Shin splints, aka medial tibial stress syndrome, is a bone stress injury. It occurs due to overuse when the stress from running or jumping exceeds our body’s capacity. Occasionally runners, regardless of level of competition (high school, college, adult), go hard into their training programs without completing prerequisite base training to meet the demands of a new or increased workload.

This injury can linger awhile when athletes try to work through the pain. In fact, a study on runners with shin splints found that it took about 100 days to run 20 minutes when running with pain greater than or equal to 4/10. This informs us that the tissues are sensitive and respond poorly to ongoing stress.

Here’s the good news: Our bodies do a fantastic job of adapting to exercise as long as the stress we give it is incremental over a sustained period of time. Bone takes 3-4 weeks to remodel to a new stress. So if you are adding mileage, interval workouts, running daily, cross training, etc, then your bones will need 3-4 weeks to adapt to this stress. The going can be slow, but good things come to those who are patient.

Step 1: Reduce You Pain:

Shin splint initial care involves reducing the load on the bone and addressing pain.

Activity modification is a must to begin to decrease the pain. No such thing as “having a high pain threshold” when treating this condition! The most important aspect of controlling the symptoms is finding the threshold amount of activity you can do that doesn’t cause pain…

I will always try to keep runners running. This may entail reducing mileage or workouts, avoiding hills or changing running form (more on this later). If these changes cannot eliminate the pain in 1-2 weeks then the next step is to focus on cross training and walking. Walking is valuable in this population as it is a bone loading activity. It will promote strength and conditioning to the shin.

Additionally, self massage can reduce muscle stiffness. This will make the area feel better and promote more activity without symptoms. The posterior tibialis and flexor digitorum longus muscles get stiffer in people with medial tibial stress syndrome. These two muscles live behind the inside border of your shin bone. Targeted mobilization to these muscles is a step in the direction of getting you back to pain-free running.

Step 2: Address Underlying Issues

Once the pain is under control, the next step is to address underlying strength and running technique issues.

Strength

What muscles are most involved with running? The calf, quadriceps and gluteals. I use this framework when assessing a runner’s strength. I prefer to use endurance tests like heel raises or bridges to fatigue. This way we can establish a baseline of strength in which we can begin a targeted strength and conditioning program

Performing single leg heel raises are a quick and easy test of calf function. A study on runners found people with shin splints averaged 23 repetitions whereas their healthy counterparts averaged 33! Once a baseline is established, the fun begins on programming specific exercises to promote stronger muscles.

Running Form

Two components of performance on running technique: land softly and well aligned.

A study of 68 high school cross country runners found runners who took less than 164 steps per minute were more likely to develop shin splints than those who ran greater than 174 steps per minute. Having a low step rate per minute is associated with a longer stride, usually an over-stride, and thus more shock into the shin bone. If fact, when runners increase their stride length by 30%, the forces on their shins increase by 43%. By reducing stride length by 10%, a runner decreases their risk of a stress fracture by 3-6%

Running mechanics such as the quantity of knee adduction or foot pronation or the speed of foot pronation have been implicated in shin splints. A common form issue seen in runners with shin splints is called crossover. This occurs when one foot steps in front of the other. The crossover sign causes the step width to become more narrow, which leads to the aforementioned running mechanic issues.

A simple cue to improve step width is to run with an actual line under foot or an imaginary line bisecting the body. I like to do this on a track or lined road, absent of cars of course. Try to keep that line underneath your body. Run without letting your feet touch the line or have one foot stay on the line and the other one stay away from the line.

For more information on landing softer while running check out my previous blog, How to Land Softer While Running.

Step 3: Reload

Bone loading is applying an exercise or activity to your body to stimulate bone remodeling. Once we can establish a baseline of activity that can be completed without pain then we can begin to progressively add more load.

A gradual running program should be applied to return a runner to their previous level of performance. Before creating a program, it is important for a runner to reflect on any changes made in their training that lead to the shin splints. This way repeating the same errors can be avoided. Also, this helps to implement different aspects of training (hills, volume, intervals) more slowly. Adding one variable to training (mileage, track work, hills) every few weeks will lower the risk of re-injury. Additionally, factors like cycling rest or adding cross training may be needed to promote bone strength and recovery.

Unfortunately, running more will not be sufficient in restoring optimal bone health. Bone stops adapting to running after several weeks of training. To supplement running, a strength and conditioning program including resistance training and jumping is necessary to facilitate stronger bones.

When it comes to treating shin splints, please don’t guess, get assessed. Working with an expert, like me, will help identify your issues then create a plan to return to happy running.

References:

Tom Goom MTSS video

Saeki 2018. Muscle stiffness of posterior lower leg in runners with a history of medial tibial stress syndrome. https://pubmed.ncbi.nlm.nih.gov/28207961/

Madeley 2007. Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: a case-control study. https://pubmed.ncbi.nlm.nih.gov/17336155/

Luedke 2016 Influence of Step Rate on Shin Injury and Anterior Knee Pain in High School Runners. https://pubmed.ncbi.nlm.nih.gov/26818150/

Meardon 2014, Effect of step width manipulation on tibial stress during running. https://pubmed.ncbi.nlm.nih.gov/24935171/

Warden S. 2014. Management and prevention of bone stress injuries in long-distance runners. https://pubmed.ncbi.nlm.nih.gov/25103133/

Saxon. 2005. https://pubmed.ncbi.nlm.nih.gov/15777679/

Marytn-St James. 2010. Effects of different impact exercise modalities on bone mineral density in premenopausal women: a meta-analysis. https://link.springer.com/article/10.1007/s00774-009-0139-6