Medial tibial stress syndrome
Shin splints or medial tibial stress syndrome is essentially a bone stress reaction. The inside/medial border of the tibia (shin bone) becomes irritated as a result of changes in training or exercise efforts.
The research of what is actually happening to cause this painful injury has found that the area of irritation is the attachment site of particular muscles running up the inside of the shin that tug at the bone tissue which breaks it down and the body cant repair it fast enough before it is continued to become irritated. Osteoclast (bone disrepair) activity is greater than osteoblast (bone production) activity.
When diagnosing MTSS the subjective history is key. The information provided about training type/duration/changes is likely to involve a reasonably obvious reason for the onset of the pain. An example of this may be a rapid increase in running distance or frequency and generally the patient will push through the pain for a few more runs after the onset of pain, leading to further irritation.
MRI shouldn't be required but can occasionally be helpful in ruling out possible stress fracture or stress reaction in the bone tissue. Xray will not help with diagnosis this condition.
Signs and Symptoms:
Pain gets worse with running - (is it gets better then likely to be tendon injury)
Pain with pressure to the posterior medial border of shin bone 5cm+
Pain stays around following exercise
Difficult to walk, go up stairs, hop and jump in a lot of cases
Should I still be running with MTSS:
A good guideline I like to follow with most patients is unless the pain goes above 4/10 then continuing with some well planned running is okay.
The most important aspect of management to recognise with MTSS is that EVERY PERSON WITH MTSS IS DIFFERENT. Management must be tailored specifically to the person and their presentation of the injury.
Identify a load tolerance for your condition and work all your rehab and training below that threshold to prevent the irritation of the bone.
RICE (Rest, Ice, Compression (Patient dependent), Elevation)
Reduce the load immediately. This may done by reducing the distances and/or intensity of your sessions. Generally continuing with the same running schedule will result in the pain either getting worse or just continuing to limit your training and running potential
After identifying how irritable the condition is, it is important to continue loading the leg/structures. Start with simple strength exercises like isometric calf holds or even just going for short walks each day. This allows the structures to maintain some stress but not to the point of irritation. Addressing the muscles away from the site of pain is a good idea in the early stages to avoid pain and irritation. For example, glute and core strength exercises.
Then progress as tolerated. As already mentioned these progressions need to be tailored to each patient specifically and therefore there is no set protocol for exercises to treat this condition. Gradual increase in calf, tibialis posterior and foot strength is important as the patient becomes more able and the pain begins to tolerate more load.
While progressing the strength, dont forget the other possible contributing factors:
Biomechanics and Gait analysis:
Due to many runners having this condition as a result of poor biomechanics, strength exercises higher up the chain such as glute, core and thigh muscle strength can be really effective. We know that is our hip control is weak then we are likely to rotate into a knee valgus position which can lead to more stress at the inside of the foot and shin.
If biomechanics is an issue, gait analysis is also an effective measure to help correct any obvious causative factors during the running.
This is something to consider with the exercises you are doing. While muscle strength and biomechanics is important, the ability of our bone tissue to tolerate load is also key. Gradually incorporate more loading to the bone tissue through a transition to hopping and landing based plyometric exercises later in the rehab program.
Return to running:
Begin by reassessing tolerance to load and being sure you are ready to increase or re-start your running. If you have been running a lower intensity and frequency during your rehab you have a good understanding to where your tolerance is. If you have been off running, start with small efforts of 100-200m of running with reasonable rest periods between of 30-60seconds then gradually increase the time running and reduce the rest periods as tolerable.
Eventually you build to doing a session of 1km jog followed by 1 min of rest or stretching and doing that 3-4 times. Following this you might be ready to try a 3km consistent run and then you can continue to build from there.
Throughout this process the key markers are:
Do I have pain during or immediately after the run/session?
Do I have pain the following morning or overnight?
Other important considerations:
Bone health - there are many contributors to general bone health. If you are concerned about yours, consulting a doctor might be a good start to get a scan done to assess density or take blood tests.
Diet - as above, this is complex but needs to be well under control to help you maintain general health as well as bone health specifically. For runners, we need to focus on getting enough protein in our diet to ensure we are effectively recovering following sessions.
Sleep - could go on forever here and will do another article on sleep but this is obviously a huge portion of how we recover and avoid injury. One study showed that active people getting less than 8 hours sleep per night were 1.7 times more likely to get injuries than those getting more than 8 hours sleep per night. We recover during sleep. Without enough, we don't recover enough and piling multiple days/weeks/months of lack of sleep you are doing your body a disservice. Its science... And well studied science. So getting more sleep is an easily controllable you can improve on to help injury prevention.
Can reduce stress on the medial aspect of the tibia
Dont correct faulty foot positions
Shouldn't be a 'final fix'
Orthotics are an option to aid recovery if you have been assessed properly and you genuinely need some form or help at the feet to improve your walking/running biomechanics. In saying this, there are a lot of people wearing orthotics who either shouldn't be or shouldn't still need them. They should be prescribed and fitted to a persons feet to simply help achieve an alteration to aid recovery or improve biomechanics but certainly not kept in the shoes forever. My biggest advice here is talk to someone reliable and knowledgable like a trusted podiatrist. The chap in the shoe shop that has 5 week experience in watching people run on a treadmill who tells you that you pronate and you must get orthotics may not be the one to listen to...
One final point, MTSS or shin splints is most certainly multifactorial, like most injuries. It is so important to attack its recovery by addressing the bigger picture. Biomechanics, strengthening and a bit of rest may help to reduce the pain for a while but to create proper change where needed and prevent reoccurrence, a wider approach that takes all of the above aspects into account is required. Understanding your own body and giving it the best chance to be injury free isn't just doing 1000s of reps of strength work. Get enough sleep, eat what your body needs in relation to your activity levels and get advice from the right people when it comes to injuries.