Are shin pain limiting your training?

It’s usually around this time of year, as the days begin to finally start getting a little longer, that a significant number of you will come up with a crazy idea to run either a marathon or half marathon as a pre-summer get fit plan. Perhaps you want to participate for a charity, or perhaps you’ve been coerced by a friend or colleague and enjoy the friendly competitiveness. Whatever your motivator, elevating your activity in any way, shape, or form is a great idea.

A lucky few newbies will get by with very few complaints (usually due to some very fortunate genetics and biomechanics) but most people will have some benign muscle imbalance , perhaps an asymmetry in their posture, a muscle group that is weak / not switching on when they should or a restriction/ flexibility issue somewhere in their muscle or fascia. This will normally make itself known once the individual increases their weekly running mileage too quickly.

One of the most common injuries new runners experience early on in training is Shin Splints. Shin Splints is an umbrella term for shin pain. The most common cause is known as Medial Tibial Stress Syndrome. The muscle Tibialis Posterior (responsible for helping to hold up the arch of the foot) tugs at the inside border of the shin with each and every foot strike during running (fig 1). This causes inflammation and will create some pretty painful lumps along the inside border of the shin over time as scar tissue develops. Sometimes this can be fixed relatively easy, but initially you must REST and a massive adjustment will need to be made to your training schedule.

Fig 1: Tibialis Posterior

Fig 1: Tibialis Posterior


TREATMENT

REST

Yes, the dreaded R word!

ICE

To reduce the inflammation and dull the pain. I’m sure you already knew this and you’ve been putting ice on your shins since the first day they started to hurt right? You can use an ice pack, however I find far less effective and far more time consuming that using a paper cup with a frozen block of ice (with the edges trimmed down) to give a deep ice massage along the inside shin . The pressure you use should be uncomfortable and you’ll certainly feel it when you cascade over the lumps. But fear not, that will numb soon. The massage will not need to be as long as it would if applying a cold pack and you don’t risk ice burns with this method. Try to massage each painful leg for 5-10 minutes a couple of times a day, ESPECIALLY straight after a run, even when things are on the mend.

FOOTWEAR

Are your trainers old enough to remember MacGyver? (Young folk: No, that’s not just the name of a guy they mention on the Simpsons). In truth even a moderate runner should be replacing their trainers every 9 months to a year, especially if they are suited to a more supportive shoe. If you are unsure what shoes are best for you, visit shoe specialists like www.profeet.co.uk in London or try www.theathletesfoot.com in New Zealand or Australia. They can digitally analyse your running posture and fit you in a shoe which helps correct your foot arch from collapsing in and causing the Tibialis posterior from tugging on the inside shin area. They may even advise you get orthotics to go in your shoe to help further. These can be purchased over the counter or they may create a custom made pair for you.

PHYSIOTHERAPY

Go and see a physio for some lovely friction massages down the edge of your shins. Yes it hurts. A LOT, but it’s good for you. You can try to rub at the nodules yourself, but you may not be as firm doing it yourself. A deep massage on the calf muscles will help a lot too as these become extremely tight in most cases.

STRENGTHENING & LENGTHENING

Fig 2: Tibialis Anterior

Fig 2: Tibialis Anterior

Often the increased load on the Tibialis Posterior and resulting shin pain is due to its antagonistic muscle the Tibialis Anterior (fig 2) becoming weak or inhibited. (An antagonistic muscle is the muscle that performs the exact opposite movement of the one in question= the agonist muscle).

If you point your toes and foot up towards your head as hard as possible you should see a nice muscle belly bulge appear on the front of your shin. This is the Tibialis Anterior. It is a notoriously difficult muscle to train and the internet is full of what I’ve found to be ineffective strengthening advice for this muscle. The difficulty arises because its job in running is not so much to contract in the way you just made it by pointing your toes and foot up, but instead to ‘actively’ lengthen, or to slow the rate at which your foot is pulled down towards the ground during that heavy heel strike. When a muscle actively lengthens, it is called an eccentric contraction. A concentric contraction is when a muscle actively shortens.

The strengthening protocol below was based on a single case study printed in the Sportex-medicine journal in January only last year. I have had good feedback regarding its effectiveness and am personally following it in lead up to a Tough Mudder race later this year. The exercises are basic and can be performed anywhere, whack them on to the end of your gym workout (yes gym; you won’t be running remember?) Or perform them at work or home. There are NO excuses not to do them. Perform them every day, and if you want to fast track your strengthening you may cope with phase 1 and 2 training twice a day.


STRENGTHENING PROTOCOL

Phase 1

Rest your back and butt against a wall with your feet about one to one and a half foot lengths out from the wall. Lift the toes of both feet up towards your shins as hard as possible pivoting off your heels and then lower your feet back to the ground. Don’t allow your forefoot or toes to actually touch the ground before lifting them up again for the following rep. (Fig 3). Perform 12-15 repetitions of these Double Shin Raises (DSR).

Once you have completed this exercise ‘superset’ (where you perform 2 or more exercises back to back) after 10 seconds rest with a set of 15 Pulses. The movement is like the last exercise but only move through a partial range (don’t allow your toes to get as close to the floor as with the last exercise. The emphasis of this exercise is on speed. Do them as fast as possible.

Fig 3: Double Shin-Raises and Pulses

Fig 3: Double Shin-Raises and Pulses


Phase 2

Continue to superset the same 2 exercises but build up until you can perform 2 and then 3 sets of each exercise using a 30 second rest between supersets.

Phase 3

Once you can perform the 3 sets x15 reps of both the Double Shin Raises and Pulses, it’s time to progress to single leg shin raises. The position is the same as with the DSR but rest one foot flat against the wall behind you. (Fig 4) Now all your body is on one foot as it would be in running and this makes it a more functional progression. Again aim for 12-15 reps (per foot) for both Single Shin raise’s (SSR) and single leg pulses and build up until you are doing 3 sets x 15 reps of each of these exercises. You will not need to rest between sets; after performing SSR’s and pulses back to back on one leg, change immediately to the other leg and continue like this until all sets on both sides are completed.

Fig 4: Single Shin-Raises

Fig 4: Single Shin-Raises

Now can also now start Heel Step Downs, this is even more functional as an exercise because it replicates the running movement even more so. Begin standing with your feet hip width apart (no leaning on a wall this time). Step forward with one foot (moderate distance) but as your heel makes contact with the ground, do not let your forefoot reach the ground by tensing up that same Tibialis anterior muscle. (Fig 5)Return to the starting position and repeat for 15 steps before changing sides. Again, progress this exercise to 3 sets x 15 reps for each side as strength increases.

Fig 5: Heel step downs

Fig 5: Heel step downs


Phase 4:

Progress the heel step downs to a much larger distance step, again building to 3 sets x 15 reps. Lastly progress to performing Heel Step Downs off a high step/ 40cm bench.

You may be comfortable to return to running before even reaching Phase 4, and you may be symptom free, but DO NOT stop these exercises until you successfully completed all phases, or else you are likely booking another ticket to painville in the near future!

Perform daily calf stretches by hanging your heels off the back of a step and shift your body weight alternating how much weight you put on each foot. Emphasise most of your body weight on one foot for 5-10 seconds and alternate 5 times of each foot. Do this as often during the day as you can.


VOLUME

As you get back into your training, increase your running volume VERY slowly. Especially if you are now in a shoe with a radically different feel to your last. This may mean only a 10-15 minute run on day 1 and increasing it by only 5 minutes on each subsequent run.

THE OTHER GUYS

Just briefly, other less common types of shin splints you should be aware of include Compartment Syndrome of the Tibialis Anterior: Basically the muscle belly swells too much for its fascial sheath when it is active and it starts to cause an uncomfortable ache down the front of the shin. The toes may also go numb during running due to compression on the nerves and blood vessels. In short: REST, ice, deep firm massage and myofascial release, and stretching.

Be aware of stress fractures too, these will normally be caused by much larger increases in training volumes although not necessarily if your bone density is low. You’ll also probably experience night pain:

Again, REST, and get an x-ray or MRI done for confirmation.

I told you there were potentially more enjoyable forms of exercise didn’t I! Happy running.


PAR (POST-ARTICLE-RANT)

I didn’t get into the whole debate about supportive running shoes versus a more minimalist shoe. The new(ish) more minimal shoes (including those creepy looking toe gloves I’m sure you’ve all seen around) require a complete overhaul of your running posture and technique which can take a year or more to completely adapt to. I sit completely on the fence on the debate on which running style is best. I think both sides have strong arguments. Getting back to all things natural and running how we would naturally run in bare feet is great in theory, hell I wish I could automatically. But modern day footwear and the increased amount of hard surfaces that we run on nowadays has seasoned most of us to require increased cushioning and support in our shoes to cope with the heavy heal strike we run with (The heel strike occurs as each foot makes contact with the ground during running) This repeated impact tends to be a huge culprit of the overloading in the lower leg muscles which causes shin splints.

But in case you are thinking of changing your running posture, forget it! there is not enough time for you to change it all for this year’s events, so suck it up!

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