This blog will cover the following points on Shin Splints:
- What are Shin Splints
- Symptoms of medial tibial stress syndrome
- What causes Shin Splints
- Treatments for Shin Splints
WHAT ARE SHIN SPLINTS?
Did you know that ‘shin splints’ is actually not a diagnosis for an injury but rather just a vague term meaning pain and/or discomfort in the shin bone? Well, if you didn’t, now you do! There are several potential causes for shin pain which will be listed shortly; however, the main condition being explored in this blog is bone stress injuries, mainly medial tibial stress syndrome.
Medial tibial stress syndrome is a common overuse injury of the tibia (shin bone). It typically occurs in athletes that are exposed to intense weight-bearing activities like jumping, running, or allegro for dancers. This presents as exercise-induced pain over the inside or front of the shin and is an early bone stress injury in the continuum of tibial stress fractures.
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SYMPTOMS OF MEDIAL TIBIAL STRESS SYNDROME:
Area of pain is usually inside or front of the shin bone itself.
Can be an achey feeling or a sharp pain, particularly when doing higher impact work.
Pain is usually exercise-induced and can get worse the more you load the bone.
Aggravating factors can be jumping, running, allegro.
WHAT CAUSES SHIN SPLINTS?
The main cause of shin splints is overuse, however there are other causes of shin splints that are listed below.
Causes of medial tibial stress syndrome or bone stress injuries:
- Due to an “error” in workload.
- An accumulation of microdamage with cumulative loading which exceeds the normal repair process and/or impairs the ability to resist damage.
- The bone resorption phase increases bone porosity which reduces fatigue resistance due to altered mechanical properties.
“Interesting fact, the pain usually presents itself 3-4 weeks post this workload “error”. And can take approx. 4 weeks to replace with new bone, taking 3 months – 1 year to fully heal!”
- There is a strong connection between the magnitude of bone tissue strain/stress plus the number of cycles before bone fatigue failure.
- An example with running: it’s estimated a 10% increase in bone tissue stress/strain results in halving the number of loading cycles before bone fatigue failure.
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Common risk factors and causes of medial tibial stress syndrome plus bone stress injuries in general:
- A quick increase in volume in the chosen physical activity you do, like running, team sports, or dancing.
- Insufficient amount of recovery days.
- Low bone mineral density.
- Bone stress risk is prospectively related to muscle size and strength, so weaker and smaller calf and shin muscles increase your risk of getting a bone stress injury of some sort2.
Bone stress injuries may occur at the front or back of the tibia (shin bone). Stress injuries that occur at the back portion of the shin bone are generally less problematic. This is due to them occurring on the compressive surface of the tibia, so they typically heal without complication2.
Other causes of shin pain:
- Tibial bone stress syndrome (at the front of the shin bone)
- Exertional tibial compartment syndrome (shin muscle and fascia pressure injury)
- Tibial or fibular stress fracture (shin bone injury – more severe than medial tibial stress syndrome)
- Tendinopathy (tendon conditions in the lower leg)
- Lumbar radiculopathy (lower back nerve root issues)
- Sural or superficial peroneal nerve entrapment (leg nerve impingement)
- Popliteal artery entrapment (knee blood vessel impingement)
TREATMENTS FOR SHIN SPLINTS:
Shin splints are a very treatable condition with physiotherapy assessment and management but it’s also key to be aware of preventative strategies which are listed below too.
Load management for medial tibial stress syndrome:
- Minimise complete rest (unloading) to balance deconditioning and unloading-induced bone loss. There’s no need for prolonged non-weight bearing or protected weight-bearing.
- Pain-free walking and normal activities of daily living (ADLs) is the main goal, however, we shouldn’t overuse moon boots and anti-inflammatory medications (NSAIDs e.g., Nurofen) due to potential negative effects2.
- Symptom not time-based progression→ gradual loading which should be symptom-free during, after, and 24 hours post activity/exercise. Any symptoms indicate the need to immediately modify load1.
- Increases in weekly volume should be small to avoid large increases or “spikes” in training volume or intensity. A good rule-of-thumb is keeping load increases to within 10% per week, but your physiotherapist will help guide your reintroduction to activity.
Other parts of rehabilitation to consider for medial tibial stress syndrome:
- Consulting a sports physiotherapist or dance physiotherapist (depending on your sport) can help you get back to the road or to performing as soon as possible.
- Maintain fitness by doing cycling, swimming, and cross-training to name a few!
- Note: monitor energy availability, don’t overdo it as bone healing may be impaired.
- Delay hamstring curls to weeks 5-6 due to tensile load on the back of the tibia.
- When it's time to return to running, a running assessment can be helpful to identify any contributors to your pain. The aim is to prevent recurrence.
- Most bone load is muscle-derived. Prospective studies suggest increasing muscle cross-sectional area and strength is relative to decreasing bone stress injury risk.
- Muscles may diffuse forces and bending moments, improve kinematics, and protect against fatigue.
- Introduce plantarflexion (e.g., calf raises) strength work in low-risk medial tibial stress syndrome as early as 3-4 weeks provided walking and activities of daily living are symptom-free.
- Seek nutritional advice from a dietician ensures good bone health from the inside out.
Returning to sport after the rehab break:
- Need to be pain-free on activities of daily living and walking for 5 consecutive days before commencing.
- It is safer to increase training volume before intensity due to higher magnitude loads being a stimulus for bone damage than the number of cycles.
- Relative disuse during rehab = in bilateral bone loss which peaks at 12 weeks which is usually when people are returning to sports, so there can then be an increase in bone stress injuries generally in the opposite limb which we want to avoid!
Prevention of bone stress re-injury:
- We know from research that we get moderate gains in bone mass from a loading program which can generate a large gains in bone fatigue resistance --> so we do indeed need to load our bones. But it must be done in a smart way.
- Previous medial tibial stress syndrome significantly increases the risk for future medial tibial stress syndrome.
- Year-round sports should consider substituting training sessions, incorporating rest periods (e.g., 1 rest day per week and 1-to-2 weeks rest every 3 months)1.
- “A jumping program that (1) applies progressively higher loads, (2) includes few loading repetitions per session, (3) occurs several times a day, and (4) occurs on at least 3 days per week may improve lower extremity bone properties”2.
- The pre-puberty optimal bone workload consists of low-repetitions of fast, high-magnitude, multidirectional, novel loads introduced a few times per day.
- Mature skeleton bone workload is focused on avoiding acute spikes while incorporating rest periods (1 day/week, 1 week/3 months).
- Explosive take-off focus is better than heavy or impact landing focus1.
- Seasonal changes in load → transitions from off/pre/in season or between skill levels. Consider a bone loading program in periods of de-load to reduce spike on return.
If you have a dance or running injury, visit us at PhysioTec, and let one of our physios assess you and provide you with a personalised program for recovery and to get you performing to your best again!
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This blog has been written by one of our experienced PhysioTec dance physiotherapists. If you would like to book with one of our dance physio's, Rhianna or Dave, call 3342 4284 or click here to book online.
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1. Preventing Bone Stress Injuries in Runners with Optimal Workload.
2. Optimal Load for Managing Low-Risk Tibial and Metatarsal Bone Stress Injuries in Runners: The Science Behind the Clinical Reasoning
Warden, S. J., Edwards, W. B., & Willy, R. W. (2021). Optimal load for managing low-risk tibial and metatarsal bone stress injuries in runners: The science behind the clinical reasoning. Journal of Orthopaedic & Sports Physical Therapy, 51(7), 322-330.