Shin splints, which is better known as ‘medial tibial stress syndrome’, is an injury more common in endurance athletes such as runners, as well as athletes involved in jumping sports such as basketball or volleyball, who are placing large amounts of stress with high volume through their lower extremities. Follow along in this clinical pearl as we highlight the low hanging fruits of treating shin splints, with 3 progressive phases that include take home exercise implications!
If you have caught shin splints before they become a more serious injury such as a stress fracture, you have won half of the battle! Both with this injury and stress fractures, the first step in the rehab process is a simple….but not always quite so simple. The athlete will need to decrease and alter their training habits. We know shin splints are commonly due to training error, whether that be volume and/or intensity as well as many other variables.
Key Takeaways From This Clinical Pearl:
-Athletes need to be properly educated on load management, how to train properly with a schedule, and regular strength training to improve resilience of the body. This is the first step that needs to be addressed before progressing towards the rehab process. Relative rest and education is the first, most important step!
-Flexibility and mobility deficits should be addressed, specifically at the talocrural joint, gastrocnemius, soleus, heel cord, and anterior lower leg compartment, all of which are culprits with shin splints.
-Strengthening should start gradual with isometrics and open chain loading, and progressing towards eccentric loading, closed chain movements, return to plyometrics, and power based exercises. Special considerations should be given towards dorsiflexor eccentrics, plantarflexor eccentrics, single limb loading, core stabilization proximally, landing mechanics, deceleration control, and re-intregration of creating stiff landings for increased power.
Acute Phase: Relative rest utilizing POLICE principle, which is protection, optimal loading, ice, compression, and elevation. Ice which is heavily debated within literature may be used in this acute phase as an analgesic. Whether it will address any swelling at the level of the tissue is still debated within literature. Listen to our podcast on this topic to learn more about icing and its indications!
Start with cross-training as well as more forgiving training surfaces: The ground reaction force through the foot up to the shins needs to be reduced initially to allow for adequate recovery before graded exposure. Examples of better surfaces would be even surfaces such as a track. Cross training such as swimming, biking, and other lower to minimal impact activities are great. This allows for continued conditioning of the cardiovascular system, which helps maintain fitness levels aerobically in addition to creating a pumping mechanism throughout the body, that assists with tissue healing!
Address muscle strength and/or flexibility imbalances: Pay special attention to the calf complex, as this area is highly associated with medial tibial stress syndrome
Core weakness is a risk factor for lower extremity injuries
Foot intrinsic strengthening especially if individuals are over pronated (have a flat arch). Work on controlling pronation as well as possible arch support and orthotic consult.
Muscle imbalances throughout the kinetic chain that you find in the evaluation process
Female Athletes: Consider the female athlete triad, as additional consults with nutrition, primary care physicians, and sports medicine psychologists may be warranted. Interdisciplinary care is essential in this situation!
Check Footwear: This is variable depending on who you discuss this topic with, but generally, shoes should change around every 200-500 miles of usage, and in some instances, a consult with a podiatrist for orthotics may be warranted.
Running Mechanics: Typically I am not on the side of trying to change a ton of someone’s running mechanics; however, a couple things to keep in mind with shin splints if you have a runner: late grounding and/or plantarflexed when striking or improper braking techniques. Also, increased cadence if it is pretty slow is an easy way to decrease ground reaction force.
Main clinical pearls from this phase:
-Begin address flexibility deficits of lower leg as patient has become less irritable in this region, especially calf complex
-Address any imbalances, strength, and/or flexibility deficits you found on evaluation
-Allow area to calm down before progressing towards graded exposure in the next phase
Some soft tissue work to the anterior compartment muscles can assist in modulation of symptoms as well as enhancing blood flow. The literature is not strong for this intervention; however, in the early phases, some individuals may respond well to this as an analgesic. Other soft tissue interventions may also be implemented, such as foam rolling, IASTM, or dry needling.
Tightness of the gastrocnemius and/or soleus are commonly involved with shin splints. Be sure to address them both by stretching with knee extended and knee bent.
Train around the symptoms! Core stabilization deficits are a risk factor for lower extremity injuries. This can be started right away for an athlete who is allowing their shin pain to calm down in the early phase of rehab.
All athletes need hip work. Nothing sexy about the side plank, but it is super effective, especially for the glute med. Check out our article on this.
Intrinsic foot strengthening and joint proprioception should also be a focus of the rehab, especially if you have an athlete that is overpronated, has poor medial arch motor control, or is lacking motor control at the foot/ankle complex.
Main clinical pearls from this phase:
-Begin lower level strengthening and eccentric training of the lower leg muscles
-Continue with progressive strengthening and conditioning in preparation for return to activity phase
Eccentrics are a crucial component of strengthening, in all compartments of the lower leg. Dependent on which area of the lower leg is the largest culprit to shin splints, pay special attention to that area with eccentrics. Watch this video above as well as the dorsiflexion video below for the anterior compartment.
The long arc quad with dorsiflexion bias utilizing a kettlebell as shown is an effective way to not only target the quad in the open chain, but also the ankle dorsiflexors, often involved in shin splints. We have to load the structures involved in an injury so they are able to meet the specific demands that are placed upon them once returning to full level of activity!
Here are a couple more open chain dorsiflexion exercises you can implement.
The soleus is often an undertrained muscle. It is vitally important and takes on up to 6-7x our body weight when running!
Clinical pearls and takeaways from this phase are:
-Reintegration of plyometrics: Double leg before single leg, brakes before gas, sagittal before frontal and transverse!
-Return to running: Utilize soreness rules as well as proper ramping up pattern.
-Progression of load: Continued strengthening, especially single leg!
When it comes time to run, the University of Delaware Return To Running Protocol is one we highly recommend. Two simple modifications with running that can also help with avoiding further shin splint aggravations are:
Athletes should be educated on why shock absorption matters, especially jumping athletes.
Start double leg, then move towards single and change plane of movement, as shown in next exercise.
Be sure to work on deceleration in all 3 planes!
Further progress joint proprioception and single limb control
If you have an athlete or runner getting back to sport, check out this youtube video where we berak down some awesome power exercises for runners!
Differentiating why an individual is experiencing lower leg pain can be difficult to ascertain as a healthcare provider. Moreover, it is of utmost importance to make an accurate diagnosis to ensure these injuries do not become more serious. Shin splints starts as a gradual pain in the lower leg, and can become more severe the more that one places stress through this area of the body. Starting with relative rest and progressing towards fundamental exercises to address any deficits present will help optimize the recovery process! Similar to other injuries, don’t solely focus on the area of symptoms! Think globally and evaluate their entire patient, and implement your treatment plan based on what you find with your examination.