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Shin Splints: Fact or Fiction?

Added: 16 July 2013

Shin Splints: Fact or Fiction?

Medical terminology is often very confusing. For some reason simple words that everyone understands aren’t acceptable. What has developed is a language that rather than informing the patient of what is happening, ironically does just the opposite. The terminology used is often confusing, sounds scary and most worryingly doesn’t mean anything to most people.

At the risk of getting a bit “Wiki-leaks”, this language is often a really good place for medical people to hide behind when they don’t know the answer. Go and see your GP with an upset stomach in January and you have Norovirus. If this stomach upset continues you have Irritable Bowel Syndrome. My point is that that these symptoms could be a lot of different things but one carefully packaged term covers them all and gives the patient an all important label. Dave down the pub is embarrassed to tell the other blokes that he’s got tummy ache but when he’s got Irritable Bowel Syndrome he’s not as shy.

This same concept applies to a lot of running injuries. If you’ve got pain at the back of your leg then you’ve got a pulled hamstring.  If your knee hurts you’ve got Runners Knee. And most commonly if you have pain in your leg between your knee and your ankle you have “Shin Splints”.

I hate this term. It doesn’t mean anything. I can just about understand where it comes from as it does sum up how it can feel. However there are multiple causes of pain in this area and the term Shin Splints doesn’t really help.

The most common region for runners to experience pain between your knee and ankle is along the inside border of the shin bone, aka the Tibia. This pain usually develops either as you start to run or progresses as the mileage increases. Dependent on how much you decide to run through it will determine how sore it gets and how long it stays sore for afterwards.

This condition is what was classically termed Shin Splints. However, somewhere along the line this label got metamorphed. Shin Splints now seems to be an umbrella term for pain anywhere in the lower leg.

As understanding of the condition has increased several other pathologies which cause pain in this area have been identified. Boring old classic Shin Splints has been glamourised to Medial Tibial Stress Syndrome. To break this down, it simply means pain on the inside border of the shin which is related to use.

I’m sure that most runners at some point will have experienced this sensation. There are a couple of theoretical mechanisms behind the pain. One is that the muscles in the area pull on their attachment and set off an inflammatory reaction of the outer lining of the bone. Another theory is linked to ineffective impact buffering from the foot up the shin which irritates the bone. There is also the possibility of muscles and tendons which run very close to the tibia causing pain.

Causes as to why this develops are of course pretty non-specific. As with any running based injury what your foot does is fairly important. Over pronation of the foot is thought to increase how hard the muscles in question have to work to help stabilise it. As these muscles work harder, they pull more on the Tibia and that makes it sore. An example is a runner who develops shin pain having recently changed footwear or suddenly increased their mileage as the Tibial muscles have to work harder than usual.

When biomechanics are discussed or when runners have their running style analysed usually it is the foot that gets the most attention. With another sweeping generalisation I would guess that 75% of runners have been told they “pronate” to some degree and require specific footwear, insoles etc. But biomechanics doesn’t stop at what happens at the foot and ankle.

Pronation and its counterpart supination are a detailed topic for in depth discussion another day, but in a nutshell pronation is the unstable, shock absorbing position of the foot. It is a completely natural aspect of the gait cycle to allow the foot to accept the ground and reduce impact up the leg.

Many people naturally pronate and even overpronate and don’t mind in the slightest. As mentioned in a previous article, 95% of Africa has hyper-pronated feet yet these guys are some of the best runners around. However for some people over pronation can be a problem through either a naturally unstable foot or as an acquired process.

A quick test to find out which one you are is to stand up. Now squeeze your bum muscles together as hard as you can; 1 of 2 things will happen:

1)  absolutely nothing

2)  or you will notice the inner arch on your feet correct and lift off the floor.

If you are “number 2” then you are quite likely to have weakness higher up the chain. This means that your ankle muscles have to work a lot harder to control the foot because the bigger muscles up top can’t be bothered. The ankle muscles overwork, they get stronger, they shorten, they pull more on the bone and the bone gets sore.

This is a very simplistic example but it’s not always the poor foot that should get the blame. You can be as much to blame as anything else. Anyone with Medial Tibial Stress Syndrome has tried to run through it. Sometimes it goes away with doing clever things but sometimes it won’t. The most simple things to do in this case are to use ice for the inflammation, review what’s on your feet and strengthen the major muscle groups higher up the chain.

However this condition tends to follow a continuum and the more you follow your “runners nature” and stoically try to run through it, the greater the inflammatory response will be. This will lead to pain getting out of bed, out of the chair at work and with day to day activities.

The worse case scenario is the determined warrior who keeps on running and running until a stress fracture develops. This is a much more unpleasant situation to find yourself in.

The pain of a stress fracture is usually a lot more severe and is more localised than experienced with Medial Tibial Stress Syndrome. Rather than a gradual build up there is often a specific incident that caused the symptoms to start. The pain may be accompanied with heat and swelling and there’s very minimal chance that you’ll be running through it. Pain may also bother you at rest which is different to most other pathologies.

At this point, I feel I should warn all female runners who have been experiencing sore shins and are running through it, particularly if your BMI is low, if you have an irregular menstrual cycle or if you have low bone density you are a lot more at risk than anyone else. I would strongly recommend you reduce your running before you are forced to rest completely.

Unfortunately there aren’t any self-help tips for this condition. Rest or even enforced rest through crutches or an Aircast boot is a necessity. Some cases may only need 4weeks, some may need 12 weeks but that depends on severity.

There are of course other less well known conditions that shelter under the Shin Spints umbrella. These unfortunately are a little more complex but equally as limiting.

Chronic compartment syndrome is one such problem. It is linked to the pressure within the compartments of the leg. It is often a vague pain which is difficult to localise. It may feel as though the muscles in your shin are very hard and tight. You may also develop pins and needles in your foot. One of the biggest things that differentiates this from the other conditions is that you won’t be able to run through it but it will stop within minutes.

Pins and needles sensations are not exclusive to Compartment Syndrome as nerve entrapments in the lower back , hip and leg are also common causes. Then we have the vascular or blood flow related conditions which again resolve fairly quickly after exercise but make it very unlikely that you will be able to continue running. These slightly more unfortunate conditions often require specialist assessment and intervention or surgery and are a consideration in people with long term and recurrent “Shin Splints”.

Unfortunately rest doesn’t cure everything and my advice if you do suffer from recurrent pain anywhere below your knee and have been told its shin splints, is it would be worth doing a bit more digging around. It’s never a bad idea to ask questions or to get someone to assess your injury and give you a specific diagnosis sorted rather than a label.

Hopefully this spreads a bit of light on “Shin Splints” and of course I apologise in advance for any confusing medical terms used. As always, happy running and I hope everyone is enjoying the summer.

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