Shin splint, also known as medial tibial stress syndrome (MTSS) is a common running injury in athletes who are exposed to intensive weight-bearing activities. The incidence rate of MTSS can go as high as 20% in runners and even higher (35%) in dancers. This condition can be overlooked as a simple overuse injury, but often, rest is simply not enough to resolve the problem and prevent its recurrence.
Figure 1. Common in athletes who experiences a large amount of force on the shin and surrounding muscles
Let’s guide you through how we resolve shin splints here at Breathe using our Roadmap:
Step 1. Pain Reduction
Step 2. Activation
Step 3. Movement
Pain reduction
To manage and reduce symptoms, it is important to understand these four concepts:
understanding diagnosis
stretches/mobility exercises
hands-on treatment
movement strategies.
It is important to conduct a thorough assessment to provide a proper diagnosis in order to carry out an appropriate plan for treatment and rehabilitation. MTSS-related pain is induced by excessive force and traction of the tibialis posterior or soleus muscle (posterior shin splint) or tibialis anterior (anterior shin splint) resulting in inflammation of the periosteum, a connective tissue layer covering the bone. People with potential MTSS are likely to present with:
Increase pain with physical activity or exercise is usually found near the medial border of the lower ⅓ of the tibia or shin
Pain with resisted plantarflexion as seen in the propulsion and absorption phase of running
Pain lasting up to a few hours or days after cessation of activity
Early stage: pain usually eases with running
Late stage: earlier onset of pain
There is strong evidence to suggest these are some of the key risk factors behind MTSS in sports:
Higher body mass or BMI
Lower previous vigorous physical activity level
Greater dynamic foot pronation (flat feet or pes planus)
Decreased cadence (step rate) - causes increased ground contact time resulting in exposure to prolonged pronation and excessive tibial torsion stress
Over-striding - poor shin positioning upon heel strike resulting in tractioning from soleus muscle and poor shock absorption
High vertical oscillation - results in increased tibial impact force usually resemble as a loud foot strike
Figure 2. Common runner’s mistakes with shin splints
By understanding the mechanism of injury and its behavior, physiotherapy management first starts with activity modification involving less repetitive, weight-bearing exercises to allow relative rest. This may be implemented as a form of the recovery phase of your program or a de-load week. For professional or scholastic athletes, it would be best to discuss the potential change in training conditions with the coach first.
These are some of the modifications we can apply:
Reduce running distance
Reduce Intensity and frequency of training
Increase cadence (step rate)
Prevent over-striding
Minimise vertical oscillation (ground clearance)
Use forefoot running
MTSS can be resolved conservatively through education and a program that introduces gradual exposure to load. Physiotherapy will initially aim to correct gait and running patterns or any biomechanical overload factors such as dynamic knee valgus, the suboptimal position of the foot in the early stance phase and etc. Having the mobility to perform quality movement helps with the walking and running technique and prevents further exacerbation. A hands-on treatment used in combination with activity modification and mobility exercises works well during the early stage of the injury which can include deep tissue release and dry needling just to name a few.
Activation
Perhaps one of the biggest contributors to the development of shin splints in an athlete is their running technique. As the mechanism of injury is caused by the overloading of soft tissue and bony structures due to altered or abnormal biomechanics during running, it is important to identify any muscle imbalances in the torso and lower limbs such as the abdominal, gluteus medius, hamstrings, and quadriceps, gastrocnemius and soleus muscles.
After the pain reduction and recovery phase, your shin and the surrounding muscles have reloaded to a point where you can begin activating and strengthening again to build back up their load capacity. Early activation exercises should revolve around running biomechanics which involves a lot of torso rotation and unilateral loading on the lower limb. Example exercises can include:
Bird-dog: Anti-rotational exercise to keep the spine stiff in neutral whilst moving your opposite limbs. Mimics running movement with low load on the shin and allow focus on stability more proximally.
Banded clam or side step: Hip stabilising exercise to help reduce dynamic knee valgus
Wall-sit heel raise: Soleus muscle activation is vital for absorbing excessive loads placed on the shin during running.
Movement
This stage is all about bringing everything we’ve learned together. This includes incorporating your knowledge of your running technique, biomechanics, and alignments of your legs and muscle activation to assist with retaining the optimal running style with minimal stress and strain on your shin. Once your pain has reduced and activation is consistent, we encourage everyone to run with neutral hip, knee, and ankle alignment. A couple of great movement exercises to practice are:
Standing bird-dog: Similar to the previous exercise but performed in standing to mimic the running movement. Focus remains on keeping the abdominal muscles stiff and preventing any dynamic knee valgus
Single bent-leg heel raise: Advanced exercise to further challenge the load capacity of your soleus muscle is important in resisting ground impact
Mid-foot strike / landing practice
Initial contact with the ground should be around the ball of your foot
Allows your body to better absorb the impact force while running
Prevents over-striding where heel strike occurs
Following these 3-steps will ensure you run pain-free with better performance. However, individuals with shin splints may present differently, therefore we recommend you consult with a physiotherapist about your specific injury.
References:
Lohrer, H., Malliaropoulos, N., Korakakis, V., & Padhiar, N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. The Physician and sports medicine. 2018
Naderi, A., Moen, Maarten H., & Degens, H. Is high soleus muscle activity during stance phase of the running cycle a potential risk factor for the development of medial tibial stress syndrome? 2020
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