When you decided to get really serious about your training earlier this year, everything went smoothly for several weeks, but one day you felt a dull ache on the inside, lower portion of your shin as you began your workout. The discomfort went away once you had warmed up, so you weren't overly concerned.
Unfortunately, the pain returned on the following day - and lasted for a longer portion of your workout. As the days went by, pain was present for the whole training session, as well as your cool-down - and even hung around during your regular daily activities. When you used your fingers to probe the area near the back, inside edge of the lower part of your tibia (the main bone in the lower part of the leg), you felt tenderness but no major swelling, and the pain seemed to centre in the tissues (muscles and tendons) near the tibia, not the tibia itself.
More information on Shin Splints:
All of our articles on shin splints
Medial tibial stress syndrome - Two quick fixes for shin splints
What was wrong?
Of course, you had developed a classic case of 'shin splints', an injury which is more accurately called medial tibial stress syndrome (MTSS). Many experts believe that shin splints (MTSS) is the most common injury among athletes whose sports involve extensive amounts of running (e.g., runners, soccer players, rugby players and other participants in field sports); indeed, research shows that up to one in five injured runners are 'on the shelf' because of shin splints ('Relieving Painful Shin Splints,' The Physician and Sportsmedicine, vol. 20(12), pp. 105-113, 1992). And it's an especially troubling injury, because it can stop quality training in its tracks and also tends to recur, defying conventional treatments. The actual site of injury in the shin area can be muscle, tendon, bone - or the connective-tissue wrappings which surround your muscles and bones.
Some exercise scientists contend that MTSS is almost inevitable, since each shin absorbs a force equal to two to three times body weight with every footfall during running - about 700 times per shin per mile, mile after mile. The cumulative effect of this repetitive stress on the muscles and connective tissues in the shin area is believed to be the origin of MTSS. For that reason, MTSS is often called an 'overuse' injury, although as you'll see in a minute, the real problem is not so much overuse as it is a lack of preparation for use. Specifically, shin splints occurs because the ankle dorsiflexors - the shin muscles which in effect pull the top surface of the foot toward the shin and also (as part of their eccentric functioning) keep the foot from being pulled away from the shin too rapidly - are not functioning as well as they should.
The key role of these ankle dorsiflexors during running is in fact to control and limit plantar flexion - the movement of the foot away from the shin. During the very earliest part of the footstrike portion of the gait cycle - right after the foot makes contact with the ground, there's a tendency for the foot to slap hard against terra firma. In a 'heel-striker,' for example (a runner who first makes contact with the ground with his heel), forward momentum tries to slap the rest of the bottom of the foot against the ground very quickly and forcefully, an uncoordinated and energy-wasting action which is resisted by eccentric contractions of the dorsiflexors.
If a runner has weak ankle dorsiflexors, you can often 'hear him coming a mile away', because his feet actually make slapping sounds against the pavement (of course, such a runner will be at high risk for MTSS, because the rapid downward movement of the foot will tear at and overstress the dorsiflexors). In contrast, the runner with strong, functional dorsiflexors will seem to pad softly along, even if he is running on rock-solid concrete. Watch some of the elite Kenyans running, for example, and compare their foot-to-ground patterns with those of elite Brits or Americans or the average recreational athlete. The Kenyans build up tremendous dorsiflexor strength and functionality because they spend their initial years of life running and walking endless miles while barefooted, instead of moving around with their feet clamped into fluffy midsoles which shield the feet from hard work - or sitting around with feet propped up on a soft hassock. As a result, the Kenyans waste very little energy during the stance phase of the gait cycle - and seldom hobble off the track or roads with a shin injury.
In addition to controlling plantar flexion, the dorsiflexors must also deal with side to side motions of the foot and ankle during running - as well as the rotational motions which are a natural part of the gait cycle. Any tendency of the foot to pronate must be controlled by the shin muscles. Any tendency of the foot to supinate must also be reined in by the dorsiflexors. If there is relentless, stressful motion in any direction, the shin muscles can be damaged. That's why many of the shin splints exercise routines which supposedly prevent shin splints don't work so well; they often emphasize only front-and-back motions, rather than the side-to-side and rotational activities which are routine aspects of the biomechanics of running. The bottom line is that if you want to prevent shin splints, you can't merely develop general strength in your dorsiflexors - or strength which exhibits itself in only one plane of motion: your dorsiflexors must actually be stronger while you are running. More on that in a moment!
That's why the classical mode of treatment for shin splints - RECEIPT (rest, elevation, compression, easy stretching of the muscles, icing, and possibly taping) - works fairly well at relieving symptoms but does a very poor job of keeping the injury from recurring. Only by improving the functional strength of the dorsiflexors and the strength and coordination of the entire ankle area can one be confident that MTSS will be held at bay. If your dorsiflexors are strong enough to handle your total training load, and they aren't yanked around too badly by poorly controlled ankle movements, your training year should be un-marked by the pain and disruption of shin splints.
So what should you actually do to lower your risk of MTSS? Well, simply utilize our shin-splint-preventing exercises, outlined below:
1. Wall Shin Raises. Simply stand with your back to a wall, with your heels about the length of your feet away from the wall. Then, lean back until your buttocks and shoulders rest against the wall. Dorsiflex both ankles simultaneously, while your heels remain in contact with the ground. Bring your toes as far toward your shins as you can, and then lower your feet back toward the ground, but do not allow your forefeet to contact the ground before beginning the next repeat. Simply lower them until they are close to the ground, and then begin another repetition. Complete about 12 to 15 reps.
Once you have finished the reps, maintain your basic position with your back against the wall, dorsiflex your ankles to close to their fullest extent, and then quickly dorsiflex and plantar flex your ankles 15 times over a very small range of motion (smaller than the nearly full range you use for the basic reps; the emphasis here is on quickness). These short, quick ankle movements are called pulses.
As you gain strength over time, make the wall shin raises progressively more difficult by advancing from one set of 15 reps to two and then three sets of 15 (for the basic raises and the pulses). It's OK to walk around for 15 to 30 seconds between sets.
Now the single-leg raise
Once you can quite comfortably complete 3 x 15 of the double-leg raises (both basic and quick), progress to the single-leg wall shin raise. The basic position for this exercise is as before, except that you begin with only one foot in contact with the ground; the other foot rests lightly on the wall behind you. Now, full body weight is on one foot - as it is during running - as you carry out the overall routine, and the exercises are considerably more difficult. Begin with 12 to 15 reps per foot (both for the basic exercise and pulses), and progress to 3 x 15 (basic and pulse) on each foot as your strength increases. There's no need to rest between sets; simply carry out 15 reps on one foot plus the pulses, shift over to the other for 15 repetitions and pulses, return to the original foot, and so on until you have completed three sets with each foot.
2. Heel Step-Downs These are simple but devastatingly effective exercises for preventing MTSS. Begin with a natural, erect body position, with your feet about shoulder-width apart, and then step forward with one foot. The length of the step should be moderate - as though you were walking in your normal manner. When your heel makes contact with the ground, stop the foot from fully plantar flexing, ie, use your shin muscles to keep the sole of the foot from making contact with the ground. After heel contact, the ball of your foot should descend no more than an inch toward the floor or ground; your foot is held in check by the eccentric contractions of your dorsiflexors (shin muscles). Return your foot to the starting position (back by the other foot), and repeat this basic stepping action a total of 15 times. Then, shift over to the other foot and complete 15 steps. As with the wall shin raises, progress to three sets of 15 reps over time.
Now with longer steps
Once you have mastered the basic heel step-downs, perform the same exercise - but with dramatically longer steps. Using lengthier steps will increase the accelerating forces placed on the dorsiflexors and force them to work more forcefully and quickly, as they must do during running. Start with one set of 15 reps of long steps per foot, and progress to 3 x 15 on each foot over time.
Finally, you will be ready to carry out the heel step-downs from a high step, which will increase the forces on your shin muscles to the greatest extent - and build the greatest amount of strength. Use a bench or exercise platform which is about four inches off the ground to carry out your stepping. Aside from beginning each step from a bench, your movements are the same as they are in the basic step-downs; the idea is to land on the heel of the forward foot and then to use the shin muscles to prevent the sole of the foot from making contact with the ground (again, don't let the ball of the foot move downward by more than an inch). The actual length of the step is moderate at first (you can progress to long steps later). As before, begin with 15 reps per foot, and progress to three sets of 15 reps as you gain strength and coordination.
Both the wall shin raises and heel step-downs can be carried out three to four times a week, along with your other strength-building exercises (you can complete them more often if you've had lots of problems with MTSS in the past; don't do them to the point of pain, however).
More information on Shin Splints:
All of our articles on shin splints
Medial tibial stress syndrome - Two quick fixes for shin splints
The following portion of the shin-splint-preventing routine can be completed during the warm-ups preceding your regular workouts. The prescribed exercises develop shin strength and resiliency, as well as overall ankle coordination, and thus are great antidotes for your ankles' desires to begin hurting during strenuous training. It's also a good idea to include the exercises in your warm-ups; doing so transforms the warm-up from humdrum routine into an important strength and coordination session. Here's what to do:
1. Walk on your toes with your toes pointed straight ahead for about 20 metres, getting as high up on your toes as you possibly can. Your legs should be relatively straight as you do this, and you should - at least initially - take fairly small steps.
Then, cover 20 metres high up on your toes, but with your toes pointed outward. Your legs should rotate outward from the hips when you perform this movement; don't merely turn each foot at the ankle - the whole leg is involved.
Finally, walk 20 metres high on your toes, but with your toes pointed inward. As you do so, rotate the entire leg in from the hip, not just the ankle. Repeat each of these activities (toes pointed ahead, toes pointed out, toes pointed in) at least one more time before going on to the second exercise.
2. Walk on your heels with your toes pointed straight ahead for about 20 metres, getting as high up on your heels as you possibly can. Your legs should be relatively straight as you do this, and you should - at least initially - take fairly small steps.
Then, simply proceed as you did with the toe walks, walking 20 metres on your heels with toes pointed outward and then 20 metres on heels with toes pointed inward. Repeat each of the heel walks (toes straight ahead, toes pointed outward, toes in) at least one more time.
As the toe and heel walks become easy for you, graduate to doing the three variations of each exercise while jogging lightly, instead of walking! At least at first, you should make certain you are on a padded or grassy surface when you jog on toes and heels.
3. Skip for 20 metres, landing in the mid-foot area with each contact with the ground, and with toes pointed straight ahead. Then, do the same, but with toes pointed out for 20 metres, and then with toes pointed in for 20 metres. Repeat the sequence at least one more time.
4. Then, get well up on your toes and skip for 20 metres with toes straight ahead, pointed out, and pointed in.
Once the skipping exercises are comfortable, try some light skipping on your heels. Gradually build up your ability to heel-skip with toes straight ahead, pointed out, and pointed in for 20 metres at a time. Heel skipping is a great way to build dorsiflexor strength, but carry it out only on a padded or grassy surface to avoid impact injury to your heels.
5. Once you've completed your walking, jogging, and skipping routines, it's time for rhythm bounding. This isn't the kind of bounding you're probably envisioning - we don't mean progressing forward with extra-long strides, at least not at first. Rather, you should jog along with very springy, short steps, landing on the mid-foot area with each contact and springing upward after impact. As you rhythm bound, your ankles should act like coiled springs, compressing slightly as you make your mid-foot landing and then recoiling quickly - causing you to bound upward and forward. Move along for 20 metres or so with these quick, little, spring-like strides, alternating right and left feet as you would during running. After 10 to 20 metres of regular jogging, rhythm bound for 20 more metres, alternating three consecutive spring-like contacts with the right foot with three with the left. After 10 to 20 more metres of regular jogging, close the set by bounding along for the full 20 metres on your right foot only, followed by 20 metres on the left (making certain that you land on the mid-foot area with each ground contact and that your ankle area, not your knee or hip, is doing most of the work). Make sure (at least at first) that all of this is done on a padded surface or soft grass. As you become stronger and more skilled, you can increase the length and amplitude (vertical height) of each bound and include additional sets of bounds (work your way up to four sets).
6. Complete some 'dorsiflexion bounces'. To do these, simply begin jumping vertically and repetitively at close to maximal height, landing in the mid-foot area with both feet and then springing upward quickly after each contact with the ground. The interesting part of this exercise is that you should dorsiflex your ankles - pulling the tops of your feet toward your shins - on each ascent, before plummeting back toward earth and plantar flexing your ankles just before making contact with the ground. Do 10 dorsiflexion bounces, rest for 10 seconds or so, and then repeat. Over time, you can add additional sets and increase the number of reps to 30. When you are really strong and skilled, perform this exercise on just one foot at a time, but only on a low-impact surface.
7. Finally, carry out rhythm bouncing. Rhythm bouncing is actually just jumping around, but what jumping! You should start with 10 jumps in place, moderately fast, with medium height, and with maximal motion at the ankles - but little flexion and extension at the knees and hips (over time, you can work up to 30 jumps). Then, after resting for a few seconds, change the amplitude (height) of your jumps to less than an inch, and complete 20 jumps as fast as you possibly can (pretend that your feet are hitting a hot stove - so that you must minimize your impact time with the ground). Again, almost all of the action should take place at your ankles, not at your knees and hips. As you become more skilled, work up to 40 quicksilver jumps.
After resting for a few seconds, complete five 'high-impact' jumps, increasing the amplitude (vertical height) of your jumping as much as possible. Over time, progress to 30 of these maxi-jumps.
So far, all of the rhythm bounces have been carried out in place, so make things interesting by jumping forward and then backward as quickly as possible. After you have made 20 'contacts' (each time your feet strike the ground is one contact), rest for a few seconds and then jump from side to side for 20 contacts. Rest again, and then jump in a direction which is about 45 degrees from straight ahead, alternating directions (first towards the right, then towards the left) for 20 contacts as you move ahead in a zig-zag manner. Remember to use your ankle muscles to propel you, not the big muscles at the knees and hips.
As you gain skill and strength, you can increase the number of sets of each type of rhythm bouncing from one to three, and then - the fun part - carry out each type of bouncing on one foot only. Moving in different directions as you bounce increases the ability of your shin muscles to handle all of the forces created during running - the side-to-side and rotational stresses, in addition to the less-overlooked front and back forces.
Of course, carrying out these exercises doesn't mean that your risk of MTSS is zero. If you suddenly change your weekly volume of running from 25 to 75 miles because you've been bitten by the marathon bug, for example, something will have to give, and it might well be your shin muscles and tendons. So, be certain to avoid dramatic changes in the frequency, volume, or intensity of your training; always gradually progress to more difficult levels of work.
Sports-medicine experts often recommend stretching the ankle area by slowly moving the ankle to 'each' end of its range of motion in the straight-back and straight-ahead plane, eg, to the fully dorsiflexed and then completely plantar-flexed positions, holding each position for anywhere from five to 60 seconds. The problem with that, of course, is that you are only stretching your muscles in one plane of motion and thus not adequately mimicking the stretching which takes place during running. At the very least, in addition to carrying out the plantar-flexed and dorsiflexed stretches, you should also stretch each ankle by fully rotating it outward and inward - and by plantar flexing and dorsiflexing the ankle while the foot is pointed both outward and inward to various degrees - not just straight ahead.
The experts also recommend strengthening the ankle area by adding resistance to the above stretching movements with the use of surgical tubing or elastic bands. That is indeed a way to increase general strength of the ankle, and it will certainly make you stronger when you carry out surgical-tubing exercises in the future. The problem, of course, is that you run with your feet on the ground - not poised in the air in the clutches of elastic bands. So, to fully prepare your ankles and shins for the rigours of running, you're better off focussing on the specific exercises we are recommending.
Does stretching actually help to prevent MTSS? No scientific evidence indicates that it does, but the idea that stretching might be protective is a logical one (overly taut muscles seem more likely to be damaged by pulling forces, compared to relaxed fibres). Don't stretch your ankle area until after your muscles are warm, however; a good time would be after a warm-up and/or at the end of your training session.
Of course, all problems in the lower part of the leg are not necessarily examples of MTSS. In particular, two conditions - compartment syndromes and tibial stress fractures - can sometimes be confused with shin splints.
Compartment syndromes owe their name and origin to the fact that the leg muscles are not simply loose straps which run from bone to bone. In reality, the muscles are often grouped together into little sections of the leg which are enclosed by a tough wrapper of connective tissue. Such an arrangement of muscles tucked into a wrapper is called a 'compartment'.
During the act of running, excess fluid can build up within one of these compartments, putting pressure on muscle fibres, nerve cells, and blood vessels - and also causing a great deal of pain. Frequently, the pain will be so severe that a runner must curtail a workout or come to a standstill during a race. And the pain will usually be accompanied by the two telltale symptoms of a compartment syndrome - numbness and weakness.
Numbness occurs because the excess pressure within a compartment hampers the activity of sensory nerves carrying messages to the brain. As a result, the runner with compartment syndrome may lose feeling in the 'web' of the foot - between the first and second toes, or the insensitivity may extend up the foot toward the ankle. Weakness is experienced because motor nerves carrying impulses towards the muscles are also damaged by the high pressures within the compartment. If a compartment in the front of the leg is involved, a runner may have trouble dorsiflexing the ankle, and the foot may seem to flop loosely. In a posterior-compartment problem involving muscles in the back of the leg, there is often weakness when an individual tries to 'toe off'.
If you truly have a compartment syndrome, you will usually observe swelling in your lower leg which tends to subside when your leg is elevated. A doctor can tell for sure if you have this troubling problem by placing a catheter into one of your compartments and measuring pressure before, during, and after running (you will usually have to run long enough to produce pain during this test).
Stress fractures are small breakdowns in bony tissue, and tibial stress fractures, which are sometimes confused with MTSS, are the most common of all stress fractures in athletes, accounting for about 50 per cent of the total. In addition to producing a lot of pain, stress fractures can actually progress into dislocation fractures, in which two parts of the bone actually separate. Stress fractures also may be 'warning signals' for an underlying nutritional or hormonal problem.
Unfortunately, traditional X-rays often fail to detect stress fractures, so a more costly procedure called a bone scan must frequently be performed to confirm the diagnosis. In a bone scan, radioactive material is actually injected into the blood. Bony tissue which is remodelling and rebuilding itself at the site of a stress fracture will accumulate more of this infused radioisotope, causing the affected bony area to show up as a dark splotch on a 'scintigram'. While it's often said that stress fractures take two to three months to heal, up to six months may be required to restore the bone to normal and remove most traces of pain, and a few athletes need more than a year to fully recover.
Sometimes called 'crescendo pain,' the agony associated with stress fractures tends to build up steadily during running, beginning as an annoying irritation and becoming a throbbing torment as an individual continues to run. There is usually little of the numbness, weakness, and swelling associated with compartment syndrome, and pain is usually not present when an athlete is at rest. Often, the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site.
If you're diagnosed with a stress fracture, you should be sure to have a nutritional analysis carried out (your problem might be the result of inadequate calcium intake or poor calcium absorption). In addition, athletes who develop stress fractures should get their sex-hormone levels checked (adequate testosterone concen-trations in males and oestrogen levels in females are required for optimal bone maintenance).
How can you differentiate MTSS from stress fractures and compartment syndromes? The pain of MTSS is usually less localized, compared to stress-fracture pain (it tends to run up and down a region of the lower leg near the tibia), and usually can't be produced merely by tapping on the tibia. In addition, MTSS produces none of the numbness associated with compartment syndromes.
If you are unfortunate enough to come down with MTSS, your recovery period will usually last from one to six weeks, depending on how severely you are stricken. If you have a mild case of MTSS (your shin hurts moderately, and only after workouts), immediately cut your weekly mileage by about 30 per cent, and start doing our recommended exercises (we're assuming that your busy schedule prevented you from carrying out the routines faithfully, allowing MTSS to crop up). Start easily with the exercises, doing only one set of each, and stop if you feel any pain. Ice the affected area down thoroughly after activity, and of course keep the whole area as loose and flexible as possible. Within a week or two, you should be able to get back to your normal training, but be sure to carry out the shin-splint-preventing exercises steadfastly.
If you have a somewhat tougher case of MTSS (mild pain crops up during workouts but doesn't seem to slow you down much), trim weekly mileage by around 50 per cent, ice and stretch religiously, consider taking non-steroidal anti-inflammatory medications (but only if you are not prone to the gastrointestinal upsets which have been linked with these compounds), and become a devotee of our shin-strengthening exercises (start gradually with them, though, since they can further inflame tender shins if overdone). Use bicycling workouts to maintain fitness. In two to three weeks, you should be ready for regular training.
If your MTSS produces sharp pain while you are training, stop all running workouts, ice and stretch, take NSAIDS as directed by your doctor, and - when pain subsides - systematically begin utilizing our exercises, starting with a few two-legged wall shin raises at first and gradually progressing to the others. Use the exercise bike to maintain fitness, and return to normal training in four to six weeks.
Remember that if you carry out our shin splint routine several times a week and refrain from making bizarre and sudden changes in your training, your encounters with shin splints should drop to a frequency rate of zero.
Owen Anderson and Walt Reynolds
More information on Shin Splints:
All of our articles on shin splints
Medial tibial stress syndrome - Two quick fixes for shin splints