SHIN SPLINTS

"But It's Just Shin Splints"

Why is it important to be aware of shin splints? In addition to being sore and annoying, shin splints can be a predecessor to future, more alarming problems in the leg*. Shin splints, or Medial Tibial Stress Syndrome (MTSS), an irritation of the periosteum - the connective tissue covering of the bone - is often considered an early stage on what is called a "spectrum" of disorders. On this spectrum, as the physical stress progresses over time or in intensity, greater tissue damage is likely to occur. When talking about bones, MTSS can advance to become stress reactions (another disorder), where the bone itself becomes inflamed, and, later, stress fractures, where there are tiny breaks in the bone.ª

* In this text, when we refer to the "leg", we are always referring to the lower leg, the area below the knee and above the foot.

ª If not addressed at this stage, it is possible that the irritation could turn into a more complicated fracture.

An Overuse Injury…And More

Shin splints are an example of an overuse injury. Overuse injuries are just that, injuries that happen when you put too much stress on the body over time, as if the body has been overused. They can cause the body's tissues to break down faster than they rebuild themselves or they can aggravate tissues, causing them to inflame or swell.

It is common, when overuse injuries first begin, for the player to have pain as he or she starts to play, pain that diminishes or even goes away after the body warms up.Later, when play is over, the pain returns once again. As the condition worsens or turns into a more severe diagnosis, however, the pain may actually be present throughout play as well.

There are certain risk factors that are known to encourage overuse injuries. Regarding shin splints, these include things like: ◊ Poor preparation    ► the failure to gradually build the body up to meet the new, higher demands of a sport like football with a lot of running and frequent starts and stops (i.e. playing at a higher league level or starting a sport again after a seasonal break)    ► the use of improper boots or arch supports for your feet and the surface you are playing on    ► running on angled, hard, or very soft surfaces to which your body cannot yet tolerate or adapt, such as:       ○ fields with a convex curved surface that helps with field drainage but forces you to run on an angle, uphill, or downhill       ○ streets with a similar curve that you run on as you prepare for the upcoming season       ○ beach or indoor surfaces played on for the first time ◊ Genetics (where things like "weak" bones, irregular foot arches, or inflexible connective tissues play a role) ◊ Medical conditions that affect and alter the bones and soft tissues (i.e. osteoporosis and thyroid deficiency) ◊ Previous injuries (that may force you to overuse the opposite leg or force a weakened leg to take on more stress than it can handle)

Be Aware…You Might Recover Faster

The interesting thing about most injuries, or at least the way we interpret injury, is that pain is usually the first sign of injury that we recognize. With acute, contact injuries like being on the wrong end of a tackle, the injury may be obvious right away. Overuse injuries, on the other hand, may demonstrate other signs first—things like swelling, increased heat, or muscle tightness—telling you there is the start of a problem much earlier on. Unfortunately, unless you are very aware of your own body, these signs are often not easy to identify. But if you can discover them, time for recovery could be a lot shorter.

Shin Splints...Or Is it Something Else?

With shin splints, tenderness at multiple sites along the inner part of the tibia bone is a good diagnostic tool. The exercise tests we talked about in the video—hopping up and down on one leg, stretching your calf (especially with your knee slightly bent), raising up on your toes—may support the diagnosis, but they may also indicate the presence of a different problem in the leg, such as a stress fracture or a compartment syndrome (we will review these diagnoses later). That's why if you have any symptoms you should always see your doctor to take a closer look.

All Surfaces Are Not Created Equal

As we mentioned earlier, the relationship of your foot, in fact your whole body, to the surface you are playing on is an important factor. For example, the wrong boots on a hard playing surface may have little if any shock absorbing ability.

At the same time, players running shoeless on the beach may have to rely on flexible and strong muscles in very soft sand that makes it harder to push off and change directions.

Keep this in mind when preparing for play and when symptoms like pain start to pop up unexpectedly.

No Arch, Less Cushion

When researchers and doctors talk about the reasons why shin splints show up in some players and not others, they usually talk about the inside ankle/foot buckling inward (becoming flat or "pronating") which puts extra stress on the bones, especially with running and landing [Figure 1].

At the same time, players with high, rigid foot arches may develop pain due to a decreased ability to absorb forces between the body and the ground―the foot doesn't move properly to accept weight, putting greater stress on the bones and muscles.

For these issues, doctors often recommend shoe inserts, or orthotics, to help improve the foot and ankle alignment (in flat feet) or more properly disperse the forces (in high arches). For flat feet, if the insert is done correctly, such a change will also improve alignment up the leg where needed (at the knee, the hip, the pelvis)—this is most important for younger players where the body is still growing and adapting.

Which Muscles Are Involved?

The muscles themselves can be the main reason why shin splint pain starts, either because the bone movement puts stress where the muscles attach to the bone surface or because the muscles put stress on the bone as they pull on the bone's surface. The most common muscles involved [Figure 2] are:

► the soleus muscle(the deeper of the two main calf muscles and the one that does not cross the knee)

► the flexor digitorum longus muscle (one of the benders of the outer four toes and it also points the foot).

Training and Prevention

Since tight muscles may contribute to shin splints by pulling excessively or repetitively (more than normal) on the bone surface, it's always important to stretch.

Also, inefficient and weak muscles can shift unexpected stress onto the bones, which is why sport-specific training that involves strengthening and balance exercises can help.

And don't forget the bones! Training the bones themselves to accept the increased demands of play through progressive plyometrics and agility exercises may keep you in the game.

Cross-Training: It's Good For Your Whole Body

You can stay in shape while you recover from shin splints by cross- training, that is, training in different sports or exercises (usually by altering regimens). The goal is to focus on exercises that don't put excessive pounding stress either on the involved bones or on the specific muscles or soft tissues that are pulling on the bone surfaces. For example, pain-free strengthening exercises and aerobic exercises, which train the heart, like:

    ● swimming (no pushing off pool walls with your feet),

    ● deep water exercises (in water deep enough to exert a buoyancy effect, an upward force on the body that opposes or "decreases" the body's weight), and

    ● bicycling (no standing on your toes, use light resistance initially, and focus on pushing with your "quads" on the front of your thigh).

These are examples of what is called "relative rest", exercises that promote health and fitness in ways that do not create further irritation and allow the body to heal.

But cross-training is not only a good treatment tool (for shin splints). It's also a good prevention tool. In fact, many doctors believe that some of the injuries we get, particularly overuse injuries, actually occur because we focus all of our attention on playing one sport instead of participating in many sports or different exercise routines.* The variety offered by other sports or exercise/training programs teaches the muscles, joints, and other tissues of the body to react to all different types of stress, limiting the ability of these injuries to sneak up on you and your body. Of course, occasional rest periods help too.

* Dr. James Andrews, "STOP Sports Injuries: Keeping Kids in the Game for Life," 2011, <http://www.STOPSportsInjuries.org >, (accessed October 1, 2011).

Treating the Problem

Treating the problem may vary depending on the cause, but in general doctors often recommend:

   ■ Ice to decrease pain and control inflammation

   ■ Elevation and ankle pumping to control swelling

   ■ Compression with an elastic sleeve to control excessive swelling (though be careful here: if your pain increases, or symptoms of numbness or swelling below the wrapped area start to occur, remove the sleeve immediately)

   ■ Get a massage (or do some self-massage), not only to help relax tight muscles and connective tissues, but also to release swelling in the area

   ■ A prescribed or over-the-counter pain reliever or anti-inflammatory medication (always check with your doctor before taking any medications)

   ■ Wear the right boots (for your foot type, your type of walking or running stride, and the playing surface)

   ■ Proper arch supports (as appropriate)

   ■ Stretching of tight leg muscles

   ■ Gradual pain-free strengthening of your leg muscles (after recovery, strengthening the involved muscles will also help)

   ■ Balance exercises to reeducate muscles (later in recovery)

If It's Not Shin Splints…Then What?

As we have said, shin splints can be a warning sign or precursor for future damage. At the same time, your leg pain may not be from shin splints at all.It can be another diagnosis entirely. The two most common candidates are thought to be stress fractures and compartment syndromes.

◊  Stress fractures are breaks in the bone that occur from repetitive use. They are like the tiny cracks in a concrete path that happen after the concrete expands and contracts in hot and cold weather over time.In the body it comes from stresses on the bone above and beyond what the bone can tolerate—the bone starts to break down at a pace faster than it can be repaired or replaced...and then it fails. Stress fractures can progress to more complicated fractures if not properly treated.

◊  Compartment syndrome is another problem that can show up in the leg. Here swelling starts in the leg, perhaps due to an irritation of the muscle, the other soft tissues in the leg, and/or the surface of the bone. The problem with swelling in an area like the leg is that the leg is divided into compartments by a tissue called fascia, which attaches between the two bones of the leg or between a bone and the skin [Figure 3].

These fascia place the different muscles and specific nerves and blood vessels into compartments where swelling can become trapped. This build-up of fluid creates pressure in the compartment, resulting in pain.If the pressure is too great, it can cut off circulation and cause nerve damage, affecting, among other things, your ability to move your foot (or ankle) and to feel your foot (or leg). While Ultrasound and MRI tests may tell you that you have compartment swelling, compartment pressure is best evaluated by injecting a specialized needle attached to a pressure gauge into the area. If the pressure is determined to be too high, the doctor will likely recommend surgery to cut the fascia. This releases the swelling, taking the pressure off of the nerves and blood vessels.

Ohhh... And Let's Not Forget

Pain can also happen in the leg for several other reasons such as tumors and referred pain from the back or hip, so it's important to see your doctor for a proper diagnosis.

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