PAIN ALONG THE FRONT OF YOUR LOWER LEG?
SEEMS TO WORSEN WHEN RUNNING OR WALKING?
REST HELPS BUT THE PROBLEM KEEPS RETURNING?
WHAT ARE SHIN SPLINTS?
‘Shin splints’ is a generic, ‘umbrella’ term used to describe pain and symptoms along the front of the lower leg. It is not a specific diagnosis. The 3 most common conditions that currently exist under this term include:
1: Medial Tibial Stress Syndrome / Periostitis: muscles along the front of the shin, thread into the periosteum (lining of the bone). On some occasions there can be increased pulling or traction of this lining which causes inflammation to develop and subsequent pain. This most commonly occurs in the lower 3rd of the shin and creates focal tenderness and sometimes a palpable feeling of swelling. It commonly occurs following long walks or when running.
2: Stress Fractures: bone is a living tissue and will constantly adapt according to the stresses applied to it. There are cells that build bone (osteoblasts) and those that break it down (osteoclasts). The balance between these cells needs to be maintained if the bone is to remain robust enough to cope with the forces applied to it. On some occasions the rate of bone breakdown occurs faster than the rate of bone development. This can occur due to dietary issues, altered body mass/ hormonal issues, changes in training patterns (frequency, intensity, duration) and training technique or general body condition. Pain will develop during activity and can eventually worsen to the point that it also occurs at rest.
3: Chronic Exertional Compartment Syndrome (CECS): the muscles in the shin are divided into compartments that are all surrounded by a connective tissue called fascia. When we exercise muscles swell and the fascia should expand to adapt to this. It is thought that during compartment syndrome the fascia is less compliant and so during exercise pressure develops causing pain and sometimes altered sensation (numbness or pins and needles in the foot and lower leg). This will cause the patient to cease activity. A period of rest can see the symptoms ease, only for them to return again as they resume activity. This is the more complex condition to treat out of the 3.
As a physiotherapist, I talk A LOT about load. It is a big buzz word in my profession and tends to play a big part in the management of sports injuries. We talk about both external load (i.e. the work that you do e.g. how far you run, how many squats you did etc) and internal load (how your system responds to the external load). Internal load is affected by variables such as strength, age and fatigue.
Sudden changes in load can be a ‘shock to the system’ and irritate the musculoskeletal system. A change in external load may be seen as a sudden return to running after 6 months out or a sudden peak in your weekly running distance as you aim for your first marathon. Tissues need time to adapt so any changes should be carefully planned. All of the below factors will effect either internal or external load to some degree:
Strength/ capacity of your musculoskeletal system: this is a variable that effects internal load. Weakness in certain muscle groups or generally poor health and fitness will reduce the ability of your system to absorb the loads you subject it to. If your hamstrings or calf muscles are weak how can you expect them to propel you forwards over a marathon? They will get tired fast and this will lead to injury. There are numerous other factors that will affect the capacity of the musculoskeletal system including lack of sleep, stress and poor diet to name just a few.
Training patterns: I will often see runners who have entered themselves for a 10K or half marathon race and very often the training programme is simply too intense. A lot of people will under-rest and the body is simply unable to cope. Training programmes need to be designed specifically in accordance with your ability.
Footwear: which is the right trainer for you? What shoe should you wear? This is a big topic in itself and also not possible to answer in this blog. What I can tell you, is that your footwear needs to be comfortable and supportive especially if you are running or walking long distances. As a runner be careful of changing the brand of trainer and do not always be swayed by what you read or hear everyone else doing. I always follow the motto ‘if it is not broken don’t fix it’. Stick with what you know and what works for you.
Running surfaces: changes in running surfaces will affect internal load. Joint loads and thus muscle activation patterns change according to the surfaces we run on so be wary of this and make sure the changes are progressive.
Previous injuries: change in joint range of motion, muscle strength, movement patterns can all occur as a result of previous injuries. This can be locally e.g. the ankle or knee or further through the chain e.g the back.
2. REFERRED PAIN
This is one factor that is not related to load. Be aware that the back, hip and knee can all refer pain to the lower leg/shin. This is why a thorough diagnosis is so important. Clearing these joints and confirming that the pain is local essential if treatment is going to be effective.
HOW DO I TREAT SHIN SPLINTS?
Having discussed 3 different specific diagnoses under the term ‘shin splints’, there will obviously be a slight variation in how the conditions are treated. However, as mentioned above; the most important factor to address is load and this can involve addressing the following:
- INCREASE STRENGTH / RESISTANCE TRAINING: I recommend that my patients do at least 2 sessions of strength training a week. Especially if they run. Resistance training increases the capacity of your musculoskeletal system to tolerate load.
- TRAINING DIARY/ MONITOR EXTERNAL LOAD: working closely with a physiotherapist to monitor your exercise or training regime can help identify potential peaks in load that may have led to injury. It may not always seem to be obvious, but something will have changed in your usual routine to cause injury.
- EQUIPMENT E.G FOOTWEAR/ RUNNING SURFACE: work closely with your medical team to work out which shoe is right for you. I will often refer patients to a specialist sports podiatrist to assist with this. If running surface is considered to be a contributing factor then modify what you are doing. I will always aim to get my patients doing what they want to do but little tweaks in how much is being done can often be the secret.
- RUNNING TECHNIQUE/ LANDING CONTROL: technique can play a major role in the development of shin pain. Patients can often be seen to land very heavy and with poor control. A detailed functional assessment by a physiotherapist can highlight potential risk factors. Treatment of these will not only reduce injury risk but will subsequently improve performance. A pain free runner is a faster runner!
- GENERAL HEALTH/ PREVIOUS INJURIES: dietary factors, sleep, stress, general medical health and previous injuries can all be risk factors for the development of a stress fracture. A thorough assessment by a doctor/ sports physician is often recommended to address these issues. A boost in certain vitamins for example may be necessary.
SO IN SUMMARY……….
‘Shin splints’ is not a specific diagnosis. A more thorough assessment is needed to highlight what structures are causing symptoms.
Excessive load/ overload is the greatest risk in the development of ‘shin splints’.
Resistance training, technique, equipment, general health and training programmes are 5 main factors to consider in the treatment of shin splints.
Specialist Musculoskeletal Physiotherapist
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