Shin Splints – Part 2 – How to treat shin splints?
I’m going to split this section into 4 parts: Prevention, Pain relief, Running re-education and a final section on other things that can help.
Prevention is always the best medicine when it comes to running injuries. Shin splints are similar to most running injuries, in that the most effective way to prevent them is to respect the laws of adaptation. This means, firstly, listening to your body. If you are feeling pain when running, it’s because your brain has decided, that a particular area of your body needs protecting. Usually, but not always, this is because too much stress, or load, is being accumulated in the painful area, and you are not leaving enough time in between stresses to allow the tissues to adapt. So the key to injury prevention is gradual, patient loading.
Now, if you’ve gone past the prevention phase and are in the painful phase (and lets face it, if you’ve found this blog post, I imagine you’re in this phase already) the next sections will be helpful for you.
The reason that most people visit me is due to pain. Pain is often viewed as the problem. It isn’t. Pain is a symptom of the problem. Your pain system is complex and has evolved through millions of years of natural selection. It is essentially your alarm system. Its purpose is to protect you, and alert you, to the fact something is not right. It’s not a nice feeling, but at the end of the day, it’s meant to be uncomfortable, otherwise you would ignore it! Pain is your friend.
Dealing with pain is important, no-one wants to be in pain, it’s not a nice sensation at all and, to be fair, once we’ve worked out what the problem is and how to address it, the sensation becomes less helpful, so turning it down a bit is one of the early goals of physiotherapy. Remember that we want to turn the pain down, but we have to work out why it’s is there in the first place, otherwise it’s like your burglar alarm going off, you getting annoyed and fed up of the repetitive, annoying sound and going to the box and turning it down. It may make the noise a bit more bearable but does nothing to address the intruder in your house (a bit of a dramatic analogy, but you get the point). When it comes to pain relief I keep it simple:
Ice – Ice works really nicely as an analgesic. Crushed ice appears to be more effective from the current research. Rough guidelines of 10 mins every 2 hours, if needed, are adequate (Remember to wrap ice in a damp towel to prevent ice burns).
Decrease the load on the sensitive area. Intuitively, if you continue to stress, the already over-stressed area, it will prevent healing or de-sensitisation. Decreasing the load can be as simple as rest, cross training or, my favourite option, running re-education -See below.
Pain medication – Always consult your GP or pharmacist before taking any medication.
The goal of running re-education is to assess an individuals running style, and see if, through subtle changes to their biomechanics, you can shift the load from the painful area, whilst not jeopardising their performance or creating an environment for another injury elsewhere in the body. So in the case of shin splints, we are trying to reduce the anterior and medial tibial bowing (click here to go back to part 1 for an explanation).
Here’s some of the running cues that I like to try with this condition. It’s important to note that there is huge variability in what works for different patients. Word of warning with these: If the cue is going to work for you, you should feel marked relief, and ideally no pain at all, within 30s – 1min of adopting the cue. If you’re not getting any relief by then, try not to run through it. If none of the below cues are working for you, then it may be time to see a physiotherapist, or other health care practitioner, for some advice, ideally make it someone who specialises in running injuries.
Increase cadence – One of my most used running re-education cues across the board. The best way to do this is via a metronome. There are lots of free metronome apps, if you have an Iphone, or you can buy one pretty cheaply from places like Amazon. There’s no set stride rate you should aim for so have a play around with it. Generally, I go for 5%-10% more than your current cadence and see what happens. You can always gradually increase it from there and re-assess the ‘experiment’. The theory behind increasing your cadence is to decrease an over stride, get you landing closer to your centre of mass (COM) and with a straight tibia, as opposed to your tibia flicking out ahead of the knee. As mentioned in part 1 of this blog post, think of it a bit like a pole vaulters pole. As they approach the jump, they plant the pole ahead of themselves so you see this big, anterior bowing of the pole, great for pole vaulting but not so good for tibas! If you can imagine the pole vaulter placing the pole down vertically, and not ahead of themselves, you will see a pretty crappy pole vaulter, but also less anterior bowing of the pole, that’s what we are looking for – less anterior bowing = less force through the painful area.
Increase step width – trying to move the load from the medial shin, to achieve less varus (side bending) tibial bowing. I try and bring about this change using a variety of cues. Generally, asking people to have some daylight between their legs or imagine running on either side of a yellow parking line, gets the right changes. Recently, i’ve been getting my runners to run with a resistance loop just above their knees, and instruct them to keep the pressure on the band – this has been working really well.
Stiffen the ankle – The idea here is to decrease the amount of dorsiflexion the ankle goes through. Lessening dorsiflexion means less tibial bowing from the action of soleus, as it tries to decelerate the tibia as it moves into end of range dorsiflexion. Stiffening the ankle also helps to pretension the muscles, so they can work reactively and elastically. Good for speed but also takes the load of the bone itself.
Change the direction of the ground reaction force. Again, we are trying to decrease the anterior tibia bowing. If we go back to our rubbish pole vaulter, as we discussed, if he places the pole out in front of him with forward and downwards force it will create anterior bowing, however, if he plants the pole down with a backward and downwards force, it will not bow anteriorly, but posteriorly i.e the force will go more through the back of the tibia. Any change in the direction of the ground reaction force, to a more backwards and downwards force, will decrease the load in the anterior tibia and may be enough for us to keep running without pain. To cue this, I often video them and freeze the frame of them running when their swing leg is at its highest (see fig.2)
From this position, I instruct them to push their leg back and down in a backwards tick type direction, using their glutes to perform the movement. Sometimes i’ll ask them to paw back on the ground (bit of a controversial cue from a performance perspective, but can just get them to direct the force more backward and down).
Posture – Encourage the patient to ‘run up tall’. I often use the ‘helium balloon attached to the crown of the head’ cue or get them to imagine their spines like a slinky toy, and wanting to open it up. This cue helps decrease an anterior pelvic tilt, or a forward lean from the waist. Both of these mechanics lead to the centre of mass shifting forwards during stance. To compensate for this, you will have to over stride with the next step = more load on knee and shin area.
Usually I use a combination of the above. Have a play around with these cues and let me know what works for you. As always, never run through pain.
There are some occasions, when no matter what alterations you make, you can’t offload the area sufficiently and pain is still present. In those cases, it is wise to take a short break from running, to allow the area to settle some more. Cross-training can be effective at this point, to maintain strength and fitness. Remember you only need to offload the painful area, not your whole body. I prefer aqua jogging, or running on an alter-G treadmill (if you’re lucky enough to have access to one). This way you can still work on technique, and keep your running specific movement patterns with very little stress on the musculo-skeletal system.
Other techniques that may help
Generally, I try to avoid orthotics or taping if I can, but they can still be great tools to offload an injured or sensitised area. Often a medial arch support works well to offload the medial tibia. Below is also an example of a taping technique that aims to offload the medial tibia. Ideally, if you do go down this route, it should be a temporary measure to prevent weakening of the area from chronic support.
Blaise Dubois from the running clinic, demonstrating a taping technique for shin splints…yes, it’s in French!
As mentioned in part 1 (here), weak calves have been implemented in shin splints. So seems like a good idea to strengthen these muscles as a way to create a stronger, thicker tibia, but also being able to take more load themselves. Here a some options.
A Simple calf strengthening regime (above)
Calf and foot strengthening exercise (above) from James Dunne at Kinetic Revolution
Here’s another one from James Dunne at Kinetic Revolution – Specific strengthening exercise for Tibialis Posterior (above)
Changing the Surface you run on?
Bit of a weird one this, intuitively you would think that running on softer ground, such as an athletics track, sand or grass, would be easier on the legs, but the literature suggests that when we run on softer ground our leg actually stiffens more to compensate for the softness, and the reverse is true when running on hard ground i.e. less stiff legs. This has led many to suggest that it may be better for runners with shin splints to run on harder ground. I remember when I had my shin splints, I found it better running on softer ground, but might be worth bearing in mind if you find the pain is worse on softer ground.
Running barefoot or in minimalist footwear
Some evidence that this can shift the load from the shin and knee, more to the foot and ankle. Probably by, subconsciously, increasing cadence and landing closer to COM.
So these are my current thoughts on this interesting (to me anyway) topic. Let me know how you get on. I will try to update this post if any new evidence comes out, or if I find success with any new techniques, cues and exercises in clinic.