Shin splints: a grey area

As a runner you hear the words 'shin splints' bandied around a lot, usually as an umbrella term for any kind of pain along the tibia (hence the medical name medial tibial stress syndrome). It is a horribly frustrating condition, partly because it is so vaguely defined. Just what is it? Why does it happen? And most importantly, how can it be cured?

Unfortunately, one case of shin splints is likely differ greatly from the next so there really is no 'one size fits all' solution. The NHS speculates that shin splints is caused by 'intense and frequent periods of exercise that your body is not used to' and is most likely to affect those who:

• have been running for less than five years;
• are running on hard surfaces or slopes;
• wear poorly fitting or worn-out trainers that do not support the foot properly;
• are overweight, as this places extra weight on your legs;
• have flat feet or feet that tend to roll inwards (overpronate), as this places more pressure on the lower leg;
• have weak ankles or tight Achilles tendons.

With so many factors at play, you're unlikely to find the answer you need on any running forum. Even with the benefit of physical examinations, experts (osteopaths, sports therapists, and physiotherapists) can struggle to find the root cause of shin splints.

Take my case, for example. I have always been active. As a teenager I ran track and cross-country and even in my lazy student days I ran intermittently and played football most weeks. Over the past 18 months I have re-established a solid base of running fitness, averaging about 25-30 miles per week. Yet whenever I tried to up my mileage to 35-40 mpw, no matter how patiently, my shins flared up badly. I've watched (and envied) other runners happily exceed 50 mpw and wondered why I couldn't do likewise.

Last summer the pain got so bad that I was forced to rest for 10 days. At that point I decided to put my hand in my pocket and see a specialist. The first person I saw was an osteopath, mainly because he was local and well reputed. Initially he put my mind at rest by ruling out the dreaded words 'stress fracture'. He explained that the tibialis posterior had been pulling hard against the tibia, causing periosteal pain. But thereafter, every session was spent treating the symptoms and not the cause. When in one session he said that he had 'hoped to see some improvement by now', I decided I'd had enough and looked elsewhere. 

My next port of call was somebody who claimed to be a sports therapist, among other things (therein lay the problem, I suspect -- beware of 'holistic' therapists). He seemed unsure of the cause but launched into massage and 'sound therapy', which I found really dubious. After two sessions I gave up.

A few months ago I moved (back) to Cardiff and had a clinic recommended to me by a local fitness instructor. Based on my own experience, I'm now happy to pass on that recommendation: the staff at DTR Clinic not only provide a thorough and tailored service, but are also frank and honest -- if they can't help you, they will explain why and probably refer you. Crucially, they won't carry on treating the symptoms of a condition without addressing its cause (which is of course an endless dynamic and frankly unethical).

The physio I saw spotted that I had flat feet and mused that my shin splints were the result of overpronation. I wasn't satisfied with that diagnosis, however: I'd had my gait analysed twice at two different running shops and been told categorically both times that I had a neutral foot plant (see the videos from my last gait analysis here). Even so, I followed the advice I was given and experimented with strapping, ice and a more diligent stretching regime. After three weeks there was no discernible improvement. On that evidence, my physio suspected my problem might be biomechanical and referred me to a podiatrist. Here were his findings:

"Patient presented with severe soreness on the medial aspect of both shins, and severe pain on palpation of tibialis posterior tendon over lower 1/3 of medial shin border.

On examination we found some limitation in ankle dorsiflexion bilaterally which did improve with knee flexion, suggesting some calf tightness. Also a severe restriction in 1st metatarsophalangeal joint (MTPJ) dorsiflexion (hallux rigidus or stiff big toe).

Pressure v time charts show heel lift at approx 30% of stance phase (normal 67%) confirming ankle equinus / early heel lift requiring either stretching regime and / or heel elevation on orthoses.

Suggests loss of motion at 1st MTPJ is primary concern requiring the foot to supinate onto the lateral border as a compensatory mechanism. This is shown in the scans below indicating reduced load through the great toe joint.

Barefoot scans illustrating increased load on lateral aspect of foot avoiding the 1^st MTPJ

The primary structure employed to create a supinatory compensation pattern is the tibialis posterior muscle. This muscle lies deep in the calf and inserts on the medial aspect of the foot on the tuberosity of the navicular. The role of this muscle is to resist pronation and facilitate supination. I would suggest that the tibialis posterior muscle has been overloaded in the compensatory movement pattern secondary to the stiffness of the great toe.

The scans below show the orthoses being used. They show the lateral load being maintained hopefully without excessive use of tibialis posterior. This should reduce symptoms quickly and effectively."

So with my new orthoses, I hope to finally run without pain. So far I have only run a couple of miles on the treadmill and it was a slightly odd sensation, but my shins did seem less irritated than usual afterwards. More to follow.