Preventative Exercises for Shin Splints

Outline1. Toe walk x 15 each foot2. Feet out walk x 15 each foot3. Feet in walk x 15 each foot4. Ankle in walk x 10 each foot5. Ankle out walk x 10 each foot6. Theraband exercises x 15 times each directionToe walk

Value for runners: Toe walking helps to develop the eccentric (support) strengthand mobility in the muscles of the foot and calf, as well as the plantar fascia andAchilles tendon. The exercise also works the foot and ankle through a full range ofmotion. Toe walking also improves balance and stability, which are critical factorsfor improving efficiency, especially if transitioning to barefoot running.Instructions and variations: Only drop the heel of your foot slightly with eachstep (not all the way to the ground) and focus on flexing your foot and ankle to getas far on your toe as possible. Walk for 30 steps (15 each foot)

Feet out walk

Value for runners: Like the toe walk, this exercise helps develop eccentricstrength in the calf, foot, plantar fascia, achilles tendon, and the ankle. Splaying thefeet outwards shifts the primary focus to the muscles on the outside of the foot andleg, which creates better overall balance and conditioning in the foot. Walk for 30steps (15 each foot)Instructions and variations: Only drop the heel of your foot slightly with eachstep (not all the way to the ground) and focus on flexing your foot and ankle to getas far on your toe as possible.Feet In walk

Value for runners: Same as the feet out walk but the focus is on the muscles onthe inside of the foot and calf.Instructions and variations: Only drop the heel of your foot slightly with eachstep (not all the way to the ground) and focus on flexing your foot and ankle to getas far on your toe as possible. Walk for 30 steps (15 each foot)

Ankle In Walk

Value for runners: This exercise stretches the plantar fascia and the smalltendons on the inside of the ankle and the to develop flexibility in the innertransverse plane, the primary plane in which the structures of the foot and lower legbalance during running. Regular use of exercise helps condition the plantar fascia,foot, and ankle to better withstand the key twisting and lengthening forces whichare placed on it.Instructions and variations: Your knees will flex in during this exercise. Try toperform this exercise on a very soft surface, which will help add a layer of difficulty.Walk for 20 steps (10 each foot)

Ankle Out Walk

Value for runners: This exercise stretches the plantar fascia and the smalltendons on the inside of the ankle and the to develop flexibility in the outertransverse plane.

Instructions and variations: Your knees will flex out during this exercise. Try toperform this exercise on a very soft surface, which will help add a layer of difficulty.Walk for 20 steps (10 each foot)Shin exercises with Theraband

(push down) (Inside)

(outside) (pull forward)

Value for runners: These exercises strengthen the ankle and the shin musclesusing the added resistance of a theraband. These are very helpful for preventingshin splints and increasing ankle strength and proprioception.Notes: Perform 15-20 repetitions each moving inside, outside, and up.

Medial Tibial Stress Syndrome (“Shin Splints”)

About the injury

Medial tibial stress syndrome, sometimes referred to as “shin splints,” is probably themost universally-known running injury. Shin splints classically present as an aching painon the inside of the shin, near the border of the tibia and the calf muscles. The area willoften be sore when poked or prodded, and will initially hurt at the end of a run. As theinjury progresses, the pain will sometimes move to a more sharp, burning sensation,and may hurt during your entire run, or even when just walking around. Shin injuriescan be diffuse, spreading out over many inches along the length of the tibia, or belocalized to a small area less than two inches long. Serious cases of medial tibial stresssyndrome, especially when localized to a small area, need to be distinguished from atibial stress fracture, which can be accomplished with an MRI or a bone scan ordered byan orthopedist or podiatrist.

While not the most common running injury, medial tibial stress syndrome, or MTSS, stillaccounts for about 5-6% of all total injuries.1, 2 Unlike many injuries, which seem tostrike at runners of all fitness levels, MTSS is much more common among lessexperienced athletes. In a typical three-month high school cross country season, forexample, between 12 and 15% of the runners on a typical team will suffer from MTSS.3, 4

Woman are 2-3 times more likely to develop shin problems than men.5 Additionally,among studies of military recruits, soldiers and sailors in poor physical condition (wholikely have little history of athletic activity) are much more likely to suffer from shinsplints.6 In contrast, very few experienced runners have to deal with shin pain on aregular basis. Understanding the mechanism of injury can help explain why.

Causes, what makes it worse, what’s going on

For a long time, MTSS was postulated to be a soft tissue injury. Many of the muscles ofthe lower leg, including the calves and the smaller muscles above the ankle, insert alongthe tibia. It was proposed that tightness or weakness of these muscles caused them totug at their insertion point, irritating the periosteum, a thin, skin-like structure thatenvelopes the tibia itself. This distinguished medial tibial stress syndrome from tibialstress fractures and stress reactions, which are indisputably true bone injuries.However, more precise anatomic studies have demonstrated that the muscularinsertions blamed for causing shin pain do not correspond to the location of the injury;7

instead, advanced medical imaging studies have illustrated that all overuse injuries tothe tibia, from mild cases of “shin splints” to true stress fractures, exist on a spectrum ofbony injuries. The most telling fact is localized bone density: in CT scans of the tibias of

runners with shin pain, pockets of low bone density appear at the location of pain. Afterthese runners have recovered, these pockets of low density have disappeared.8

Additionally, runners with tibial stress fractures often have larger areas of lowered bonedensity around the fracture.

With this new information, scientists now hypothesize that the root cause of MTSS isrepeated stress to the bone during running, caused not by straight-on impact, but aslight bending of the bone when it is loaded. Much like a beam on a bridge or in askyscraper bows slightly when it’s supporting a lot of weight, your tibia bendsbackwards slightly on impact with the ground, putting compressive forces on the medialside of the bone. In healthy runners, the bone stress after a long, hard run is not aproblem. The body responds to the stress on the bone by remodeling the tibia to bestronger and thicker. This is why shin problems are more common in less-experiencedrunners: their bone has not yet adapted to the stresses of a high-impact activity likerunning. Unfortunately, this remodeling process takes several weeks to a few months tocomplete, and there is a period where the bone is actually more vulnerable to damage.Just like remodeling your house entails tearing out some walls before adding newconstruction, your body has to tear out some of the old bone tissue beforestrengthening it. As a result, having a small tibia or weak bones puts you at an increasedrisk for shin splints, since your weakened tibia is more vulnerable to injury when it isremodeling its bone structure.

Research backed treatment options

The current theories for treating and preventing medial tibial stress syndrome revolvearound reducing the relative amount of stress on the tibia. Reducing impact and tibialloading, strengthening the supporting muscles, and strengthening the bone itself shouldall lower your risk of developing MTSS and may also speed recovery. Unlike some otherrunning injuries, there are no solidly vetted treatment protocols. Rather, what follows isan extension of work on the precipitating factors for MTSS.

Reducing impact loading should be a priority for anyone with shin problems. Increasingyour stride frequency by about 10% (bringing it close to 180 steps per minute or more)will markedly decrease the impact your tibia has to absorb each time your foot strikesthe ground.9 You might think that running on a softer surface or in more cushionedshoes would also reduce impact, but because the leg adjusts its stiffness to compensate,the actual forces going into the ground hardly change at all. In fact, there is even a littleevidence that running in thinner shoes on a harder surface might be a better idea, sinceit lowers your leg stiffness!10

Strengthening your calf and shin muscles might absorb some shock, reducing the strainon your tibia, but more importantly, will lead to a stronger tibia in response to theincreased muscular strength and size. It’s been demonstrated that female runners with

a small calf circumference have a much higher risk of developing a tibial stressfracture,11 so it is no surprise that runners with shin splints have poor calf strength.12

While there is no set protocol as of yet for increasing calf strength, a program ofstanding calf raises to fatigue twice daily will go a long ways towards building your lowerleg strength. There is also a lower-leg-strengthening routine of “foot drills” developedby Russ Ebbets, outlined below. These can also be done once or twice daily, and oughtto be done barefoot on grass if possible.

Standing calf raises for calf strength and endurance:

Ebbets’ six “foot drills”:

1. Toes in

2. Toes out

3. Toes up

4. Heels up (walking backwards)

5. Inside up

6. Outside up

Other possible treatment options

With respect to orthotics, a few studies have demonstrated some success in usingcustom shoe inserts to treat MTSS.13 This is a good sign, as many other injuries respondpoorly to treatment with orthotics. Custom inserts might shift the distribution ofpressure on the bottom of the foot, which may be associated with shin pain.Nevertheless, orthotics are not a panacea and shouldn’t be your only treatmentmethod. Many runners find good success with over-the-counter semi-rigid orthotics likethe SuperFeet or PowerStep insoles, and these are much cheaper than custom orthotics,so give them a shot first.

Among more exotic treatments, extracorporeal shockwave therapy (ESWT) has emergedin recent years as a treatment possibility. In ESWT, shockwaves are applied directly tothe tibia to encourage new bone growth. Only one study has tested ESWT, and itsuffered from some design flaws, but it showed a significant reduction in recoverytime.14 ESWT treatment may be expensive and difficult to find, and its experimentalevidence is still not up to snuff.

Outline of Treatment

Conservative treatments

These are methods that are fairly simple, inexpensive, and can be done on your own athome.

1. Work to reduce stress on the tibia by increasing your stride frequency by 10% orso to avoid overstriding and excessive impact.

2. Ice your shin using ice cups several times a day, and always after running

3. Calf raises starting with one set of 20 repeats and building to three sets of 20 (ormore), twice per day.

4. Russ Ebbet’s foot drill routine. 10m each, once per day:a. Toes inb. Toes outc. Toes upd. Backwards with heels upe. Inside upf. Outside up

5. Modify your training so you don’t put as much stress on your tibia. Reducingmileage, intensity, and duration of your runs will all help. Remember, it can takeseveral weeks to a few months for the tibia to heal.

Aggressive treatments

These are treatments with more cost and less certainty about outcomes, but may proveuseful in recalcitrant cases.

1. Custom shoe orthotics or over-the-counter semi-rigid orthotics (SuperFeet,PowerStep) may be able to modify how forces are transmitted up the tibia,though this is unproven. Many runners find that orthotics greatly improve theirshin pain, but possibly just as many find that they are no help.

2. Consider running in a thinner, firmer shoe on a harder surface. While the actualbenefit for people with shin pain is as-of-yet unproven, biomechanics researchhas linked soft surfaces and soft shoes with higher leg stiffness, which is itselfconnected to higher shocks going up the tibia on impact.

3. Also consider taking a calcium/vitamin D supplement with 200% of your RDV ofboth. One study found that doing so reduces the risk of tibial stress fractures by25%. Since MTSS is on the same “injury spectrum” as a tibial stress fracture, it’spossible that supplementation can help prevent medial tibial stress syndrometoo.15

4. If conservative treatments don’t help, you also should be evaluated by a doctorfor a tibial stress fracture. X-rays are very inaccurate for diagnosing stressfractures, so your doctor should use either an MRI or a bone scan. MRIs areslightly more accurate and allow your doctor to get a better idea of the severityof the injury, so they are generally the preferable imaging technique.

Return to running

You will need to modify your training program to allow your body time to strengthenyour shin bone. Mild cases of MTSS may only require modifying your running form anddoing some lower leg strength, but more serious cases will require at least a few weeks

off. Keep in mind that shin splints are the same type of injury as a stress fracture, so ifyou feel like your shin injury is getting worse, you should not continue to run on it.While many coaches recommend that a “10% rule” for increasing mileage is best toavoid injury, the dynamics of the tibia’s healing mechanism suggest that perhaps astress/adaptation cycle would be better. So, instead of increasing mileage every singleweek by 10%, you might increase by 10% for three weeks, then take a “down week” toallow your tibia to recover (ex. 40mi-45-50-40-50...). Another option would be an“equilibrium” style buildup, as favored by Jack Daniels, where you maintain the samemileage for 3-4 weeks, then make a larger jump of 20-30% (ex. 30mi-30-30-40-40-40...).When returning to running, you should be conservative when building back yourmileage.

References1. Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., Aretrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine2002, 36, 95-101.2. Marti, B.; Vader, J. P.; Minder, C. E.; Abelin, T., On the epidemiology of running injuries-the 1984 Bern Grand-Prix study. The American Journal of Sports Medicine 1988, 16 (3), 285-294.3. Plisky, M. S., Medial Tibial Stress Syndrome in High School Cross Country Runners:Incidence and Risk Factors. Journal of Orthopaedic and Sports Physical Therapy 2007, 37 (2), 40-47.4. Bennett, J. E.; Reinking, M. F.; Pluemer, B.; Pentel, A.; Seaton, M.; Killian, C., Factorscontributing to the development of medial tibial stress syndrome in high school runners. Journalof Orthopaedic & Sports Physical Therapy 2001, 31 (9), 504-510.5. Yates, B., The Incidence and Risk Factors in the Development of Medial Tibial StressSyndrome Among Naval Recruits. American Journal of Sports Medicine 2004, 32 (3), 772-780.6. Sharma, J.; Golby, J.; Greeves, J.; Spears, I. R., Biomechanical and lifestyle risk factors formedial tibia stress syndrome in army recruits: A prospective study. Gait & Posture 2011, 33 (3),361-365.7. Beck, B. R.; Osternig, L. R., Medial tibial stress syndrome. The location of muscles in theleg in relation to symptoms. Journal of Bone and Joint Surgery 1994, 76 (1057-1061).8. Magnusson, H. I.; Ahlborg, H. G.; Karlsson, C.; Nyquist, F.; Karlsson, M. K., Low regionaltibial bone density in athletes with medial tibial stress syndrome normalizes after recovery fromsymptoms. The American Journal of Sports Medicine 2003, 31 (4), 596-600.9. Heiderscheit, B. C.; Chumanov, E. S.; Michalski, M. P.; Wille, C. M.; Ryan, M. B., Effects ofStep Rate Manipulation on Joint Mechanics during Running. Medicine & Science in Sports &Exercise 2011, 43 (2), 296-302.10. Butler, R. J.; Crowell, H. P.; Davis, I. M., Lower extremity stiffness: implications forperformance and injury. Clinical Biomechanics 2003, 18 (6), 511-517.11. Bennell, K. L.; Malcolm, S. S.; Thomas, S. A.; Reid, S. J.; Brukner, P.; Ebeling, P. R.; Wark, J.D., Risk factors for stress fracture in track and field athletes: a twelve-month prospective study.American Journal of Sports Medicine24 1996, 6 (810-818).12. Madeley, L. T.; Munteanu, S. E.; Bonanno, D. R., Endurance of the ankle joint plantarflexor muscles in athletes with medial tibial stress syndrome: A case-control study. Journal ofScience and Medicine in Sport 2007, 10 (6), 356-362.

13. Beck, B. R., Tibial Stress Injuires-An Aetiological Review for the Purposes of GuidingManagement. Sports Medicine 1998, 26 (4), 265-279.14. Moen, M. H.; Rayer, S.; Schipper, M.; Schmikli, S.; Weir, A.; Tol, J. L.; Backx, F. J. G.,Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlledstudy. British Journal of Sports Medicine 2011, 46 (4), 253-257.15. Lappe, J.; Cullen, D.; Haynatzki, G.; Recker, R.; Ahlf, R.; Thompson, K., Calcium andvitamin d supplementation decreases incidence of stress fractures in female navy recruits.Journal of Bone and Mineral Research 2008, 23 (5), 741-749.

How Improving Calf Strength Can Fix Your ShinSplints

Shin pain, or “shin splints,” is a common and frustrating problem for a lot of beginning(and experienced) runners. It’s one of the most common ailments in runners, fromsprinters all the way up to marathoners.

While there are a variety of remedies out there for shin splints—more properly referredto as “medial tibial stress syndrome”—the purpose of today’s article is to highlight somerecent scientific studies that point to an easy method of preventing and treating shinpain: calf strength.

How calf strength influences shin splintsImpact forces bend the tibia

The shinbone, or tibia, absorbs a lot of shock from impact during running.1 As a result,it’s particularly prone to injuries, both mundane and serious.

A recent scientific review by Maarten Moen and colleagues at a medical center in theNetherlands concluded that shin splints, viewed as an irritating but ordinary problem,and tibial stress fractures, a serious bone injury, are actually caused by the samephenomenon: bending of the tibia during running.2

Now, the tibia doesn’t bend like a wet noodle; it’s more like a bridge under strain. Afteryour foot hits the ground during running, the force traveling up your legs puts stress onyour shin, causing it to bend slightly backwards. The degree to which your shinbonebends with a given impact depends on two factors: how thick the bone is, and how wellit’s supported by the muscles around it. Fortunately, having strong calf muscles helps onboth of these fronts.

Running helps you develop stronger muscles and bones

With all the talk about the evils of impact and the dangers of running injury, you mightbe under the impression that runners are risking their bodily integrity in pursuit of theirgoals.

But it’s quite the opposite.

Runners, and anyone else who participates in a high-impact activity, have stronger anddenser bones than sedentary people. That’s because bones adapt to the stresses they

encounter during your daily activities. And stronger muscles means thicker bones, asshown by a 2009 study by Kristen Popp and coworkers at the University of Minnesota.3

In this study, Popp et al. used CT scans to examine the bone thickness and muscularcross-sectional area (a more quantifiable measurement of muscle size) in femalerunners with a history of stress fractures, mostly to the tibia, then compared theserunners to ones who had never suffered a stress fracture.

The results showed that the previously-injured women had smaller bones, but moreimportantly, smaller muscles than the never-injured runners. In fact, when theresearchers looked at bone size relative to muscle size, there was no difference betweenthe two groups! So, the tibia “grows” in response to the size of the muscles around it,and the calves are by far the largest muscle group surrounding the tibia.

Calf muscles support the tibia

The calf muscles also make the shinbone more resistant to bending by resisting andredirecting some of the forces on it.

Getting back to our bridge analogy, the calf muscles are like the strong cables on asuspension bridge. When the muscles tense up, as they so during impact with theground, they counter the bending forces that are attempting to deform and strain thetibia. So, in theory, runners with stronger calf muscles will be more resistant to shininjury.

This hypothesis was put to the test in a 2007 study by Luke Madeley, ShannonMunteanu, and Daniel Bonanno at la Trobe University in Australia.4 Like Popp’s study,Madeley and his two fellow researchers compared two groups of runners: one with shinsplints, and one without. Both groups were asked to complete as many consecutivesingle-leg calf raises as possible, with the researchers ensuring they didn’t “cheat” bygoing too low or leaning forward.

As predicted, the injured runners averaged only 23 calf raises, with the healthy runnersaveraging 33—a difference of 30%!

Calf strengthening as a treatment for shin splints

So, calf strength should be considered as a serious treatment and prevention option ifyou are prone to shin pain. Even if you’re healthy now, it’s an easy and simple way toward off future injury.

Unfortunately, there’s no standard protocol as of yet. But doing single-leg calf raises tofailure, like the runners in Madeley et al.’s study, once or perhaps twice a day is a goodplace to start.

Stronger calves looks as though they will will “straighten up” your shinbone in the shortterm, preventing the kind of bending that causes excessive strain on the tibia, andstrengthen your lower leg bones in the long run, making them more resistant to injury.

Finally, if you’ve had severe shin pain for a week or more, you ought to see a doctor toensure it hasn’t developed into a stress fracture (especially if the pain is localized to anarea only an inch or two in size). It usually takes high-tech imaging to diagnose a stressfracture, and they are definitely not something you want to try to run on.

References

1. Milner, C. E.; Ferber, R.; Pollard, C. D.; Hamill, J.; Davis, I. S., Biomechanical Factors Associated with Tibial Stress Fracture in Female Runners. Medicine& Science in Sports & Exercise 2006, 38 (2), 323-328.2. Moen, M. H.; Tol, J. L.; Weir, A.; Steunebrick, M.; De Winter, T. C., Medial tibial stress syndrome: a critical review. Sports Medicine 2009, 39 (7), 523-546.3. Popp, K. L.; Hughes, J. M.; Smock, A. J.; Novotny, S. A.; Stovitz, S. D.; Koehler, S. M.; Petit, M. A., Bone Geometry, Strength, and Muscle Size in Runnerswith a History of Stress Fracture. Medicine & Science in Sports & Exercise 2009, 41 (12), 2145-2150.4. Madeley, L. T.; Munteanu, S. E.; Bonanno, D. R., Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: Acase-control study. Journal of Science and Medicine in Sport 2007, 10 (6), 356-362.