The Taming of the Shins

Caution Shin Splints

I’m a few kilometres into my regular run when I notice it, that familiar ache right on the shins. It starts off fairly mild so I decide to keep going and ignore it. Perhaps it’ll ease. I slow up a bit and in fact it doesn’t get much worse. A dull, nagging ache that I can keep out of mind if I concentrate on running instead. A couple of kilometres further I reach the finish and pull up. Then… A stabbing, electric pain in the shins like little lightning bolts shooting up and down the bone. Owwww! The walk home is a bit of a hobble, and I mentally cross off the next couple of days on my running calendar.

A familiar scenario for me over the last year and a half, and I dare say for plenty of other runners too. My first experience with shin splints came not long after I started running, pushing through it on the treadmill then hopping off and limping upstairs unsteadily. The pain would ease by the time I was in the shower, offering hope that maybe it wasn’t serious, but next time on the treadmill I’d be real sore again. At the time I remember feeling quite embarrassed about it. I guessed it was “shin splints” and although I didn’t really know what that meant, my preconceptions told me it was a totally avoidable, beginners ailment; a booby trap for noobs I should have tried harder to avoid. That embarrassment factor probably held me back from ever seeing a physio about it, which is incredibly silly. I did my usual “ignore it and hope it’ll go away” thing, which meant a year and a half of problems rather than getting on plan early to mitigate it. My preconceptions were off the mark. While there are ways to lessen the risk of developing shin splints it’s not entirely avoidable, especially for people with particular types of feet. It’s a very common injury for runners, especially beginners, and perhaps the best thing anyone can do is get clued up about it. And consider seeking professional advice from a doctor or physio.

Footballers, dancers, anyone who does high impact footwork can be affected by shin splints. When I spoke to New Zealand Parkour Association (NZPA) trainer Max Bell about his experience with shin splints he described it as “a dull, aching pain. Quite a mild pain that didn’t go away, like a permanent bruise.” Although the stress imposed on the legs by Parkour is not quite as repetitive as running, it’s certainly high impact. If you’re not familiar with Parkour, have a look at this video. It’s a kind of high stakes urban gymnastics which is thrilling and beautiful to watch. But it doesn’t come without its pitfalls. Quite apart from the risk of broken bones or twisted ankles there’s the common problem of shin splints.

Max Bell (photo: stuff.co.nz)
Max Bell (photo: stuff.co.nz)

I got in touch with Max after reading an excellent post on shin splints he wrote for the NZPA website. Max is an athletic guy in his mid-20s who got interested in Parkour while still in high school. He began to encounter shin problems about 6 months after he started training, but at first wasn’t sure that it was an injury at all. “It’s tricky because it’s not like a traumatic injury where you fall down and hurt yourself. It builds up over time, and at first you don’t know you’re injured so if you keep training through it, it gets worse and worse.”

So what are we talking about here? Shin splints is a term often used to refer to pain felt at the front of the lower leg, near the tibia (the leg bone that often connects with the coffee table when you’re reaching for the remote). But pain felt in this area can arise for a number of reasons, only one of which is shin splints in the strict sense of the term: medial tibial stress syndrome (MTSS). “I actually dislike and don’t use the term shin splints,” says Dr Ruth Highet, medical director of Wellington Sports Medicine, “because several other conditions that cause pain between the knee and the ankle end up getting lumped in with the term. Often when people present with pain in this area it’s not what they think it is. The important part of assessment is to sort out which patients actually have shin splints in the strict sense of the term, and who has stress fractures, compartment syndrome and other problems including vascular problems which also cause the patient to present with shin pain.” [1]

So what is shin splints ‘proper’? “Medial tibial stress syndrome (MTSS) is an overuse injury or repetitive-stress injury of the shin area. Various stress reactions of the tibia and surrounding musculature occur when the body is unable to heal properly in response to repetitive muscle contractions and tibial strain” [2]. But what, exactly, is the bit that hurts? To me the pain always felt right on the bone, but if it’s not a stress fracture then what is it? It’s generally thought that the pain associated with medial tibial stress syndrome is caused by a disruption of the periosteum, a membrane which lines the outer surface of our bones and provides the surface that muscles and tendons attach to. The periosteum is everywhere ‘glued’ strongly to the bone. We feel the pain of shin splints when the periosteum surrounding the tibia is inflamed, or even loosened or pulled off (tibial periostitis). This can happen for many reasons, such as overloading of the muscles that attach to the tibia, or even repeated twisting or bending of the tibia itself. [3]

ShinNow that we’ve narrowed things down to a specific problem, medial tibial stress syndrome, we need to take a broader view again when thinking about what the underlying cause might be and what do do about it. This is going to vary a lot from person to person, but especially for new runners a common reason for developing medial tibial stress syndrome is a lack of prior conditioning, and simply impatience. According to Dr Ruth Highet it is common to see runners with shin splints caused by doing “too much too soon, often in runners with poor technique on poor training programs with poor lower limb biomechanics, including heavy pronators. Doing the same sort of running, on the same run courses.”

How much is too much? There is a general rule of thumb for runners that says you shouldn’t increase your weekly mileage by more than ten percent each week, which I have to say asks for a lot of patience and self control! I can’t say I stuck to it myself, but then again I might have avoided problems with shin splints if I had! Going hand in hand with this slow approach to building up mileage is strength training. I’ve found regular stretching and doing low impact workouts that help to strengthen the legs a very useful complement to running, and I wish I’d done more of it when I was just starting out. There are no shortage of articles on the web about stretches for runners, but the four classic stretches that make up my daily routine are: calf stretch (straight knee), quad stretch, soleus stretch, and hamstring stretch. There are probably a dozen others you could add to that list, but that’s my favourite four. Similarly there’s an astronomical amount of workout advice available on the internet. My usual home workout is pretty basic and involves things like lunges, steps and crunches, even some jogging on the spot. Just remember, there is no way to do jogging on the spot without looking completely ridiculous, so close the curtains before you start and embrace the silliness.

Poor running technique can also contribute to medial tibial stress syndrome. A recent study at Harvard university confirmed what a lot of people had suspected for ages, that heel strikers were more prone to injury. “Those who habitually rearfoot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike” [4]. I realised I was guilty of this when I started trying to get faster. I thought the thing to do was to lengthen my stride, but then I noticed how abruptly I was landing on my heels. My foot would be extended in front of my body each time it landed, essentially putting on the brakes with each footfall and sending the shock of impact right up through the leg. A more efficient running technique emphasises landing near the midfoot rather than right on the heel, with the foot connecting with the ground under your centre of gravity and with knees slightly bent. Then it’s easy to roll quickly and lightly through each footfall and push off again. Take a look at this slow-motion video of Kenyan runner Moses Mosop for inspiration. Elite runners seem to run so elegantly and effortlessly, as if gliding down the track on invisible bicycles. All their energy propels them forward in the most efficient way possible. If you’re a heel striker who is constantly falling foul of injuries, like shin splints, then it could be time to reassess your technique.

Invisible bicycle

Finally, an often cited cause for media tibial stress syndrome is over or under pronation of the feet. Pronation is the natural side to side rolling of the foot while it is in contact with the ground. People with flat feet or low arches will tend to overpronate, meaning that the foot rolls inward more than normal, while people with high arches tend to underpronate, meaning that the foot rolls less than normal. Both of these conditions, particularly underpronation, impose extra stress on the tibia and the muscles of the lower leg which can result in medial tibial stress syndrome. This was the diagnosis when Max Bell sought the advice of a physio. “He told me that I have flat feet, flat arches, and when I would bend my knees they would track slightly inwards. That leads to more pressure on the inside of the shins.” The treatment often involves some sort of orthotics, or shoe insert, as well as rehabilitation exercises. “He recommended these insoles that were made of soft rubber,” says Max. “I’d wear them for maybe a few weeks then add a new part to them and they’d get higher. Then a few weeks later I’d add a new part and they’d get higher and higher to boost up my arch. I found that really good. I read online that a lot of the time people are prescribed solid insoles, something that will disable your foot, stop the foot moving, like a cast that would over time weaken it. But he recommended the opposite, something that was soft and would strengthen my foot.”

It’s been suggested that the typical running shoe with lots of heel cushioning is not doing us any favours when it comes to injuries, that the human body already has a natural gait that efficiently absorbs shock and propels us forward, but modern running shoes force all that to change [5]. I’m not sure I’d like to do without my well cushioned shoes, although I see the logic of adopting a more efficient gait and avoiding heel strike. Max Bell tried the minimal approach to footwear on advice from his physio: “He also recommended Vibram 5 Fingers shoes to train in, minimalist shoes, going barefoot and practising picking up balls with my toes. Mainstream advice for Parkour would be to go for shoes with extra cushioning to soften the impact, but I think going minimalist and putting in the effort to strengthen and condition yourself is much better.”

or how about running in shoes and adopting the proper form at the same time?
or how about running in shoes and adopting the proper form at the same time?

How long is the road to recovery? “It varies depending on the cause, and how far along the continuum from bonestress to periostitis to stress fracture they are”, says Dr Highet. For Max it was a long slow process, but it paid off. “I agreed with [my physio’s] philosophy which was to try and strengthen it up, which took a lot longer and was a lot harder but much better in the long run. It was maybe a year til my shins started feeling better, and probably two years til the shin splints finally went away. I find I can train normally now, go out and do Parkour, go for a run, and be fine.”

Personally, a year and a half down the line, I feel like I’m on the mend. Through trial and error I’ve worked out what sets me off, although I’m sure I would have benefited from a trip to a physio at some point. Now it’s up to me to be disciplined enough to stay well.  Stretching, strength training, and trying to run more efficiently have all helped. What’s left is for me to take a careful approach to speed training, because short fast runs affect me more than slow long ones, and most importantly I need plenty of sleep. My shins react to sleep deprivation as badly as the rest of me!

Finally, the abundance of information on the internet is no substitute for professional advice, so it’s always a good idea to seek the help of a qualified doctor or physiotherapist if you encounter an injury. What works for one person might not work for another, and probably I just got lucky with my eventual rehabilitation (slow and haphazard as it was!). Get professional help if you need it, because Wikipedia can’t watch you running on a treadmill and talk it over with you, and it won’t give you a lollipop on the way out either.

Huge thanks to Max Bell at Movement Unleashed and Dr Ruth Highet at Wellington Sports Medicine for their contributions towards this article.

Linkage

Full interview with Parkour instructor Max Bell

Wikipedia on shin splints – If you haven’t already looked this up.

Medial tibial stress syndrome: conservative treatment options – Review of published literature on the treatment of MTSS, appeared in Current Reviews in Musculoskeletal Medicine (Springer Verlag).

Does foot form explain running injuries? – New York Times health and science article about the Harvard study concerning heel strikers.

Is barefoot running really better? – Article on the Smithsonian website pointing to a new study into barefoot running.

Movement Unleashed – Developing health and wellbeing through fitness. Classes and educational blog posts by Max Bell and others.

Wellington Sports Medicine – A multi-disciplinary sports medicine facility located at the newly developed ASB Sports Centre in Kilbirnie, Wellington.

Notes and references

1. It’s worth being aware of what these other conditions are, although I don’t propose to write much about them here. Compartment syndrome is a serious condition in which there is increased pressure inside a muscle compartment (a bag which contains the muscle but doesn’t expand). The increased pressure restricts blood flow, which can lead to damage to the muscle and the nerves. Stress fractures arise when repetitive stress, like running, eventually exceeds the bone’s ability to repair itself. If left untreated these tiny weaknesses can develop into full fractures.

2. Medial tibial stress syndrome: conservative treatment options Curr Rev Musculoskelet Med. 2009 September; 2(3): 127–133.

3. According to the article “Medial tibial stress syndrome: conservative treatment options” [2] there may be a spectrum of problems which contribute to the pain of MTSS, including tendon damage and muscle dysfunction, as well as tibial periostitis.

4. Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc. 2012 Jul;44(7):1325-34

5. Is barefoot running really better? Comment on a new study about barefoot running.

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3 thoughts on “The Taming of the Shins

  1. Thanks guys. The exercise in the video is something I’ve seen recommended elsewhere for shin splints, looks like it could be useful. Maybe jogging on the spot is helpful in the same way.

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