Shin Splints (Medial Tibial Stress Syndrome – MTSS)

Shin splintsShin splints is ‘THE’ running injury. However, the term ‘shin splints’ is a bit of an umbrella term which covers up to 30 different conditions which all cause pain at the front of the lower leg. ‘True’ shin splints is now often called ‘Medial Tibial Stress Syndrome’, amongst other, less accurate terms.

Symptoms of Shin Splints

The typical symptoms of shin splints (MTSS) include pain in the lower half of the shin, just to the inside of the shin bone. The pain is usually difficult to pinpoint to one spot and there may be tenderness when pressing along the inside of the shin bone. The pain is usually worst when you first start to run and then eases as you warm-up. It is often then bad again the next day.

What is it?

MTSS is now thought to be caused by stress on the inner side of the Tibia, or shin bone. There have been many theories over the years from muscle tension to traction on the periostuem lining the bone, but this current concept seems most feasible.

The thinking is that we run, certain forces are applied to the bone. Compression forces are fine, the bones can deal with those nicely. However, other forces including torsional and shearing forces are more difficult for the bone to deal with and repeated forces like these lead to an overload of the cortical layer of bone (on the outside). Overtime this causes tiny cracks in the bone, which if left, can develop into a full stress fracture.

What causes it?

Increased torsion and shearing on the medial Tibia are caused by factors such as overpronation and weak hip rotator muscles. Add this to training errors such as a sudden increase in training or not allowing enough rest and shin pain can soon develop.

Pronation is a movement at the foot, whereby the foot rolls in and the arch flattens as we place all of our weight on that foot. Pronation is normal and healthy, overpronation is not. Excessive or very rapid pronation like this causes an increase in internal rotation of the Tibia. Combine this with an external force coming from the Femur (thigh bone) above as occurs in many runners due to weak hip muscles and you have a shearing force on the bone which it finds difficult to deal with.

In addition, a lateral heel strike coupled with the more medial compression force from the Femur above, results in a torsional, bone bending force. Another force the Tibia struggles to deal with.

On top of all of this, overpronation increases the stress on the muscle groups which try to control it. For example, as the foot pronates the Tibialis posterior muscle (which supinates the foot normally) contracts eccentrically (i.e. it lengthens as it contracts) to try to slow down and control this excess movement. If this keeps happening, the muscle can become overworked and creates a further traction force on the medial Tibia.

Running shoes should be suitable for both the individual and the event and not be worn out. Overpronators need motion control or support shoes and those with a severe problem may need addtional orthotic inserts as well. As a general rule of thumb, replace trainers every 400 miles. This sounds a lot, but if you run 20 miles a week, that’s just 20 weeks or 5 months. Trainers may not even look worn at this point, but the amount of cushioning and support deteriorates quickly. Just imagine your whole body weight pounding down on them with every step!

Whilst running is the main cause, footwear outside of running should also be considered as flat, unsupportive footwear when walking day-to-day will not support the arch adequately and increase stress on the muscles and bone.

 Shin Splints Treatment

The treatment of shin splints should start with rest. Don’t continue to run as this will only make it worse and mean you’ll need longer out of action eventually in order to let it heal. Rest from running and from any excessive walking and ensure you wear supportive, cushioned footwear when you are walking anywhere.

Apply ice to the shin for 10 minutes at a time, every 2-3 hours, or as often as possible. This will help to reduce pain and inflammation. A Doctor may also prescribe anti-inflammatory medications to help with this.

A compression support may be worn to help with muscle warmth and so flexibility, as well as mild compression which has been shown to help with bone remodelling. There is no harm in wearing something like this although the jury is still out as to whether they really work, but I have had clients who swear by them.

Get stretching!

Start stretching all muscles of the lower leg – calf and shin muscles, at least 3 times a day, if not 5 or more! To really increase the flexibility of a muscle group you need to be stretching it this often. To stretch the calf muscles:

  • Stand on a step with the forefoot on the step and the heel hanging off the back.
  • Hold onto a wall or banister and slowly lower the heel down below the level of the step until a stretch is felt in the calf muscles.
  • Hold for 20-30 seconds.
  • Then bend the knee slightly. You should feel the stretch move lower in the calf, around the achilles area.
  • Again, hold for 20-30 seconds.
  • Repeat the straight leg, Gastrocnemius stretch and then repeat the bent leg Soleus stretch so each is performed twice.

Stretching the shin muscles isn’t quite so straightforward. You may see stretches demonstrated where you essentially sit back on your heels with the shins on the floor and knees bent. These should be performed with caution as a lot of weight is put through the front of the ankle in a maximally plantarflexed position. Don’t do this if you have any existing or previous ankle injuries. An alternative involves a similar position, but stretching one leg at a time (so the weight is on the other) and actually lifting the knee up using the hands to increase plantar flexion and the stretching sensation.

As well as stretching, I would highly recommend sports massage for shin splints. This helps increase flexibility of the calf muscles as well as the shin muscles. It encourages blood flow for healing and just ensures all soft tissues are in good condition to reduce the stress on the bones.

Footwear

If you haven’t had a gait analysis, make sure you get one before you consider running again. Even if you had one before, but maybe a few years ago, consider going again as things can change and the initial analysis may not have been accurate.

Specialist running stores or a podiatrist are the best places to go for this. It is not enough to simply look at arch height as it is the movement of the Subtalar joint which is really important to the decision over what running shoes you need. The arch of your foot when stood still has very little imput, so don’t trust someone who simply looks at your feet and states that you overpronate or don’t! A specialist can then recommend the right running shoes for you and also if you need insoles for your day-to-day shoes.

Returning to Running

As a big cause of shin splints is overuse and running too much too soon, make sure you don’t make the same mistake on returning to running. When you can start running again is difficult to judge with shin splints as in most cases, sufferers don’t feel any pain until they run.

My advice is to rest until you have made clear improvements in your calf and shin muscle flexibility and you have addressed possible causes. If you need insoles in your day shoes or if you have changed to a different type of running shoe, take some time to adjust to these before you start running again. Go for walks in them first and make sure this causes you no pain, either at the time or in the following days.

Once you are sure you are ready to return, start with a very short jog. 10 minutes max. The good thing is that you will know almost as soon as you start whether you still have a problem. If you feel any pain, stop immediately, walk home and apply ice for 10 minutes. Return to treatment and seek more advice.

If all goes well, have three days rest and then try again, same distance, same steady speed. Have another three days rest, always continuing with stretches and other treatments. Start to steadily increase the time you spend running, by no more than 5 minutes per increase and don’t increase distance more than once a week, running two – three days per week.

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