What is medial tibial stress syndrome AKA “Shin Splints”? Read on and check out full video at end of blog.
Shin splints, or Medial Tibial Stress Syndrome (MTSS) as it is medically known, are terms used to describe pain on the medial (inside) portion of the shin pain during and after running. Generally, this is a result of inflammation to the outer layer of the bone (periosteum). Shin splints can develop slowly, if are not treated with respect and caution, can be rather debilitating for the runner/athlete, forcing them to either reduce their running dramatically, or in some cases cease running completely for a period until their symptoms settle.
Typically, MTSS is worse in the morning and improves with exercise (in non-severe cases). Pain location is normally diffuse, up to 5-10cm of tenderness along the shaft of the shin, and usually on the lower third.
Are there other causes of shin pain I should be aware of?
We need to be careful as clinicians that we do not classify all runners with shin pain as having MTSS. There are several other causes of shin pain that we must be aware of as differential diagnosis to aid best management. The two other most common causes of running related shin pain are
- Chronic exertional compartment syndrome
- Stress reaction/stress fracture which are often seen as a progressive continuum of bone stress
See below for differentiation:
What causes medial tibial stress syndrome?
There are various theories as to why MTSS arises, however despite volumes of scientific research we have yet to discover definitive causes. Research suggests that the pain is generated from inflammation along the lining of where the fascia (connective tissue) meets the shin bone. One theory is that these muscles create a traction effect on the bone, causing pain. Other theories suggest compressive and impact forces create bony inflammation and therefore pain.
There are various risk factors that can lead to someone developing MTSS. These include:
- Inappropriate load (increasing volume/frequency/intensity of running beyond our capabilities)
- Experience as a runner (adapted to loads associated with running over time appears to decrease risk of injury)
- Biomechanics (navicular drop, plantarflexion range, hip external rotation, orthotics)
- Body mass index (people who have MTSS have a significantly higher BMI than controls)
- Tissue capacity/strength (weakness in certain running specific muscles can contribute to overload)
- Running technique
- Poor Recovery
Despite public perception, predominantly from being misinformed via social media, there is currently no evidence to suggest MTSS does arise from “tight calves”, “flat feet”, “hard grounds” or “running too much”. The amount of running is not the problem, but how you get there can be.
How do I treat MTSS pain?
The key to successful treatment is to be sure of a specific cause, which then guides the rationale for successful treatment. Often there are multiple contributing factors involved which demand a thorough assessment.
Treatment principles generally involve:
- Load modification/education
- Restoration of muscle imbalances/strength deficiencies in the kinetic chain
- Addressing biomechanical factors than may contribute to shin overload whilst running
- Weight loss strategies
- Running mechanics
Passive treatment strategies such as massage, needling, joint mobilisations, taping and icing can be beneficial short-term options to reduce pain and help a runner/athlete continue running for a period, but are not viable long-term options. Too often people are just treated with these passive modalities as a recipe formula, only for the problem to not settle down or to return in the future.
How long will it take to get better?
Recovery time depends on a number of variables including:
- Ability to be compliant with treatment recommendations
- Needs for continual running (elite level runner with an upcoming race vs a recreational runner that can be flexible with running loads)
- The stage of bone stress (had pain for 1 week vs 1 year)
- Contributing factors to pain (load and running mechanic issues generally respond much quicker than biomechanical, strength and weight issues)
In an ideal world, most people will return to pain free running via a graduated program in 6-12 weeks.
Surely the way I run can’t be the issue? How do you change that?
Running assessment for running related injuries has gained traction over the past 10-15 years, which makes sense right? For far too long, physios have treated running related injuries within the four walls of the treatment room. For injuries that occur during something as complex and as varied as running, it seems almost negligent to treat someone without looking at them run!
Running retraining is not for everyone, yet in the right person can be invaluable. MTSS typical involved movement patterns than involve a slower cadence and an over striding technique. At times, using verbal cues such as “quicken up your stride” or “land more under your foot” can provide dramatical decreases in pain instantaneously.
As mentioned, running retraining is not suitable for all people and involves inherent risk of changing loads through the lower limb. Running retraining should be overseen by a physiotherapist or other allied health specialist specially trained in this area.
Do I need new shoes/orthotics?
No! Orthotics in two studies (Burne, Khan & Boudville, 2004., Hubbard, Carpenter & Cordova, 2009) have been shown to actually increase the risk of developing medial tibial stress syndrome. In addition, despite what major shoe brands would love you to think, except for very minimalist shoes there is no evidence to suggest that one shoe type helps/hinders with respect to shin pain. The most up to date advice with respect to runners is that we run in those that are most comfortable, ideally having 2-3 pairs that we cycle through if we are running regularly (more than 3-4 x week).
Can I continue running?
Yes! As long as symptoms are stable and low level, and not worsening overall. Just because you are in pain does not mean that you are doing damage. I generally allow runners to continue running as long as their pain is less than 2-3/10 whilst running, does not flare to greater than 4/10 afterwards, and is back to baseline by the following morning.
Written by Physiotherapist Ben Bond
If you have any questions related to shin pain in running, or running injuries in general, Ben would be more than happy to assist.
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