3-4 shoes rotating throughout the week. Ie. one that has 100, 200, 400 miles in it, as it allows different forces to be applied to your shins
Variability in surface: A misconception is running outside is bad for your joints. This is untrue, as your muscles adapt to the demands, and soften the load.
Treadmill runners often develop more shin splints as there is less variability, could be from bounce on the treadmill, you often land down harder. I would encourage indoor treadmill runners to mix it up a bit and add some outdoor training especially if your goal is to be good at an outdoor sport. Eg. 3 days treadmill and 2 days outdoor as opposed to 5 days treadmill.
One of the problems with treadmill running is its similarity to running downhill. As your heel hits the treadmill and is dragged backwards, the accelerated motion is similar to downhill running and can cause painful shin splints if you lack the muscle strength in your shin and surrounding muscles. An easy fix is to adjust the treadmill incline. The incline should be at least “1” at all times. You can vary the incline by a degree or two every mile to make it feel more like outdoor terrain.
Generally speaking, if your shins hurt after a run, the next run should be as different as you can make it, (ie. change shoes, shift from hard to soft surface etc.)
Training To Prevent Shin Splints
Running Biomechanics vs Shin Splints
A large heel strike where the front foot lands can lead to shin splints, and is generally due to runners OVER STRIDING
Usually someones really reaching out when they run, their center of mass when they land their foot is way in front of the knee, it's like running with the emergency brakes on. Heel smacks the ground and it sends the force through the shin (studies show anywhere between 3-6 times our body weight is going through the ground) —> The solution is to take short quick steps when running, trying to land underneath your knee when the foot hits the ground
Research shows that those with lower step rate (cadence) are at risk for overstriding. Therefore increasing your step rate can help improve over-striding. Ie. If your cadence is 140, which is quite low, aim for gradually achieve 180. Ie, try 150, 160, 170 then 180.
Collapsing gait pattern
For the female runner, research says that there is a tendency for running gait pattern called “collapsing gait pattern”. This may lead to a pelvis and hip drop, knees may go in, results in a lot of torsional type force, and it’s common to see these people get shin splints too.
Usually there's some sort of underlying weakness (Motor control issue of the muscles not turning on because you don’t know how to turn them on. Or you had previous knee injury ie. ITB symdrome or achilles tendinopathy. When you had those injuries, your side hip muscles may shut off because you had pain. When we get pain the brain says “i’m going to protect this area, I’m not going to activate certain muscles”. Sometimes if you don’t activate those muscles and wake them up, they can still be sleeping for a while. And you might be running for a while and not be turning those muscles on.”)
Common muscle groups in shin splints is weakness in the side hip muscles (Gluteus Medius and Gluteus Minimus)
Starting a strength and conditioning program with exercises that target these muscles involve internal rotation and abduction of the hip, and as you progress, add in some plyometrics.
Orthotics do a good job in stopping motion of the foot in the short term BUT
the long term usage of orthotics may lead to stiffness in foot, ankle joint and a lot of atrophy of the deep foot muscles which help stabilise the structures in the foot.
Ultimately, you want the foot to do the work, not the orthotic, and if the orthotic is doing the work, the foot is no longer up for the task of doing the work, and that’s a dangerous space to be in.
Train smart with proper progression: 10% guideline (it states that you should never increase your weekly mileage by more than 10 percent over the previous week. To be safer, even go less than 10% increase per week).
+++ Note that 10% is a guideline and specific changes will differ depending on each individual+++
If you’re starting out as a novice, take your time to know the actual sport. Have a running plan that is appropriate for your body to tolerate.
How to interpret a training plan, and pick the right plan for you
Look at first week at training plan, that should be easy
The peak of the training plan should not be more than about 10% of what you did in the past
If these 2 boxes are checked, then the program is probably a good fit for you.
Barefoot training
Activating short foot muscles. Strength training in less supportive shoes will allow you to feel the ground and feel the intrinsic foot muscles. Taking it to the next level is to do some short runs on the grass (barefoot running).
Static stretching
Static stretching can help for tight calves (ankle mobility). It reduces the risk of straining the calf muscle when you’re running and also reduces the strain on other compensatory muscles.
Final Thoughts
Shin splints are extremely common but also persistent. The risk of getting shin splints doesn't mean that you can't run. Instead it means that you should develop a strong running body so that you can withstand a training cycle, or train for a race. Lastly, it’s not going be that one training cycle that’s going to give you the best result that you’ve been yearning for, it’s going to take months and years to build and put you in the position to succeed.
Hope this helps.
Your friendly neighbourhood Physio,
Tony
Resources
Barefoot running survey: Evidence from the field.
Retrieved from: https://www.sciencedirect.com/science/article/pii/S2095254614000337
Dubois, B., Esculier, J. (2019). Soft-tissue injuries simply need PEACE and LOVE
Retrieved from: https://bjsm.bmj.com/content/54/2/72
Gabbett, T. (2016). The Training - Injury prevention paradox: should athletes be training smarter and harder?
Retrieved from: https://bjsm.bmj.com/content/50/5/273
Heiderscheit, B., Chumanov, E., Michalski, M., Wille, C., Ryan, M. (2012). Effects of Step Rate Manipulation on Joint Mechanics during Running
Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3022995/
Hryvniak, D., Dicharry, J., Wilder, R. (2014). How To Do Tempo Runs.
Nakagawa, T., Moriya, E., Maciel, C., Serrao, F. (2012) Frontal plane biomechanics in males and females with and without patellofemoral pain.
Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22460471/
Tocci, K. (2023). Heart rate training zones for runners: Complete Guide.
Retrieved from: https://marathonhandbook.com/heart-rate-training-zones-for-runners/
Train, J. (2008). Medial Tibial Stress Syndrome: Evidence Based Prevention.
Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386425/
Warneke, K., Brinkmann, A., Hillebrecht, M., Schiemann, S. (2022). Influence of Long-Lasting Static Stretching on Maximal Strength, Muscle Thickness and Flexibility
Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9174468/Zeitoune, G., Leporace, G., Batista, L., Metsavaht, L., Lucareli, G., Nadal, J. (2020). Do hip strength, flexibility and running biomechanics predict dynamic valgus in female recreational runners?
Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32442897/
