(Original Post Date: 4/5/23)
Spring has arrived in Maine, and with it comes the promise of warm, sunny days and an increase in outdoor activities. For many, this means returning to running after a winter hiatus. However, this is also a common time for overuse injuries to occur, and one of the most common among runners is Medial Tibial Stress Syndrome (MTSS), commonly referred to as "shin splints."
Shin splints is a general term for pain in the lower leg region, and there can be upwards of 30+ specific diagnoses associated with pain in the front of the leg. MTSS, or medial tibial stress syndrome, is defined as exertional pain observed over the distal medial ⅔ of the tibia, which is the lower, inner region of the shin bone. The pain commonly increases with increased training volume or intensity with impact activities such as running, and while rest often helps, the pain is commonly stubborn and sticks around when eventually returning to activity.
It's important to seek professional help for shin splint pain, as there are a few serious complications associated with pain around the shin, such as stress reactions, stress fractures, and compartment syndrome, that all should be ruled out with testing by a skilled clinician. Additionally, there are many potential risk factors for MTSS, including training errors, calf weakness, core and hip weakness, hyperpronation, poor foot mobility, and previous lower extremity injuries.
Historically, the first steps to manage MTSS involved placing the athlete in cushioned shoes and avoiding training on hard surfaces, but recent evidence suggests a multifactorial cause with the muscles in the lower leg themselves causing greater stress on the bone. Ground reaction forces have been measured at 2x bodyweight through the shin bone on foot impact but nearly 6x bodyweight when the lower leg musculature is at peak contractile force. This means that the muscle pulling on the bone (via its tendinous attachment) imposes more force on the bone than the ground reaction impact forces directed to the bone. Therefore, it's suggested that the tibia actually gets more stress when running on softer surfaces, as the muscles are working harder and therefore pulling more on the bone.
The primary risk factor for MTSS is doing "too much, too soon," usually involving training volume and/or intensity. The key first step is to find a training load that produces only minimal symptoms. This may or may not mean that a cross-training method should be involved. The mantra to reiterate with MTSS is "High pain, NO gain." The condition does not respond well to working through higher levels of pain, and a high pain response often means the bone is being irritated beyond the ability to repair itself and it therefore has more difficulty recovering.
The next step would be to strengthen the lower leg musculature, especially the calves, and address any significant foot weaknesses or mobility deficits.
A later stage rehab step should include some form of higher impact movements like plyometrics, which produce higher muscular forces. This can help indicate an athlete's readiness towards ramping up their training volume.
The final rehab step is using a progression of training as part of the rehab, increasing the total weekly volume and intensity in specific ways to promote positive adaptation, until the athlete has eventually reached their goal mileage and intensity.
MTSS can be a complicated injury, and it's important to be very specific with the timing of your progression. If you or someone you know is dealing with shin splints, reach out to admin@steadystatehealth.com or click the button below to schedule an initial discovery call and determine the best course of action to help you achieve your goals!
Winters et al. (2016) – The MTSS Score