Shin Splints

David J Buckles, ATC.

Over the next few weeks, we’re going to take a look at common running related injuries. These blog topics are going to be covering etiology of the injury, pathology of the injury, signs and symptoms, prevention, treatment and rehabilitation of the injury. If you don’t know what I just said, basically we’re looking at how the injury happened and how the structure in your body is affected. With a clear understanding of what is going on, it will be much easier to fix these issues. Chances are, if you’re reading this, you have or have had one of these injuries. If you have an alternative treatment, or used something that has worked for you, please post a comment at the end of each article.

 

Now, just so you don’t think I’m hypothesizing, making stuff up, or just giving you my personal insight on what has worked for me, I am a credible…and an incredible source…ok, not incredible, but certainly credible. I am a licensed Athletic Trainer in the state of Utah, worked for years at a D-II college with football, basketball, and cross country athletes. I’ve seen many injuries, rehabilitated many of them, and they ALL lived to tell a tale. I have a bachelor’s degree in human performance and sport with a kinesiological emphasis, biomechanics, and rehabilitation techniques. Now that that’s out of the way, whew… here we go.

 

We’re going to start with an injury commonly known as shin splints. “Shin splints” is a generic term for any pain experienced in the front of the leg below the knee and above the ankle. There are a lot of structures in there, so let’s split them up, shall we?

 

TYPES OF SHIN SPLINTS

The most common type of shin splint is known in the medical community as Medial Tibial Stress Syndrome (MTSS). This is usually the more painful of the ‘shin splints’. The medial tibial muscle is known as the Tibialis Posterior, meaning it is behind the tibia bone. And obviously a stress syndrome is when more stress is being placed on said structure than what is familiar to it. Put it all together, and we have stressed out posterior tibial muscles. Let’s take a look at what the muscle itself does, and how it can be over stressed.

 

 

The muscle is responsible for movement of the ankle… specifically plantar flexion and inversion of the ankle. I use big words just to show you all how smart I am, but if you look at your foot while in a seated position and your foot off the floor, the muscle is responsible for pressing your gas pedal and then pointing the toes in, that’s it! Since we know what the muscle is responsible for, how in the world would it become stressed out? Easy, it becomes stressed by going in the exact opposite direction. Dorsi flexion and eversion of the ankle is responsible for straining that muscle. The etiology (or the ‘how’) of this injury is known. Let’s take a look at the pathology ( the ‘what’s happening’). When the ankle becomes dorsi flexed and everted, the muscle stretches and stretches and eventually something has to give. How in the world does your ankle dorsiflex and evert while you’re running? A simple word: Pronation. Every time your foot comes in contact with the ground, it must absorb impact somehow. The arch in your foot flattens out, the bones in your foot act like shock absorbers, and the ankle pronates to a certain extent. This is crucial to the shock absorbing process and MUST happen. When the ankle pronates a certain degree, unbeknownst to you, it everts also! Along with that eversion, just before the propulsion phase of a step, or right before you take off; as your foot transitions from back of the foot to the front of your foot you are in a dorsi-flexed position. If you are a runner who happens to pronate a great deal, imagine the stress you are putting on your Tibialis Posterior. The muscle is attached to your tibial bone by a membranous tissue known as the Periosteum. What actually happens is that the muscle rips away from this membranous tissue, and the membranous tissue can rip away from your bone. Gross! Does that about sound like how it feels? For those of you who have had this, the answer should be ‘yes’.

Signs and symptoms for MTSS may include, but are not limited to:

 

• Swelling
• pain (behind tibia, or medial to tibia bone),
• pain with walking
• broad tenderness (meaning you can’t pinpoint tenderness, pain is described as “this area”).
• Pain with inversion and planter flexion of ankle.
• Pain with Dorsiflexion and eversion of ankle.

 

Preventative measures that you can take to avoid coming in contact with this dreadful running related injury can be as easy as a new pair of shoes. Make sure that you have enough support in a shoe. Even if you don’t think you pronate, take a look at your daily mileage. Just because I don’t pronate in 30 seconds on a treadmill while doing a gait analysis, doesn’t mean I’m not going to pronate 12 miles in to a run when my arches and leg muscles are dead tired.

Arch supports or inserts can be another big helper in shin splint prevention. Remember, when the arch flattens out (and everybody’s arches flatten out to a certain extent when running) it leaves the foot wide open to extra pronation. Controlling the flattening out phenomenon by a higher, more rigid arch support can reduce the amount of pronation.

 

Rehabilitation of MTSS can be very easy.

• Ice after your runs. This can reduce the amount of swelling that will be introduced to your tibialis posterior post runs. This can also prevent a phenomenon known as secondary hypoxic injury. Your lower legs are comprised of many compartments. When these compartments fill with blood and extra swelling they can put stress on other compartments and actually cut off circulation. That’s bad!
• Strengthen your Tibialis Posterior muscle.
  • This can be accomplished by tracing the alphabet with your toes while sitting around wherever you are. Trace the capital letters, lower case letters, cursive letters, trace them while wearing sweaters. Trace them fast, trace them slow, trace them on the go. Yep, that’s Dr. Seuss.
  • Once you get used to the motion of the alphabet, gradually put a bit more weight on your toes.
  • Once you’ve graduated from alphabets, or you become bored with alphabets, move to a resistance band. I’m not looking for heavy resistance, you’re never going to win a body building competition based solely off of your tibialis posterior definition and bulk. Attach your resistance band to a fixed point. Now position yourself sitting parallel to said fixed point. Attach one end of your resistance band around your toes. Put a rolled up towel under your calf so that you have freedom with range of motion of your ankle. The objective is to invert your ankle. Once ankle inversion is achieved, keeping the inversion, move the ankle from dorsi flexion (toes to the nose) to plantar flexion (stepping on a gas pedal).
  • With that same resistance band and resistance, move from inversion to eversion in a slow, controlled fashion, and repeat. The goal is to invert just the ankle, if your whole entire leg is moving during this exercise… you are wrong, FIX YOURSELF!

 

• Stretch out your Tibialis Posterior.
  • How do you stretch this muscle? If you read carefully enough earlier, you would know this answer! But I shall tell you again. The department of redundancy department says: Eversion and Dorsiflexion. Natural inclination is to stretch directly after a run, avoid this temptation. You already created muscle fiber trauma while running, don’t inflict more trauma on an already damaged muscle.
• Massage. Dig in with your thumbs, hire a massage therapist, or better yet, use a massage stick (conveniently found at Salt Lake Running Company). While massaging your muscles, the intention is to break up any scar tissue, break up any trigger points that may have found their way inside the muscle, and get rid of them. While massaging, try to do so in a manner that returns blood and flow back to your heart. When I massage my own shins for this purpose, I don’t want to start from the knee and move downward. I want to start at the ankle and move up towards the knee.
  • After you’ve created trauma via massage, you want to recover as efficiently as possible. For this particular reason, I love the compression socks/sleeves. Compression has myriad benefits.
    • After massage, in order to prevent all the inflammation from returning to the areas that you just massaged it out of, compression is gradient and should prevent blood from pooling up in your muscles.
    • When you make impact with the ground while running, your muscles vibrate and reverberate from the shock, a tight compression can reduce the amount of vibration that you will have in these muscles.

 

 

Another common form of “shin splints” takes part in a muscle close to the medial tibial muscle. It is called the Tibialis Anterior. This muscle attaches to the upper 2/3 of the outside surface of the tibia bone. Pain associated with this muscle is much less involved than the previous, but can ache just as bad. The motion of the ankle that the tibialis anterior is responsible for is called dorsi flexion. Bringing your toes towards your nose is pretty much all it does. Wanna see it in action? Take off your shoes and socks and bring your toes towards your nose… see that big tendon on the front of your ankle… that’s your tibialis anterior. Anterior Stress Syndrome (ASS)… haha, just kidding, that’s not really a correct acronym, I just wanted to be able to get away with writing that on a blog. Quit laughing and pay attention. Since we know what the muscle does, and we get the general idea of what a stress syndrome looks like, let me give you an example of why it hurts so bad. If you did pushups Monday, and lots of them, you would probably sore on Tuesday. Now imagine you do 1,000 pushups every day for the next month. If you’re sore Tuesday from doing pushups Monday, and you do pushups on Tuesday, how much more sore will you be on Wednesday? I’ll tell you, if you’re not used to doing pushups and you jump in to 1,000 of them all in one day, you are going to be pretty darn sore!!

It’s the same thing with running and the tibialis anterior. I call this the over-exertion injury.

 

Most people when running strike the heel first. When this happens the ankle is dorsi flexed, when you lower your toes to the ground, the tibialis anterior is working eccentrically (controlling force). Upon taking the next step, the toe must again dorsiflex to avoid dragging on the ground, when you are producing a force by lifting your toes up, it is a concentric contraction. That’s twice your tibialis anterior worked… in just one step. Assuming the average runner takes 180 steps per minute, runs an 8 minute mile, and averages a 6 mile run (I’ll do the math for you…) That’s 8600 steps you just took in your 6 mile run. If that Tibialis Anterior works twice with each step, that is 17,400 times that your muscles have stretched and contracted. That 1,000 pushup-a-day example doesn’t sound so silly now, does it? Take a look at your daily mileages, if it sounds like you are doing more than what you think your body is ready for, ease back the distances a tad.

 

Signs and Symptoms of anterior tibialis stress syndrome include, but are not limited to:

• Pain with dorsi flexion
• Pain with extreme plantar flexion (stretching the tibialis anterior)
• Possible swelling
• Often times tender to the touch

Preventative measures that you can take to avoid this debilitating injury are pretty simple. Since I call this the ‘over-exertion’ injury, you may want to cut back on your large volume of training. Hill repeats and speed work can exacerbate this injury, so gradually build up to hill work and speed work. The body responds well to a principle known as the SAID principle which stands for specific adaptations to imposed demands. Meaning the more demands you put on your body, the more adaptations your body will make to accommodate those demands. However, if you work too and hard too fast and don’t allow the SAID principle to take effect, you may risk injuring yourself.

 

Rehabilitation of your tibialis anterior can be relatively simple:

• Strengthen your tibialis anterior
  • Walk around on your heels keeping your toes in the air. In this dorsi-flexed position, an isometric contraction will be placed on your muscle making them essentially impervious to stress.
  • Use that same resistance band that you used on your tibialis posterior, except set yourself up so that the resistance is being used while bringing your toes towards your nose. Repeat this several times in a day.
• Massage and stretch your muscles.
  • This muscle can be difficult to stretch. The best way to attack it is with extreme plantar flexion. I accomplish this by kneeling down with the laces of my shoes on the ground. Once you are in this position, rock yourself side to side to alternate stress on each leg.
  • Foam rollers work great for this! (conveniently another product sold at SLRC!) In the same position as above, except your shins are on the foam roller, roll from knee to ankle.
  • Use the massage stick to work out sore muscles, inflammation, and potential scar tissue in the tibialis anterior.
• KT Tape can be a pretty effective ally in the fight against induced stress. This product can mimic the alignment of the muscle fiber and can actually aid the action of the muscle. Consult a professional before tape application, or follow the directions very closely.

 

These are the 2 most common forms of shin splints that most runners will suffer from. Of course there are many others that can often times plague a runner. These injuries are not as common, but if you think you may have them, please feel free to contact me at the Draper Salt Lake Running Company. Here is a list of potential alternative injuries felt in the ‘shin splint’ arena.

• Periostisis- an inflammation of the membranous tissue that surrounds your bones. Commonly follows MTSS if left untreated.
• Exertional compartment syndrome- A syndrome that is characterized by the inadequate draining of excess blood accumulated by activity in each respective compartments of the lower leg. Identified by a tight, shiny-appearing lower leg. If you can bounce a quarter off of your leg after a run (not in a good way), that’s bad!
• Stress Fracture- When tremendous stress builds up behind a muscle or over-worked structure and the bone ends up micro fracturing. Usually pin point tender, meaning you can point with one finger exactly where the pain is. Commonly missed on X-ray. Often times identifiable with a tuning fork. Rap a tuning fork on an object, once the fork is reverberating, put the handle on the pin point tendernesss… if you yelp out in pain, congratulations, you have a stress fracture!

I’ll see you next time for another exciting installment of ‘running related injuries and YOU’