If you are a new runner, or ramping up your training, and getting pain in your shin – you might have ‘shin splints’. Shin splints can be a mild annoyance or could really derail your training. Read on to find out what they are and why you need to get on top of them.
I’ve also given you some suggestions at the end for what you can do to get yourself back on track and running pain free.
So, what is it?
Shin splints, sometimes known by its more technical sounding name ‘medial tibial stress syndrome’ (MTSS) is a general term for a continuum of bone stress injury that can cause pain on the medial (inside) border of the tibia (shin bone).
When the tibia is loaded, it bends slightly. All long bones have this capacity to bend a bit – they are not quite as rigid as we might think. One theory is that a stress injury can develop at the point of greatest bending. Another theory is that contractions of deep calf muscles – specifically the soleus and flexor digitorum longus – can transfer stress to the periosteum (outer covering) of the tibia at their attachment sites. Not everyone agrees, though, whether the exact location of the attachment points support this theory (1).
If a new or increased repetitive stress is applied to the bone, this causes microtrauma. This in turn stimulates the bone’s remodelling process – new bone is laid down to make it stronger. However, before new bone is laid down, damaged bone is resorbed. It can take 3-4 months for the bone to reach a new equilibrium of resorption and remodelling, and in the meantime the bone is even more vulnerable to stress. Symptoms of MTSS are likely to be the result of an ongoing, hyper stimulated remodelling process brought on by repetitive stress (2).
This process can just keep bubbling over, or it might eventually develop into a Medial tibial stress fracture (MTSF). MTSS and MTSF are different pathologies, but they can be considered to be on a continuum whereby a stress fracture is a more severe progression of bone stress. So, although it is always frustrating to have to step back your training, it’s worth nipping it in the bud and saving yourself potentially having to sit on the sofa for much longer down the line.
What causes it?
MTSS is common in runners and the most likely cause is ‘training error’ – the infamous ‘too much too soon’. For example, suddenly increasing mileage or adding in speed workouts. It’s generally more common in newer runners who perhaps haven’t built up as much structural adaptation to the repetitive demands of running.
The lower leg muscles act as shock absorbers, reducing how much stress goes to the tibia. If calf muscles are weak, this could reduce their ability to absorb load which then gets redirected through the tibia. Muscle fatigue has also been shown to lead to increased tibial strain and ground reaction forces when running (2).
MTSS is 1.5 – 3.5 times more common in women than men. There is an association between bone stress injury and the ‘female athlete triad’ of ‘bone mass, menstrual dysfunction and energy availability’ (2). So, for example, restricting food intake combined with demanding training can lead to hormonal disruption and menstrual dysfunction. This in turn can have an effect on bone mass, making them more susceptible to stress injury. There is also a connection with bones stress injury and lack of calcium and vitamin D (2).
How do I know if this is what I have?
If you have a feel along the inner edge of the tibia (shin bone), from the middle down, it will feel tender to touch. A less serious, more generalised irritation will feel more diffuse or spread out, whereas in the case of an actual stress fracture there will be more intense pain focussed at a particular spot on the bone.
You may initially experience pain during running which subsides when you stop. As it progresses, the pain you feel will get worse and persist for longer after training. If it starts to become painful when walking or at rest or even at night, you might want to consider the possibility of a stress fracture. There might also be swelling and pain on impact for example if you hop up and down on the affected leg (2).
I think I have shin splints! What can I do?
If you suspect a stress fracture, then it’s important to get this checked out. Stress fractures of the medial tibia are low risk (2) because they are on the compressive side of the curve made by the bowing action of the tibia. This makes it relatively quicker to heal than other kinds of stress fracture, but rest is essential.
Allow it to calm down
The most effective ‘treatment’ for MTSS is rest (3). If you have an MTSF, a period of complete rest might be necessary. For less severe cases, a reduction in training might be enough to bring pain levels down. Consider replacing some runs with cycling or swimming if you are worried about keeping your fitness levels up.
New running shoes will be more effective at shock absorption than worn out ones, so make sure you replace your trainers if they are too old! Uphill and downhill running produce greater tibial strain. In general, a flat, level, moderately firm provides the least stressful running surface for your shins (1). Running on grass might help but, on the other hand, when you run on a softer surface, your legs stiffen more in response which can actually increase the shock on landing, so you may need to experiment.
Graded return to running
You need to ease in gradually, taking time to return to your normal training regime (4). Wait until you are pain free during and after normal daily activity. Bones seem to need some degree of loading to stimulate the remodelling process. It’s about listening to your body – giving it enough stress to stimulate adaptions, but not too much that you aggravate symptoms. Take it slowly, monitoring any pain and making sure it stays below around a 3 out of 10. If symptoms flare up, rest for a couple of days and start back up at a lower level.
Strengthen your calves
Strengthening your calves will improve their ability to absorb load and so may help by reducing stress on the tibia. Eccentric strengthening (where muscle is contracting as it is lengthening) can help lengthen as well as strengthen the muscle. It’s important to wait until symptoms have calmed down and to build this into your routine in a gradual way so as not to flare anything up.
Stand with your toes on the edge of a step and your heels down as far as they can go. Lift up for a count of 3, hold at the top for 2 and lower all the way back down for 3 (this is the eccentric portion). Work up to 3 sets of as many reps as you can do with good form 3 or 4 times a week. Start out slowly and back off if you experience pain that goes over 3 or 4 out of 10. If this feels ok, progress to single leg raises. If you can do more than 12-15 in one set, then add weight. For example, hold a dumbbell or wear a heavy rucksack to make it more difficult.
It may be that weakness of the hip abductors can be a factor in development of MTSS and at least one prospective study has shown a link (6). Here is a link to a great glute strengthening routine with an emphasis on the hip abductors. I love this routine and recommend it all the time to runners that aren’t already doing some glute strengthening.
If you need any help, then get in touch!
- Beck, Belinda (1998) Tibial Stress Injuries: An Aetiological Review for the Purposes of Guiding Management. Sports Med Oct; 26 (4): 265-279
- Warden S J; Davis S J; Fredericson M (2014) Management and Prevention of Bone Stress Injuries in Long-Distance Runners. JOSPT 44(10)749-765.
- Richard T. Bouché and Cherie H. Johnson (2007) Medial Tibial Stress Syndrome (Tibial Fasciitis). Journal of the American Podiatric Medical Association. 97(1): 31-36.
- Moen, M.H., Holtslag, L., Bakker, E. et al. (2012) The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. BMC Sports Sci Med Rehabil 4(12): 1758-2555.
- Galbraith M & Lavallee M (2009) Medial tibial stress syndrome: conservative treatment options. R. Michael Galbraith. Curr Rev Musculoskelet Med 2:127–133
- Verrelst R, Willems TM, Clercq DD, et al (2014) The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study. British Journal of Sports Medicine 48:1564-1569.