One of the most common running injuries we treat in our clinic is shin splints or Medial Tibial Stress Syndrome (MTSS). Shin splints cause one in five athletes to stop running. In addition to running, engaging in soccer, rugby, basketball, volleyball, or any sport that involves running or jumping can cause shin splints.
Most people would describe the initial pain of shin splints as a dull ache along the inside of the the lower leg (tibia). Shin splint pain is often felt at the beginning of a run and then diminishes as the run continues, only to return near the end of the run.
In this initial stage the pain from shin splints will often dissipate completely with rest. If the shin splints progress, the pain will often be present with both activity and rest. Once shin splints reach the stage of constant pain, a medical professional should be seen to determine if additional injuries are present (stress fractures or compression syndrome).
The exact location of shin splints is often hard to find, because it is usually more of a diffused pain in the soft tissue (fascia, tendon, muscle) rather than on the bone (tibia) itself.
Causes of Shin Splints
The most common cause of shin splints is repetitive motion. This is not surprising considering the force of impact of each runner’s stride. A runner’s shins are subject to two to three times the runner’s body weight on foot impact. This high level of force can easily overwhelm the shin muscles (dorsi flexors) if they are not strong.
Any type of muscle imbalance, or abnormal motion pattern in the ankle, knee or hip could cause increased stress on the dorsi flexors as they try to control motion. In other words, the dorsi flexors may be the site of the shin splints, but the root cause could be far from the location of symptoms.
Treatment of Shin Splints
The classic treatment of shins splints involves: rest, icing, elevation, compression and some easy stretches. This is good advice especially in the acute stage of the injury. However, exclusively following this advice will not prevent the return of the problem.
To resolve MTSS, the removal of any myofasial restrictions that may have formed in the soft tissue is required. This will be done in combination with a program of functional strengthening exercises for both the dorsi flexors and other areas that are affecting gait stability.
Any type of restriction that forms in the dorsi flexors, or other related areas should be removed for a full resolution of shin splints. Some of these restrictions can be removed through the process of self-myofascial release (foam rollers, and stretching). If the restrictions are severe, a manual therapy practitioner (MSR, ART, Graston, Massage) will be needed to break the restrictions.
Any time a restriction is removed from one muscle the antagonistic and synergist muscles must also be assessed for restrictions. This is a key point that many manual therapists fail to recognize. For a full resolution, myofascial adhesions must be removed from the entire kinetic chain.
It is very important in diagnosing shin splints to make sure that you are actually dealing with shin splints and not a stress fracture or a case of compartment syndrome.
The question you should ask yourself when you feel shin pain from running is, “Am I feeling shin pain from shin splints or is something else going on?” This may not be an easy question to answer.
In the initial stage of shin splints pain often reduces in intensity after the first few kilometers into a run. In contrast, the pain from a stress fracture tends to build up gradually during running, often beginning as an annoying irritation and becoming unbearable as the run continues. In the early stages of shin splints there is often a clear differentiation. The problem lies in that the pain in later stages of shin splints could be so severe and continuous that it would be impossible to determine if a stress fracture is the actual injury. That is why professional advice should be obtained early on.
There are several tests that a sports practitioner can perform which will help to differentiate which condition you are dealing with. Unfortunately, routine X-rays will probably not be one of those tests. X-rays are often of little value in detecting a stress fracture. A much better test is a bone scan (or MRI) which is much more sensitive in detecting these fractures.
Another condition that must be ruled out is compartment syndrome (CS). The muscles of our legs are divided into rigid compartments. These compartments are bound by strong fibrous tissue (deep fascia), and bones.
The anterior compartment contains some very important structures. It contains the dorsi flexors, the muscles directly linked to shin splints.
The Anterior compartment contains:
Dorsiflexion muscles of the ankle and foot
Extensor digitorum longus
Extensor hallucis longus
Anterior tibial artery
Deep peroneal nerve
CS occurs when the pressure inside these compartments increases to the point where it interferes with the blood supply to your muscles and nerves. This can occur when the muscle inside the compartment becomes too large, increasing the pressure. CS can also occur from trauma, bleeding, swelling, overuse or even excessive medication.
In a case of anterior compartment syndrome, a runner may experience sharp pain and swelling over the shins. They may also notice weakness of the dorsi flexors, especially against resistance. In addition there is often a decrease in the extremities pulse and a decrease in sensation. There are two types of compartment syndromes: chronic and acute.
Chronic Compartment Syndrome is not a medical emergency and can often be treated with manual therapies (MSR, ART, Graston, Massage). Chronic CS is also referred to as exertional CS. The pain of exertional CS in runners usually comes on with the first 15 minutes of running, then subsides within an hour after the run. The pressure of these compartments can be measured by a medical practitioner. A resting pressure of greater than or equal to 15 mm Hg is an indication that compartment syndrome is present.
Acute Compartment Syndrome could be a serious limb-threatening condition. Any delay in treatment may lead to infection, complications and even limb amputation. In most cases an acute compartment syndrome occurs after a traumatic event, and is most commonly seen with traumatic fractures.
If you suspect a stress fracture or compartment syndrome you need the help of a medicial practitioner.