Shin Splints (Medial Tibial Stress Syndrome)
By Seth Donelson (Doctor of Physical Therapy)
This article was submitted by our local Physical Therapist Seth Donelson who trains with my group here in Maryland. Not only are we excited to have him join us and experience our workouts, but also he assists by providing common injury articles such as this:
This document covers basic information about how shin splints occur, how to identify them, and ideas to guide treatment and prevention. There are 2 graphics that summarize the risk factors for shin splints and identification/treatment, but I highly recommend you review the written information as it contains more detailed information. This is not a substitute for medical care or advice. If you’re unsure of the severity of your condition or feel it may be more serious, then seek out professional medical care.
Pathophysiology and Risk Factors:
Shin splints, formally known as Medial Tibial Stress Syndrome (MTSS), are typically classified as early stress injuries. Stress injuries are generally believed to be on a continuum with shin splints being the least severe while stress fractures are the most severe (1). Shin splints are stress reactions that occurs from the muscles of the lower low pulling on the tibia (shin). This pulling action causes inflammation and remodeling on the outer surface of the bone. This process is normal, but shin splints occur when the bone cannot remodel fast enough, typically due to overtraining. (1,2,3)
Factors that are consistently linked to increased risk for stress injuries are significant increases in bone loading (i.e. dramatic increase in running volume or intensity), lack of calf flexibility, high Body Mass Index (BMI), increased pronation/arch collapse of the foot, a history of MTSS, inadequate nutrition, and inadequate recovery (1,2). Additional items to be considered are that weak muscles can absorb less impact during running and asymmetries between legs (foot strike pattern, strength, flexibility) may lead to differences in loading/impact capacity and altered running mechanics (3).
This is arguably the most important section to read. As there is not a best course for treating shin splints, preventing them is of the utmost importance. The key to prevention is gradual exercise progression and ensuring that you’re eating and resting enough to recover from your workout. You’ll want to be familiar with the 10% rule as this is going to guide your exercise progression.
- 10% Rule - don’t increase your running and/or weight-lifting volume, intensity, or frequency by more than 10% per week. An example would look like this: you can run 10 miles a week while still feeling healthy and injury free; it’s safe and reasonable to add another mile next week or to increase your pace for one of your shorter run days by 1 mile (10%).
Nutrition – It’s generally recommended to consume 0.6 – 1.0 g/lbs of protein (1.4–2.0 g/kg), approximately 30% of your calories from fat, and the rest of your calories from carbohydrates. A sample from a 2000 calorie diet and 160 lbs person would look like this:
- Protein – 384 – 640 calories or 96 to 160 grams
- Fat – = 600 calories or 67 grams
- Carbohydrates – 760 to 1016 calories, or 190 to 254 grams
- This was based on a 2000 calorie diet. To determine how many calories you should be eating, you need to consider your resting metabolic rate (RMR) and your activity level. Calculators can be found online to give you a good estimate.
- Rest/Recovery – Resting isn’t just about how much sleep you’re getting, it’s also about what activities you’re doing outside of your training routine. A key example is the person that runs 6 miles in the morning and then works a heavy manual labor job afterwards or plays volleyball for 2 hours in the evening. The stress on your body is cumulative from the whole day.
Shin splints typically present as:
- Vague, diffuse pain along the along the lower 2/3rds of the tibia (>5 cm span) associated with exertion (2)
- Initially - pain is worse at the beginning of exercise and gradually reduces during training and shortly after stopping exercise (3)
- Advanced - pain with less activity (slow jog or walking) and at rest (3)
Symptoms that may indicate a more severe or alternate condition
- Bony tenderness, usually less than a <5 cm span
- Bony tenderness on the front of the tibia
- Cramping, burning, numbness, or tingling in the lower leg or foot
- Pain during normal daily activities
There is a limited body of high-quality research dedicated to treating shin splints/MTSS. Most of the treatment recommendations have come from clinical experience and expert opinion (3). As a result, prevention and early intervention are vital for maintaining high performance and function in the long term. It may be helpful to implement movements that help indicate your readiness for returning to running. If it is painful to walk or hop with both feet, then you’re not ready to run. If you can hop on one leg or run in place with no pain, then begin implementing running back into your routine.
Phase 1: Early treatment
- Rest from running/loading 3-4 days at first sign of injury, or longer if injury has progressed
- Ice for 15-20 minutes after activity
- Cross train with low impact activities (i.e. biking and swimming)
- Limit calf stretching to once a day or < 1:30 minutes total
Phase 2: Little to no pain
- Reduce running/loading by 50% (volume, intensity, frequency) and gradually progress 10% each week in one of the three listed domains at a time
- Address gait/running asymmetries
- General stretching and strengthening of the lower extremities 2-3 days/wk (straight leg calf raises, bent knee calf raises, toe raises/heel walks, lunges, single leg hip thrust, squat, deadlift, plank variations)
- Scale back exercises that cause pain
Phase 3: Full participation
- Running and loading progressed with no pain
- Recognize early signs of overuse injury and act early
Additional Resources to Maximize Learning:
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1: Kiel J, Kaiser K. Stress Reaction and Fractures. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507835/
2: McClure CJ, Oh R. Medial Tibial Stress Syndrome. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538479/
3: Galbraith, R. M., & Lavallee, M. E. (2009). Medial tibial stress syndrome: conservative treatment options. Current reviews in musculoskeletal medicine, 2(3), 127–133. https://doi.org/10.1007/s12178-009-9055-6
4: Beck, B. R. (1998). Tibial Stress Injuries. Sports Med, 26(4), 265-279.
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