A New Approach to Shin Splints
Shin splints (aka medial tibial stress syndromes) are one of the most common injuries in jumping and running athletes, yet their treatment has consisted of little more than icing and stretching for decades. The occasional laser therapy is now thrown in nowadays, but little is done to discover why the shin splints developed in the first place.
Shin splints develop due to the inability of the muscle of your lower leg to properly absorb force. Thus athletes begin to rely on their tendons, bones, accessory muscles, etc. to absorb some of the force.
This inability to absorb force can be due to overtraining, undertraining, poor landing/running mechanics, previous injuries or improper footwear.
Footwear
Let’s tackle this one first as it is common in runners to get the most cushioned shoe they can find. Unfortunately, this is not a good idea. Also many shoe salesmen like to mention high arches, motion control and custom orthotics. Each of these lead to long-term compensations and the deconditioning of the muscles of the lower leg, which actually causes shin splints.
In my office I am either wearing “Xero Shoes” or no shoes at all in order to make sure that while I stand all day and treat patients, I don’t lose foot strength and create compensations. I definitely have gotten a few comments on my feet being unshod, but once you understand the importance of foot health on the rest of your body’s health, you will want to be as barefoot as possible too.
Remember if you transition from marshmallow shoes (see video below) to barefoot or minimal shoes, you must do it slowly.
How not to choose shoes….
Overtraining Athletes (Lots of overgeneralizations here)
The three major categories that seem to fit the majority of athletes that are improperly training are the novice athlete, the “over trainer” and the under-recoverer.
The novice athlete begins running or playing a sport without much previous experience, their form is atrocious, their strength is subpar and their shin splints are blazing. For them, coaching and getting into a regular pain-free training routine is important. This also includes the beginner “cross fitter” who has never lifted before and the x-endurance athlete that is ready to make a comeback at Boston within 1 month of getting off the couch.
The “over trainer” is the typical endurance athlete that just can’t stop training. If they have extra time, they log another 5-50 miles. They usually love the high that comes from training or they are on a weight loss journey and let burning calories rather than avoiding calories be their motto. This high intensity and highly inflammatory training method leads to pain all over, but shin splints often come with it.
The last but not least is the “under-recoverer”. The under-recoverer may be the most common type of weekend warrior, high school athlete or stay-at-home mom around. They train hard, play hard, work hard and sleep…. not so hard. They often eat a poor diet, stay up too late, train through the pain and injuries and think that more effort is the key to all success in life. They also enjoy the benefits of pain that comes with it.
Muscular Imbalances
With modern footwear like I mentioned above, the lower legs, tendons, ligaments, and stabilizing muscles weaken and develop compensations. Many people get new shoes or new orthotics and experience some relief, but more often than not, over time the shin splints return.
This is because external devices can’t strengthen and stabilize the muscles in the lower leg. Just like wearing a neck brace doesn’t strengthen your neck, wearing and ankle brace or foot brace (aka shoes) doesn’t strengthen your foot.
There are 3 main muscles of the lower leg that I frequently find in treating difficult cases of shin splints. They are the tibialis anterior, the tibialis posterior and the soleus. The tibialis anterior is on the front/outside part of the lower leg, the tibialis posterior is on the back/inside of the leg and the soleus is usually the widest muscle of the lower leg. (see image)
These 3 muscles often have trigger points that need to be located and worked on in order for the muscles to begin properly contracting, relaxing and working together. Often times if you can get to these trigger points fast enough you can actually work them out yourself and see dramatic decreases in pain.
Unfortunately, if you have had these imbalances (shin splints) for an extended period of time, it is likely you will need help as more imbalances and compensations above the knee and throughout the body may have occurred.
Hormones, Inflammation and Ligaments
One thing we know about ligaments is that they are highly sensitive to inflammation. The reason this is so is because they need to be able to heal in the case of a minor tear or injury. In fact, even if you get shin splints, if you rest a few days, you should be able to heal and move on, unless there are other underlying factors.
Tendons and ligaments are also sensitive to hormonal changes. (see here and here) Elevated estrogen levels have been linked with injuries and thus in today’s society of overstressed, over-caffeinated, excessive sugar individuals many patients that have an injury that refuses to heal often have a hormonal or insulin regulation problem that perpetuates their inflammation and injury.
You may think that you don’t have a hormonal problem and that you are skinny and don’t’ have diabetes, so there is no way that you could have an insulin problem, but endurance athletes often have sugar/insulin problems due to intense training even when their diet is overall health.
Lastly, What Not to Do
The last thing you want to do is stretch your calf muscles if you have an injury and by now we should all know that icing provide little to no benefit at all other than a little bit of pain relief, but not due to decreasing inflammation substantially. These two techniques have been one of the reasons why shin splint treatment has remained in the ice ages (pun intended) and that the prognosis and progression of therapies has been limited.
So if you have shin splints, make sure you are looking at the whole picture of what may be causing or perpetuating your problem. In a second article I will cover rehab and trigger point therapy of the lower leg in more depth.