In this installment of our “injury of the week” series we’re going to be talking about shin splints. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system so that you’ll have a “sample treatment session”.
First off, shin splints is one of those diagnoses that used to refer to “pain in the lower leg”. Since we now know “pain in the lower leg” can be a number of different things (muscle strains, fascial injuries, compartment syndromes, and stress fractures to name a few), the term shin splints is no longer used in the medical world. In this post we’re going to talk about what we now call tibial stress syndromes instead of “shin splints”.
So what is a tibial stress syndrome?
When you look at the front of the lower leg, you have long skinny muscles running from up near the knee down the tibia (shin bone). As they travel down the bone they become tendons that attach to the midfoot and toes. These muscles are then wrapped in fascia which attaches to the bone which is wrapped in periosteum. Confused yet? Here’s an easy way to look at it:
bone -> periosteum -> fascia -> tendon -> muscle
A stress syndrome is an injury that occurs within these structures when tension in the muscle and tendon builds to a level that starts to damage not only the muscle, but the fascia and periosteum as well. In severe cases, you can actually start to tear the periosteum off of the bone and damage the tibia itself. This can result in avulsion fractures and stress fractures and eventually when the nerves and blood vessels that run through the fascia get involved compartment syndromes.
Sound complicated? It is, but here’s the important part. These syndromes all start on that muscle strain/sprain level. To truly fix them once they progress to the “stress syndrome” category, you now have to fix what broke down, but also what caused the shin muscles to shut down in the first place.
What are some potential causes?
In normal gait, the muscles along the front of the shin are responsible for lowering the foot all the way to the ground. The front muscles or dorsiflexors (your anterior tibialis + long toe extensors) slowly lower the foot to the ground from heel to toe. The outer muscles (your peroneals) slowly lower the foot to the ground from the outside foot to inside of the foot so that you can load the big toe for push off.
As you move forward over your foot and push off using the big toe, calf and hip muscles, the muscles along the front of your shin get to relax and rely on elastic recoil to pull the toes and ankle up for clearance through the swing phase. This reduces a large amount of the stress on these muscles and allows them to recharge their full strength for shock absorption at heel strike. However, if push off is decreased in any way (over pronation, high arches, tight calves or joints for example), these muscles must then work overtime to pull the toes/ankle up so that you don’t trip over them. When this happens there’s no relaxation for them before that foot hits the ground again. Over time, the muscles will become overworked and break down.
Here are some examples of things that can be the culprit:
#1 Shoe selection. You’re foot is designed to rotate as you move over it. It’s part of our shock absorption and it allows us to stay on our foot long enough to properly push off. That being said, the wrong shoes for your foot can throw a huge wrench in this. They can allow too much motion and likewise they can actually block motion if there is too much support in the shoe. Both of these will result in a shortened stride and shock absorbing duties moving up to the muscles along our shin. Bottom line: not sure about your shoes and have a history of lower leg/foot pain? See a pro. Not the high school kid selling shoes at your local sporting good/running store. These rotations occur during movement, not while standing still with wet feet to look at what your foot print looks like or on a Dr. Scholls like machine.
#2 Bunion/loss of big toe extension. In the event that motion becomes restricted in this area, the foot will become unable to fully load the big toe in preparation for push off. Over time this will lead to compensation and rotation of the lower leg and ankle to allow the foot to fully flatten to the ground during full weight bearing. Typically this is seen as the foot pointing out and push off coming off the side of the big toe. The problem here is that as the rotation occurs, the big calf muscles become less efficient and the smaller muscles of the lower leg must assist with forward propulsion. The foot isn’t designed like that and the “cube” and all of the bones/joints/muscles in it can get all twisted up.
#3 Ankle restrictions. In particular, not enough dorsiflexion of the ankle (being able to pull your foot up towards your shin). When this is limited, you’re stride is shortened and your push off decreased. The larger muscles will be unable to fully help and the workload will shift from the big toe to the mid-foot and arch. Sprain your ankle often or break it as a kid? This is where old sprain/strain injuries and fractures can sneak back up on you.
#4 Restrictions up stream. Just like the ankle can be a huge factor, so can the knee and hip. I know we’ve all heard “it’s all connected”, and probably rolled our eyes, but it is very true. For example, the gastroc (large calf muscle) and hamstrings criss cross behind the knee. Restrictions in one, will affect the other. Period.
Where would it hurt?
There are two main locations for stress syndromes. Both will result in pain along the tibial bone itself.
1) Medial tibial stress syndrome (MTSS)- which affects the post tib.
2) Anterior tibial stress syndrome (ATSS) – which affects the anterior tib.
My shin hurts? NOW WHAT?
The first step is determining if it is truly a tibial stress injury or something else. Remember, the goal of this series is not to keep you away from your doctor so that you can self treat everything. It’s to teach you how to catch the early symptoms and take care of them before it becomes a full blown injury. That being said, stress syndromes start gradually as a dull ache/pain during workouts. In the early stages, the symptoms probably won’t be enough to stop you from training, however, the symptoms will progressively worsen if untreated.
Typical symptoms include pain or tightness on the inside of the calf in the middle of the shin bone (tibia). They can move down towards the ankle slightly as well. If the symptoms are along the anterior tib, they will be along the front of the shin bone in the middle portion of the bone. Symptoms are typically worse with activity and better with rest.
Here are some guidelines for when seeing a doc should be your top priority: 1) If you see any bruising and/or swelling, 2) feel numbness/tingling in the leg (knee to foot), 3) have pinpoint pain along the bone, or 4) have temperature changes/weakness in the lower leg. A stress syndrome is a symptom of a bigger problem. Think of it like a link in the chain. Something stopped working and that chain got snapped due to the increased strain on it.
Be smart. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait months and even years before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:
- Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Stress syndromes respond well to hands on/massage work. If this is something that’s been around for a while, exercise alone won’t cut it as the whole leg has learned to compensate and multiple muscle groups will require attention.
- Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Not really. Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.
How to treat it.
( Click here for a walk through of how to use our PDF pages! )
Step 1- Traditional R.I.C.E. treatment:
When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage.
Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.
Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.
Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them or calf sleeves). In this case, full compression socks (versus the calf sleeve where the foot is free) are best.
Step 2- Kinesiology taping:
By now you’ve probably seen athletes covered in all kinds of colored tape. Some of you have probably even tried it out. Make sure to read the application instructions first! This stuff should last 3+ days, not fall off in an hour. That means you need to prep the skin so that it is hair free and clean.
1) Anterior stress syndrome application. Click here.
2) Medial tibial stress syndrome application. Click here.
3) Foot application. Click here. Why the foot? This application helps to support the mid-arch of the foot and evenly distribute the weight. Apply this application first, and then the one above!
Step 3 – Getting mobility back
The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a post tib injury isn’t about no pain, no gain. Don’t overdo it in an attempt to speed up your recovery.
1) R.I.C.E. + gentle stretching. There should be no pain with stretching.
2) Begin using the foam roller to work around the injury first. The goal here is to start getting slack into the muscles without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll the muscles around the area of pain -> stretch -> RICE. (** Remember- with stress syndrome you need to fix two things: 1) the muscle injury itself and 2) the muscles/restrictions that led to the injury. Fix just one and the other will be back to stir up problems again.)
3) Begin using the foam roller over the painful area to tolerance. The order should be foam roll the muscle around the injury-> over the injury -> stretch -> RICE.
4) As the tendon/muscle heals, we can really start to go after the muscles using the deeper cross friction and trigger point techniques.
5) Lastly, to really loosen up the the lower leg, we’re going to add muscle mobilizations as well as joint mobilizations at the hip and down at the ankle. The order should be foam roll around the injury -> over the injury -> cross friction/trigger point -> mobilizations -> stretch -> RICE.
How long do you need to R.I.C.E for??? Until it’s 100% gone.
Step 4- Strengthening
We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.
What you’ll need: 1) resistance band/tubing. This is easy to find in any sporting good store these days. You can probably even get it in walmart or target.
Optional equipment: a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20.
Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.
To help put it all together, I’ve also created a PDF you can download to walk you through what a “treatment session” would look like. In it you will find everything you need including links to the videos and posts. Click here.
Hope that helps, and fire away with any questions in the comments.
1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.
2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.
5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.
6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.