Medial Tibial Stress Syndrome
also known as “shin splints” accounts for six to 16 percent of injury among runners, but it’s something that we’ve all experienced at one point or another. You may push through the pain in some instances, while other times, the pain may force you to take several days off of training.
First described in 1913 as “spike soreness” in runners, there has been much disagreement about how shin splints is caused and how to properly classify the pain. Arguments have been made for 18 different acute and chronic conditions that have been suggested as the cause of shin splints. One theory, now, is that shin splints is caused by an overload of force on the tibia. Unfortunately, research hasn’t been conclusive enough to sway an overwhelming majority in any one direction.
Regardless of what the condition is called or how it’s caused, there is a consensus among researchers about risk factors that increase the likelihood of someone experiencing shin splints. These risk factors include being female, increased foot pronation, increased plantar flexion strength (pushing the foot away from you), and external hip rotation in extension. Other risk factors include low calcium intake among females, increased training intensity, improper footwear, and hard running surface. While many of these risk factors are non-modifiable, some can be modified to decrease or prevent the recurrence of shin splints.
The strongest evidence in the prevention of shin splints is in the use of shoe orthotics to correct hyperpronation of the foot and to absorb shock. Weak or fatigued muscles cannot absorb shock as well as strong, rested muscles can. When muscles are fatigued, forces are transmitted to the bone, and the risk of injury increases. The amount of wear or total mileage on a running shoe will also show decreased ability of shock absorption. Running shoes should be replaced after being worn between 300 and 600 miles. This number will vary within the range depending on body weight, running mechanics, and training surface. There are also active steps that can be taken in treatment and prevention.
Support for strength, agility, and flexibility training was weak when performed as an independent intervention. Support for these forms of training was strongest when done concurrently with gait retraining to correct faulty mechanics. Strength and flexibility training are most effective when started during preseason training and continued throughout the season. Static stretching should occur on training days and not immediately before competition. Static stretching does not decrease the risk of injury when done prior to activity and can negatively impact sport performance. In preseason workouts, graduated running programs have been shown to decrease the risk of shin splints due to the gradual progression of impact and demand on the muscles and structures of the leg.
example of a graduated running program.
Phases 1-4: interval training, duration is 16-20 minutes, intensity is increased from light jogging to a speed where talking becomes difficult.
Phase 5: continuous running, 16 minutes, intensity is increased from light jogging to a speed where talking becomes difficult.
Phase 6: continuous running, 18 minutes, intensity is increased from light jogging to a speed where talking becomes difficult.
*Progression to the next phase is made when the current phase is completed with pain less than 4/10 on a scale of 0-10. Training should occur three days per week on non-consecutive days.
Extracorporeal Shockwave Therapy
(ESWT) is a form of treatment that has seen some positive results in a limited number of studies. ESWT is a non-invasive form of treatment involving a device that directs shockwaves to the affected area. These waves are pulses of mechanical energy that are intended to break up the target tissue. It is commonly used to treat plantar fasciitis and tendinopathies.
Overall, the current body of evidence in treatment of shin splints is weak. Many forms of treatment require further studies with larger samples. Much of the current research is also not high caliber enough to make definitive conclusions about treatment methods. Studies were flawed in not properly randomizing test subjects or others were deficient in reporting their methodological details, which makes it unclear the amount of influence systematic errors had on their results. There is hope in that the research seems to be in most agreement on the use of shoe orthotics/proper footwear and the use of a graduated running program, as discussed above.
If you feel you may benefit from strength and flexibility training of the muscles and tissue surrounding the shin, below are some exercises with clinical relevance to absorb loads throughout the running cycle and to combine with gait retraining.
- Step Ups
Step up using the lead foot and try not to assist using the foot that is on the ground. Three sets of 10 reps.
- Soleus Squat
Slide down the wall on both feet until you reach approximately 70 degrees. From this position, tilt the TherRexTM balance board trainer forward slightly so more weight is on your toes. Hold this position for 20-30 seconds and repeat 4-6 times.
- Soleus Bridge
Lay on your back with one foot on the TherRexTM Board. Use your arms for support as needed and lift your butt off the floor using one leg. Use two legs if needed before progressing to use of one leg.
- Calf Raises
Position one or both feet further back on the board, as shown. Raise your heels and tilt the board forward to increase range of motion.
- Bent Leg Calf Raises
Same as the standard calf raises, but with the knee(s) bent 30 degrees in order to isolate the soleus muscle.
- Calf Stretch
Start with your foot parallel to the feet patterns for a lighter stretch, and as you need to progress, turn the balance exercise board 90 degrees and use the arc perpendicular to the feet patterns for a more intense stretch.
Chad Franche, PT, DPT
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