This past month I was asked to answer some questions by The Mother Runners to help with a blog they were writing regarding shin splints. This was serendipitous timing as we are entering autumn, the shin splint season!

Every fall, unfortunately, runners of all levels are upping their game to prepare for high school or college cross country or a fall full or half marathon. More miles and fast workouts are attempted (hopefully completed)! If a runner has not prepared their bones or muscles with months of base phase running and lots of strength and conditioning, the training often proves too much and, likely, results in dreaded shin splints.

This blog hopes to answer some burning questions as to why shin splints happen, who is at risk, and what you can do to ease pain and continue training. Rock creek park, capital crescent trail, the mall as well as many other DC running destinations are at their peak beauty… and like a bit cooler. Don’t let pain prevent you from enjoying running in Washington DC this fall. If you are left scratching your head or need more insights, we are always happy to help!

1. what are common causes of shin splits in runners?

Easy, running is the common cause :) Next question…

Let’s discuss what a shin splint is. It is commonly called “medial tibial stress syndrome.” This title indicates the shin bone, aka tibia, is the tissue that develops the issue.

There are 2 competing hypotheses on how this happens and both have evidence to support. First, the muscles attaching on the inner aspect of the shin, namely the soleus, tibialis posterior and flexor digitorum longus, pull on the bone. The rate or intensity of muscles contracting leads to excessive stretching of the periosteum on the bone surface resulting in pain. When this stress exceeds your tolerance and ability to recover the result is pain.

The second theory is the impact of running causes more breakdown down of the bone than the body can tolerate leading to microcracks which then cause pain.

So what factors contribute or place someone as risk for the development of shin splints? 

I will categorically list the risk factors as noted in this systematic review and discuss each:

1. Structural- Higher BMI, Dropped navicular(pronated foot), males with high amounts of hip external rotation mobility.

Higher BMI likely causes more force per step on the tibia.

A dropped navicular leads to more pronation which then causes more torsion on the tibial bone and/or muscle activity to limit the torsion.

Not sure what’s up with the males… may be similar underlying issue as the dropped navicular group in which more rotation is occurring through the leg resulting in more muscle work or torsion at the shin.

2. Demographic: prior history of shin splints, females and newer runners

Females are more at risk to develop shin splints. I suspect this is because the above gait dysfunctions are much more frequently observed in female runners.

Folks with a history of shin splints likely have structural, behavioral, or biomechanical factors that predispose them to more shin stress.

And newer runners have likely not had enough time or exposure to develop stronger tibial bones, of course if you are coming from a long running based athletic background this may not hold true. Anecdotally, I have treated a plethora of swimmer’s with shin splints. I suspect they body’s have not had enough history of land based training which makes them a vulnerable population to development of shin splints.

3. Training.

The volume, intensity and frequency of running exceeds the body’s ability to recover and adapt, leading to pain at the periosteum or in the bone. Recall, running is stressful on the body. This is good because the stress causing tissue breakdown, which then leads to tissue build up. This new tissue is now stronger. This cycle is referred to as adaptation. When training is too much or the recovery is not enough, the rate of bone breakdown surpasses the bodys ability to repair it causing sustained breakdown of the bone.

4. Overuse and misuse of the calf muscles.

If the calf muscles have limited endurance or strength, this lower’s their resiliency, leading to less capacity and overload. Similarly, the calf muscles will become misused and overused if there are biomechanical factors causing more substitution of the calf muscles like excessive pronation, pelvic drop, knee collapse.

2. what exercises can you do to help or prevent shin splints?

In the short term, I like to use massage and taping to assist in providing immediate relief along with actitiy modifications such as rest or reduing running workload.

For the long term best outcome, key exercises would involve calf, and lateral hip strengthening and coordination. 

I like to test all my client’s endurance via a heel raise test. A study on runners found people with shin splints averaged 23 repetitions whereas their healthy counterparts averaged 33!

At baseline If they can perform 25 or more single leg heel raises without fatigue, loss of control or pain then I promote them to do the exercise with weights. If then cannot achieve 25, then I give them this as homework. If they are limited by pain, then I scale the exercise back to double limb or with support.

For lateral hip strength and lower extremity coordination, I will perform a battery of tests which include a single leg step down, bridge with SLR and side plank with opposite hip lift. This will give me insight into the ability to control the shin with movement and if the strength of the glutes is appropriate. Whichever tests they do poorly, then becomes their program. I may scale up or down depending on competency, skill level and challenge to yield the best result.

3. if you have shin splints, what course of action should you take?

First make sure you have the correct diagnosis. Stress fractures, compartment syndrome, posterior tibialis tendonitis, and referred pain from the knee or spine all must be excluded. This is something a trained medical professional can do an should not be something you take lightly on your own.

If you have shin splints, then a combination of reducing the running program, massage to the calf muscles, as well as addressing the underlying strength and flexibility deficits as well as the running biomechanics assists in decreasing the pain and restoring load tolerance back to the shin bone.

Treatments like dry needling and massage can help reduce pain the in short term. Dry needling, a technique involving the insertion of thin needles into trigger points within muscles, has shown promise in reducing pain associated with shin splints. By targeting specific areas of muscle tightness or dysfunction, dry needling can help release tension, improve blood flow, and promote tissue healing. Several studies have suggested that dry needling may alleviate pain and improve function in individuals with shin splints, providing a potentially effective adjunctive treatment option alongside other therapies such as stretching, strengthening exercises, and rest. However, further research is needed to fully understand the mechanisms and long-term effectiveness of dry needling for shin splint management.

Occassionally, rest is needed to reduce pain. I want all my runners to be able to walk painfree for 30 minutes before even thinking about returning to run. Beware! Rest is rust AND rest is not rehab. Pain will undoubtably decrease with rest. However, all the underlying dysfunctions in movement, training plan and behavoirs must be addressed for a successful return to running.

I recall working with a high school runner with shin splints a few years ago. He came to me after dealing with shin splints the entire previous year. He tried rest but it did not enable him to run more without pain. We had a similar conversation about running injuries needing active solutions. We were able to address his strength and running mechanics as well as give him and his coach recommendations on training progressions. He went on to complete his high school running career without a return of his symptoms!

4. is there a test you can do (like a hop test) to make sure you are okay to try running?

Single leg hopping can help to rule out a stress fracture. It’s not a catch all test, but is sensitive to more severe injuries. Coupling single leg hopping with 5 to 10 minutes of walking or slow jogging will be informative as to whether or not to run. Our tissues will vary day by day as to their stress tolerance; therefore, checking in, like a warm up, before running can help you decide if you should run or take a day off.

A note on pain intensity. When it comes to shin pain, we are more guarded with recommending running even with mild or moderate amounts of pain because bone is much more sensitive to breakdown in the presence of pain. So pain that is >1/10 is a red light. If pain is <1/10 then running is a green light. I have had clients with suspected bone stress injuries who had no pain but their form was really off and they could feel themselves compensating. So excessive compensation would also be a red light.

Back to hopping… If hoping causes pain, then I would walk for 5 to 10 minutes and try again. If the hop feels good then I would run. If not, then do not run on that day… 

5. how do you know it is shin splints and not a fracture or something else?

Ruling out a stress fracture is my primary goal in clients with shin splints. The pain behavior of shin splints is usually exclusive to running and may even warm up with activities; whereas a stress fracture gets progressively worse the more you are running. Also, stress fractures hurt with daily activities like walking and standing.

Clinically, a stress fracture is very locally tender. There may even be a lump/nodule on the bone at the site of tenderness. Shin splints are typically sore over a larger area usually described as the middle or lower 1/3rd of the shin bone.

The other condition to rule out is compartment syndrome, which is characterized by cramping or burning pain in the back of the leg. It may also cause numbness or tingling in the leg or foot.

If your history and presentation are not clearly leaning towards a shin splint or you are unsure, then I would recommend following up with a physician or physical therapist to assist in your diagnostic process.  

6. any shoes you like for shin splints?

No shoes come to mind specifically for shin splints. Footwear is very important but should be viewed as unique to each individual. Modifying footwear should come after an appropriate diagnosis is made and making sure appropriate exercise, and running program adjustments have been installed.

I encourage all runners to run in shoes they are considering for purchase. When buying a shoe, you are conducting a personal experiment. You are looking to see if the shoe is comfortable, facilitates your natural running form and, most importantly for shin splints, reduces pain. If pain does not happen until later in a run, then find a store or online shop with a good return policy- buy the shoe then test it out. If it helps to decrease pain, keep it. If not, return it.

Here are my considerations. First and foremost, the shoe should be comfortable and facilitate a runner's movement. You should not feel odd hot spots nor find the shoe alters your running gait. For example, this may be experienced as running more on the inside or outside of the foot.

If the comfort and feel of a shoe do not yeild satisfactory outcomes. Next, I would look to try altering a shoe’s shock absorption OR adding more heel and arch support.

It is suspected that overstriding and high ground forces may contribute to MTSS. Although the research does not necessarily indicate a cushioned shoes can cause less ground reaction force, it may yield less pain which is a better performance indicator for a person with shin pain. Conversely, if a more cushioned shoe does not make the pain noticeably better then I would move in the opposite direction and try a stiff shoe.

Lastly, if you are still trying to find “the right shoe” I would wear a motion controlled shoe or add an over-the-counter foot orthtoic to reduce the effects of pronation on the lower extremities. In a randomized controlled trial of 260 runners, those who work a motion controlled shoe were less likely to sustain a “pronation” related injury like shin splints.

A few years ago, I wrote this blog dispelling common shoe myths and providing recommendations on shoe selections. This may be helpful to further understand the role shoe’s play in injury.

7. anything you would like to add?

Shin splints are not soley an orthopedic, movement related issue. The health of bone is heavily influenced by our diets and hormones.

Bone is a complex tissue that requires high amount of energy availability through food. Whether is a specific nutrient like calcium, vitamin D, or food group like protien or overall caloric intake, if you are not feeding, literally, the body with an appropriate amount of food then it will take nutrients from bone. For example, our muscles and organs require calcium to aid in their function. If there is not enough calcium brought in through food, then the body will take it from bone. Additionally, If you are not consuming enough food then the bone your body repairs will be weaker and less capable.

If you know you are going to be ramping up your training then you should do the same with your eating. Just as you may have a marathon training plan, you should have an eating plan that is progressive to keep up with the demands of training.

Additionally, bone is also very influenced by hormones. If you are a female runner who has amenorrhea, then you are likely estrogen deficient. Estrogen tells the body to build more bone. This is vital to aid in recovery from any exercise but especially running.

If either of these areas, diet or homones, feels familiar to your situation or if you are unsure then talk to your PCP or OB/Gyn OR consult with a dietician who works with female athletes to talk through your case. 

Don’t Let Shin splints spoil your fall running!