[Updated Case Study] Risk Factors For Shin Splints & How To Prevent

by marathonman

Shin splints are a common injury for runners. They can also be known as medial tibial stress syndrome (MTSS). Symptoms include pain in the front of your lower leg and at times along the inside of the lower leg, next to the shin bone (tibia). Because shin splints are very common and often discourage new runners from continuing to train, I have put together this comprehensive resource which not only explains symptoms and causes of shin splints, but most important, treatment and prevention.

Self diagnosis of any sporting injury is dangerous. Every injury is different in some way and each requires specific assessment and treatment. It would be irresponsible of me as a certified coach to attempt to manage your injury in an article. So use the following information for guidance. Although I provide much researched details along with a logical and effective rehab program, I encourage athletes to seek professional medical opinion for diagnosis and to confirm treatment protocol for any injuries.

The role of the shin bone during running is to help absorb and dissipate the impact generated with each foot fall. Shin splints are generally an overuse injury that occur when too much stress is put on the tibia or when the muscles next to and around the tibia are overworked. In healthy runners, the stress a bone experiences after a long, hard run is not a problem and doesn’t result in shin pain. However, in less experienced runners or athletes who have a muscle imbalance with weak shin muscles and underdeveloped hip abductors & calves, the shin bone has not yet adapted to the stresses of a high-impact activity like running.

Unfortunately, shin splints often recur with many runners who aren’t able to address their overall weaknesses. This is because, many resources on how to get rid of shin splints (even from trusted medical sources) don’t address the root cause of the problem.

Risk factors for shin splints

The biggest risk factors for shin splints is a rapid increase in mileage or intensity of your running activities, such as a big increase in mileage or over-training on hills or hard/uneven surfaces. However, in order for these risk factors to lead to shin splints a pre-existing muscle imbalance between quads and hamstrings or weak shin muscles and underdeveloped hip abductors & calves will often lead to shin splints.  Other factors include inadequate footwear, poor bio-mechanics such as over-pronation, flat feet or high arches.  Each of these risk factors contributes shin splints.

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In a recent study of high school runners, a significant relationship was found between Body Mass Index, internal hip rotation angle and shin splints in females, and between limited single leg raise and stress fractures in males.  This would support the need for strengthening and stretching exercises which are discussed below.

Symptoms of shin splints

Shin splints result in pain in the front of the outer leg below the knee. Typically this pain is located on the outer edge of the mid region of the leg next to the shinbone (tibia). In my experience dealing with runner’s with shin splints, they complain about discomfort in an area of their leg that’s anywhere from 4-6 inches in length (as opposed to a stress fracture which is typically pain in a much smaller area). Oftentimes, the pain the runner is experiencing is at the beginning of the workout, then gradually lessens, but then can reappear at the end of the training session. Most people describe shin splint discomfort as a dull ache at first. However, as the trauma continues, it’s not uncommon for the pain to become so unbearable that it causes the athlete to stop their workout altogether.

Treatment

There are many articles regarding treatment of shin splints. The aim of most “traditional” treatment methods involved rest & ice, which typically reduced the pain. Medical studies of shin splints have attempted to confirm the most effective treatment, but no study is conclusive.

The proper progression of treatment and along with a planned exercise program will help alleviate the pain and most important prevent shin splints from recurring. First, I strongly suggest getting a diagnosis from a medical professional.  We must confirm that the trauma is actually due to shin splints and not a stress fracture.  There’s a big difference between the two injuries, especially in the treatment and length of recovery.

Assuming that the injury is shin splints, first order of business is to minimize the pain.

1. Rest – avoid activities that cause the pain or discomfort. However, don’t give up on all physical activity.  Try low impact exercises like elliptical, swimming or stationary bike.
2. Ice – apply ice packs to the affected shin for 20 minutes at a time 2-3 times per day.
3. If the pain persists when you’re not engaged in physical activity, consider taking an over-the-counter pain reliever of your choice. Discuss your best options with a medical professional.

Use of KT Tape

KT Tape can help treat shin splints by relaxing associated muscles, relieving pressure on tissue to reduce pain, and increasing circulation. Although I haven’t tried KT Tape as a means to minimize shin splints, you can follow the directions in this KT Tape video

In parallel to the above pain relieving regime, preventing shin splints involves a program of stretching and strengthening.

Best Prevention Strategy

Improving calf strength, abductor strength and strengthening shin & hip muscles are the best approach to preventing shin splints. The calves are the largest muscle group in the lower leg, when we strengthen them along with hips and shin muscles, we help stabilize the tibia with each impact.

1. Regularly stretch your calves and hamstrings.

Use the stretching routine below to help avoid tight muscles in your leg that can put you at greater risk for shin splints and other lower leg injuries.

2. Avoid sudden increases in physical activity.

Gradually increase your weekly mileage & the intensity of your workouts. The rule of thumb for most runner’s is to limit weekly mileage increases to 10%.  More experienced runners can increase by slightly more, but it’s always best to err on the conservative side.

It’s also very important to ensure proper recovery after long & hard runs.  This not only includes spreading out days between hard activities, but also completing alternate forms of exercise (like elliptical, stationary bike and swimming).  It’s also really important to run slow on your easy days.  Bottomline, getting sufficient rest will ensure proper recovery and help to avoid injuries.

3. Run on softer surfaces whenever possible.

This tip isn’t just for runners that are experiencing shin splints.  It’s a good idea to try to minimize running too often on hard surfaces, such as concrete (sidewalks & bike paths). These hard surfaces over time will increase the amount of force that your bones and muscles have to absorb which can cause muscle fatigue and overuse and ultimately possibly result in shin splints.

Choose soft surfaces like dirt, grass and synthetic tracks.  Make it a goal to go for a weekly run on a nice wooded trail to break up the monotony of running on surface streets. This will help to prevent your bones, muscles, tendons and joints from having to absorb so much shock.

4. Complete exercises that will strengthen your foot, ankles and the arch of your foot.

The arch of your foot forms by the time you are 7 to 8 years old. Injury, age, and other health conditions can alter the structure of the arch; lack of physical activity can actually create weakness in the muscles of the foot, lower leg, thigh, and trunk. These changes can affect your lower leg and is often why beginner runners experience shin splints.

Strengthening your feet is important. An excellent exercise is using your toes to pull a towel on the floor closer to your foot while sitting. This helps to strengthen the arch muscles. Stronger arch muscles ensure the arch works more effectively.

Foot orthotics (ie, arch supports) may be prescribed by your doctor or physical therapist if you pronate or require additional support for low arches. Alternatively, orthotics help with  high arches by helping the foot absorb more shock and decrease stress.The use of orthotics should be prescribed by a medical professional.

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5. Strengthen your hip muscles.

Strengthening your hip muscles will help your legs absorb more of the shock and pressure during running. Below are some excellent exercises that will help.

6. Ensure you are wearing running shoes that are right for you.

Shoes that don’t fit right or that lack proper features can contribute to shin splints. Speak with your physical therapist about the right shoe features for you. I also recommend rotating your running shoes. One strategy is to rotate your shoes. This means having 2 pair of the same or slightly different shoes and use them each 3 – 4 times per week.

It’s essential to regularly replace worn running shoes. Typically replacement is recommended every 350 to 500 miles (560 to 800 kilometers). You can find a detailed article discussing how to buy new running shoes.  It’s a quick, but informative read that will help you get the appropriate shoes to accommodate your gait and size.

7. Maintain a healthy body weight.

Increased body weight, being overweight, or obesity can lead to a higher risk of shin splints. Even if you if you run or exercise regularly, you should still regularly consume a well balanced diet.  You can find some suggestions about How To Improve Your Diet Right Now.

8. Have your running technique analyzed and corrected by a physical therapist.

Incorrect running, jumping, and landing techniques can cause shin splints. Your physical therapist can help you understand how to improve your exercise technique to avoid shin splint pain. Your physical therapist also can check to see which muscles are tight or weak, and teach you how to stretch and strengthen them.

Physical therapists can observe how a person moves, determine how their body reacts, and then establish a program of care for prevention, recovery, and progression of desired activity.

A formal video analysis of your running technique can help to identify movement patterns that can contribute to shin splints or other injuries. In many cases, a slight change in your running can help decrease your risk.

How to Prevent Shin Splints Routine

So now that we know all this information about the cause of shin splints, it’s essential to develop a routine to prevent them. Below is a recommended strength training program. The exercises shown will strengthen and stabilize your legs, ankles, hips and core. They will help prepare your legs and body to deal with the high-impact of running.

Clams

Start by lying on your side, legs stacked on top of each other with your knees bent at around 45 degrees and pulled slightly behind you.

Put your bottom hand under your ear to support your head or along the floor and use the upper hand to push into the ground right in front of your chest.

Keep your heels together, slowly open and close your upper knee up and down. Switch sides and repeat, opening out the opposite leg for the same amount of reps.

Clams help to maintain hip flexibility and provide knee stability. The small controlled movements activate all the small muscle groups in your glutes and inner legs to improve strength and range of motion without any impact.

Wall Press

Stand approximately 18 inches from a wall with both feet shoulder-width apart, toes pointed inward.

Press your pelvis to the wall, adjusting the distance from the wall and the angle of the toes to gain the best stretch of the soleus muscle. Keep your heels on the floor.

Hold stretch for 15 – 30 seconds and repeat.

Donkey kicks

Get on all fours with your hands under shoulders and knees under hips.

Keep right knee bent 90 degrees, flex right foot and lift knee to hip level.

Lower knee without touching floor and lift again. Complete 15 reps.

Switch legs and repeat.

Standing Calf Stretch

Stand, facing a wall with one leg extended backward, foot planted on the ground. The other leg, flexed at the knee, has the foot planted on the ground straight down from the hip.  Arms are extended forward at upper chest height, shoulder width apart. Hands are placed on the wall.

Press gently into the wall and gradually press your heel of the extended leg into the floor. A stretch should be felt through the length of the calf muscle.

Stretch statically for 15-30 seconds, repeat multiple times and then switch legs after every rep.

Runners with either neutral or underpronoted biomechanics often suffer from tight calf muscles. This stretch will help to alleviate the pain associated with recurring calf injuries.  This stretch will also help to prevent calf injuries by keeping the calf muscle supple.

Hip thrusts

Hip & Glute on Ground

Thrust Hip Up, Point Toe Forward & Hold for 5 seconds

This exercise helps to improve glute strength

Standing Heel Raise with Eccentric 

Stand with both feet on a step with the heels off the step. Hands are pressed against the wall in front.

Raise up onto your toes of both feet to full extension

Lower gradually to full extension (dorsiflexed).

This exercise both shortens the calf muscle and then lengthens it.  Including an eccentric (or negative) component adds value to the the calf. Performing exercises with an eccentric component actually shortens the time it takes to heal an injury.

If you’re currently experiencing shin splints or they have plagued you in the past, incorporate the above routine into your training two to three times per week. Now you’ll be targeting the real cause of your shin pain rather than strengthening a muscle that really doesn’t contribute to the injury.

References:

Zimmermann WO, Helmhout PH, Beutler A. Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces. J R Army Med Corps. 2017;163(2):94–103. Free Article.

Yagi S, Muneta T, Sekiya I. Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. Knee Surg Sports Traumatol Arthrosc. 2013;21(3):556–563. Article Summary in PubMed.

Authored by Andrea Avruskin PT, DPT.

Claude T Moorman III, ScientificAmerican.com/article/what-cause-shin-splints. May, 2004.

Mayo Clinic Staff, https://www.mayoclinic.org/diseases-conditions/shin-splints/symptoms-causes/syc-20354105

Shin splints, SSD Patil – Foot and Ankle Sports Orthopaedics, 2017 – books.google.com

Running Anatomy, Joe Puleo & Dr. Patrick Milroy, 2010 Human Kinetics.