Shin Splints? Quit Pulling My Leg!

Stay the CourseIf you’ve run far and long enough, you’ve had ‘em: shin splints – that pain around the shin bone (or tibia). Shin splints involve irritation of either of the two “tibialis” muscles: anterior – on the front and outside of the shin, or posterior, on the inside of the shin. The tibialis anterior serves to dorsiflexion (“flex up”) the foot, along with inverting (“tilting out”), while the tibialis posterior is a plantarflexor (“flex down”) while also inverting. Both muscles play an important role in stabilizing the foot while we run, yet for the ultrarunner, the anterior muscle tends to be more problematic. Why?

The Causes of Shins Splints

Abnormal forces on normal tissue
The tibialis anterior (or “TA”) is typically more commonly injured in ultrarunners because the abnormal forces of a long, hilly run can overload the muscle/tendon unit. The TA must work to “lift” our feet up the hill, and it works to slow down our foot as we fly downhill. A particularly hilly run or race can result in abnormal forces, causing tissue strain and injury.

Inefficient running mechanics also result in abnormal forces. Heel- or lateral foot striking can overwork the TA – which has to “slow down” the foot as it strikes the ground. Also, landing too far in front of your body – or “braking” – can overwork the TA. More on those later.

Normal forces on abnormal tissue
Sometimes anterior shin pain can come around near the end of the season, even as your workload is decreasing. Why? One factor is the mobility of the foot and ankle. The TA passes over the ankle and attaches into the midfoot. Severe stiffness of those joints from with heavy training can cause the TA to over-strain. The TA is an ankle flexor, but if the joint is too stiff to flex, the muscle is, in effect, pulling against a brick wall!

So what can we do about it when anterior shin pain strikes?

Initial Treatment of Shin Splints

Inflammation and Pain Control
Rest from running until you can walk around freely without significant pain or the urge to limp. Cross-training is OK; elliptical or free-pedal cycling are safe options. But avoid cycling with a “clip-in” foot that stresses the TA. Also be careful of pool running, where kicking water can stress the TA.

Ice liberally, passively (with a bag or water bucket) or actively, using an ice cup lengthwise along both muscle and tendon. Twenty-minute sessions, several times a day, is optimal. Ice after cross-training, soft tissue work or stretching.

Compression plays an important role in TA rehab. The TA lives in an anterior compartment – a fascial tube containing multiple muscles in a confined space. Inflammation and swelling have no place to go in a tight compartment – if it builds up, this can cause greater pain and slow healing. A compression sock or sleeve is helpful at clearing out swelling. Wear during times of activity (walking, standing, cross-training, and return to running), but allow periods of “off time”, namely when you are icing.

Soft tissue massage can speed recovery. Wait a week after the initial injury, then spend 4-8 minutes a day working this tissue: both muscle and tendon, apply a cross-friction force (sideways across the tissue). Mild soreness is OK. Follow with light stretching and ice. Perform only once, daily!

Recovering from Shin Splints

Now that healing is occurring, how do we correct and prevent the problem?

Mechanical: Stretch-stretch-stretch…the other direction!

Conventional wisdom says that you stretch the hurt muscle. However, a strained muscle is an over-stretched muscle! You can stretch the TA, but gently! A simple quad stretch (heel to butt) will do. Amore aggressive stretch would be to kneel and gently sit on your heels, stretching your ankle with toes straight. Do this with caution, as over-stretching will slow recovery.

A vitally – and frequently overlooked – factor in TA injury and rehab is the mobility of the ankle joint, namely its ability to dorsiflex (toes up). If the joint is stiff and cannot flex, the TA will be overworked! Make the TA’s job easier by keeping the ankle joint as flexible as possible. Stretch your calf, so that your ankle can easily and fully flex upward, taking as much strain and effort away from the ailing TA as you can.

Keep the mid-foot moving, too! The TA attaches to the bones of your foot arch. Keep it mobile by doing simple ankle circles, or by rolling the underside of your foot with a golf ball, or simply grasping your foot with both hands and wiggling the bones back and forth.

Neuromuscular: Strengthen the TA!

There are a few key things you can do to rehabilitate the muscle. Most easily: flex up and down your ankle. Painful or difficult to flex up? Be sure it’s flexible, first. After stretching your calf liberally, perform simple ankle pumps. Mild soreness here is OK, so long as it dissipates quickly after the exercise session.

The next step is walking drills: walk on your heels, toes up, alternating lengths with toes in versus toes out. Expect some pain and soreness with these, as well.

If you can tolerate those first two exercises, then try some “Tug of War”: Eccentric strengthening is muscle activation as it lengthens (as opposed to concentric, where the muscle does work while shortening). Start with your ankle flexed up as high as it can go. If you have a helper, have them grasp the top of your foot and apply a downward pull. Resist, but “let them win”: slowly pointing your foot downward, over the course of three to five seconds. Once fully extended, release all resistance and freely flex up. Repeat, upward of ten to twenty times. No helper? Use your other foot to apply the resistance.

Motor Control: Strike whole foot! Quit braking & “be forward!”

Mechanical flaws can play a huge role in TA pain. Heel striking is the biggest culprit: if you land heel-first, the TA must stop the foot as it slaps down.

Also common is lateral foot striking (i.e., striking on the outside edge of the foot). Excessive lateral striking creates the same forceful slap, but in an inward direction. Since the TA also works to invert (or flex outward), lateral striking overstresses it.

Run whole foot – land only slightly on the outside, then adequately engaging the ball of the foot. Not sure how? Try some barefoot running. Find a grass or turf field, lose the shoes, and run. The ball of the foot should be the primary weightbearer – not the heel or lateral foot. Incorporate short bouts of barefoot running at the beginning of runs to get the feel of landing “whole foot,” then slip on your shoes and carryover that same “feel” to the rest of your run!

What about “braking?” Maximal efficiency occurs when your foot is precisely beneath you as your body passes over it. If your foot lands (and stays) out front, your body must absorb impact forces, then regenerate new force to “pass over” your foot. Bad news!

It’s bad news for the TA and the ankle joints, too! Braking typically involves heel striking. But braking will also stiffen the ankle, making the TA’s job more difficult. Moreover, if you’re braking, the TA has to work hard to pull your foot forward.

A lot to think about? Make it simple. “Be forward.” Lean slightly forward at the ankles to ensure you’re getting your body over your foot with every stride. This can be practiced in a mirror – be straight up-and-down, bending forward only at the ankle. You should look like a ski jumper in mid-air (only not as extreme)!

Back to Running: tricks to get you going.

A strained TA will hurt. Period. A healed TA will also hurt, as it is comprised with irregular scar tissues that require remodeling. How do you remodel? Stretching, soft tissue work, strengthening and – running!

All of the above will be sore and painful. Recognize this as “normal;” however, still respect the symptoms. Your goal should be to have pain dissipate as soon as possible after activity, and gradually decrease day to day: is your shin less painful this morning than yesterday?

Don’t blast through pain; however, don’t avoid it entirely either. No pain = no remodeling = vastly longer healing time. Just like a runner getting fit, TA integrity increases with gradual build-up of load.

So how do we do it? Here are some tips:

  • Stick to the flats. Elevation stresses the TA in both directions. Stay flat, and only introduce elevation in measured doses.
  • Go light! A shoe is a resistance workout for the TA. One way to make its job easier is to lighten the load. With caution, try a lightweight trainer or flat, reducing the stress with each stride.
  • Try barefoot running! This is the ultimate lightweight running. Short bouts of barefoot running (3-5 minutes at the beginning of a run) will do two things: (1) reduce load on the TA, and (2) help you to work on efficient, “whole foot” running mechanics that will also reduce TA stress!
  • RELAX! When you return to running, be sure your lower leg is absolutely relaxed. Pain makes us favor and protect. In the lower leg, that often means restricting motion, keeping the ankle “tight.” This tightness overworks the TA! Keep it loose! Let it “flop!”

Professional experience and anecdotal feedback from runners says that a typical TA strain will take 2-4 weeks to heal. If it is taking longer for you, consider:

  • Does your ankle and foot have full range of motion (at least equal to the other side)?
  • Are you running efficiently (landing “whole foot”, avoiding heel striking, landing beneath you)? Have someone film you with a camera or cell phone!
  • Are you keeping your foot relaxed and properly progressing your running?

Tib anterior tendonitis is a pesky injury, but if you work these concepts, you’ll get better. Just as important, you’ll stay better and avoid this issue later down the trail!

Call for Comments (from Bryon)

Have you battled shin splints? Share your story.

[The contents of this column as well as the author’s comments are provided for general informational purposes only and are not intended as a substitute for professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition.]

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 42 comments

  1. Andrew

    Thanks – this is great. Just had a flare up so it's cool to have exercises to do and stretches etc.

    Just got to get through a 40km mountain race with 1800m (5400ft) of vert ascent and then the same descent this weekend first…haha could be sore.

  2. Trail Clown

    This might be a strange question, but does the accumulation of many other injuries but total life-long absence of this injury indicate bad (i.e. compensatory) mechanics? I've had seemingly everything else (IT, PF, Knee, etc.) but never shin splints. I know it seems like I'm patting myself on the back, but it's a serious question. Would it be "better" to have shin splints than the other injuries? In other words, would that mean I'm progressing as a runner–working my way up to "better" injuries on the way to no injuries at all?

    1. OOJ

      Mr Clown-

      There's no way that the absence of an injury could indicate *bad* mechanics. In fact, the absence of all injuries wouldn't equal *good* mechanics, either!

      Injuries happen (read: "abnormal forces on normal tissue"); when injuries recur over and over, that's when you have to question what you may be doing, mechanically, to perpetuate the issue

  3. Bartman

    Nice article; it's all there.

    One little tip I picked up recently from the Inov-8 pamphlet "Making the Transition to Natural Running" was found under FAQ's, "If you can see your feet in your perpheral vision, you are doing something wrong!"

  4. Andy

    Great and thorough article. I also have been lucky enough to not have shin splints (yet), but battled PF for over a year. At the risk of sounding like a minimalist zealot, I agree with the lighter/barefoot approach to improving foot-strike and overall mechanics to reduce injury. It worked for the PF. Just ran an uber-technical 50m on Saturday in 110s and have no pain or injury. Seems that developing foot and ankle strength (and overall flexibility) serves as the best protector.

  5. James @reddirtrunner

    Timely article for me. However, my issue is with the posterior side of things. Coming off a sfx (base 5th metatarsal) and was up to 4 mile runs. I had been doing walking and cycling in the weeks prior to running again. In my infinite lack of wisdom I thought since I was only running 2, then 3 then 4 miles I would just run them fast. How hard could that be, right? I haven't experienced this pain since HS soccer. I've done the icing, the compression sleeve and rest (taking a few days off now).

    Is there anything different, treatment and/or prevention wise, for the TP compared to the TA?

    1. OOJ

      James-

      Your 5th MET fracture provides a clue about your run mechanics: excessive lateral striking. That causes compression stress on the outside of the foot, and the pronation/"slapping" force to the inside of the foot, where the posterior tib is anchored, thus over-stretching.

      Try a *small* amount of barefoot running, where you focus on landing on the ball of your foot. Then slip on the shoes and apply those same "whole foot" mechanics to your regular run. Just be sure you're progressing running gradually…

    2. Will T.

      James,

      I had the same experience. A Jones fracture on my 5th metatarsal, followed by the Posterior/Medial shin split on the same leg (albeit 2 years apart). What OOJ says is probably the correct advice, but I'll tell you my thoughts and how I recovered.

      I actually blame both of my injuries on being stupid in shoes more minimal than I normally wear and trying to incorporate barefoot running or minimalist running into shin split recovery just prolonged the issue.

      Instead I got back in my normal 10mm drop shoes and logged slow, flat miles on small loops close to my car/home and as soon as I felt a twinge, I would stop and potentially take a day or two off or go shorter distances until I could hit that distance without pain. I made sure NOT to do any stretching and avoided walking barefoot around the house. After a few weeks I was able to go as long and slow as I wanted on the flats, so I slowly incorporated hills back into my runs, making sure to take it super easy on the ups. I was able to make a full recovery 4 weeks out from WS100 last year and was able to successfully finish on race day.

      Good Luck!

      1. OOJ

        Will-

        Great feedback – *excellent* insight on how to progress and build up "tissue tolerance" — in other words, doing the right thing, then gradually/progressively adding load!

        And congrats on your WS finish!

        Bear in mind: my advice for "minimalist" running is *small* portions: in the form of 3-5 minutes at the beginning of runs. This would account for <1% of all running for most folks…

        1. Will T.

          Agreed! I could have avoided both of these injuries if I would have been "smart" & "patient" in my minimalist running to begin with. And now that I'm healed, I find adding "small" portions of minimalism to my regular training are helping me to develop better form to avoid getting these injuries going forward.

      2. Trail Clown

        You overdid the minimalism, and so to control the pain symptoms you went back to regular shoes. The regular shoes provided symptomatic relief, but you will not strengthen your feet/ankles in regular shoes. Not saying you should go back to minimalism yet, but ultimately the only way to completely address the underlying weaknesses that led to injury are to strengthen the foot through more natural running. Now you could run/race for the rest of your life without incident in regular shoes, but the point is you masked the symptoms with a built up shoe. Which is fine, if you are fine with it. Now off the minimalist soap box…

  6. Randy

    Good timing Joe,have what i believe is that posterior tibia problem,more toward the side above the bone on the outside of the ankle.will try the different approaches you mention(well,maybe not all,running on flats,Ugg).Curious if you think shoes can be a factor,been trying these newer(what i call old racing flats)in training,worked good,but used a thicker,heavier shoe for a rocky,hilly race,injury soon after.Could the more stiffer,more robust shoe have tilted my foot(inverting as you call it)out more,causing strain?Also trying a KT pro tape,they even have a short video on how to wrap ankle on website,seems to really help.

    1. OOJ

      Randy-

      I DO think shoes play a role — they let us get away with excessive heel/lateral foot striking. I have a significant lateral foot strike issue, but when I do (occasional) runs in light shoes, I get immediate feedback (=pain!) if I'm too lateral.

      Stiff/big shoes play an important role; just be sure you're "normal" in and out of them!

      1. Randy

        Thanks Joe,was blaming the shoes,but sounds more like i was letting the stiffer shoe dictate my foot strike,instead of staying focused on how my foot hit the ground,guess i'll take them back from the dog and give them another try.

  7. Gabe

    I had chronic shin splints for about 6 years. I used to be a very heavy heal striker… I slowly changed to a forefoot/midfoot strike and my shin splint pains have gone away, seemingly forever.

  8. Martin

    Massage, light shoes or even barefoot running very much contradicts my experience with posterior tibialis injury. Reminds me of how one boneheaded ultrarunner has been treating his PT for more than a year.

    I can not see any way compression might be helpful, but whatever.

    1. Jeremy

      What is the answer then, sir? Mine comes and goes, but I can't figure out why. I definitely land laterally and due to a very high, rigid arch, do not pronate enough. This is easily seen in my shoe wear pattern.

      How does one calm down a hot and angry PT? I need peak mountain miles NOW and each one seems to dig a deeper PT hole.

    2. OOJ

      Unfortunately, posterior tib pain is a little more complicated, because it's also a plantar flexor, and plays, in my opinion, a larger role in foot stabilization than the anterior tib.

      The posterior tib is also scapegoated for another issue, called "Medial Tibial Stress Syndrome" — which has more to do with issues like foot stabilization and overall running stress (e.g. braking forces, ground reaction forces/vertical excursion). In that case, minimalist approaches might not be helpful.

      If these issues were easy and straightforward, I wouldn't have a job! :)

      1. Jeremy

        Yep, you got it. Downhill/braking forces are what triggers the pain- sounds like MTSS. I do not wear low-drop shoes usually but I mix it up with some Kinvara type shoes occasionally. I roll and massage it, but that generally does not fix it. When the trails melt out and my mountain mileage picks up, it just goes away…last 3 years same story. I did find that "dry needling" is an amazing treatment. I will be able to get some one week before my next race and I am betting the house it will allow me to perform. The needles slip into bad adhesions in the rear compartment behind the tibia and twitch for a second…then disappear. Massaging and stretching just doesn't seem to get in there far enough.

        I waiver between feeling like I should strengthen the area (heel walking, theraband, yoga balancing, eccentric calf lowers, etc), or should I make it more flexible with stretching (any in particular for this?) and massage, or should I leave it alone to let the inflamed tissues rest?

        Just over one month until 100 miles in the hills. Getting the miles now but missing the quality because the pain. Any tips?

          1. OOJ

            Jeremy-

            This combination of info you provide tells me you might have a *braking problem* — landing in front of your body (regardless of where on your foot).

            MTSS or post tib soreness can be the result of the body having to absorb braking forces. The "lower hamstring" radiation is also a sign of this — possibly a sacroiliac referral (but impossible to say without examination).

            The tough part about all this is, *not* braking while pummeling downhill is very difficult. One thing you may try is to quicken your turnover and work on getting your foot closer beneath you — both on flats, and for sure on the downs!

            What 100 are you running?

  9. tomdog

    Great timing as I am just trying to figure out what is happening to my ankle. I did a 50m race in March, and then did another 50m run 3 weeks later (I am very new to ultra-running), and my ankle/shin started hurting. I have been off of running for about 2.5 weeks and just been biking and then icing it daily. It has just started improving, so I will ease back into running here soon.

    1. Joe Uhan

      Tomdog-

      Sorry to hear of your injury!

      Of all comments, I'm surprised no one has posted anything about dorsiflexion/CALF stretching. You never, ever hear about this as a vital treatment approach, but again: if the ankle can't dorsiflex, the tib anterior pulls-and-pulls-and-pulls on an immovable object!

      Be sure your ankle is fully flexible – a great place to start. Self-assessing can be difficult, but you should be able to lean forward, with foot flat, and make >45 degree angle (leg to ground) for adequate "runner" mobility in the ankle!

  10. Paige

    I came down with a nasty episode of this last year after a fast road marathon. Stretching my calves throughout the day made a huge difference in my recovery, as did sticking to flat running on grass. Running on pavement for the first couple weeks after it flared up was no good, but running on soft grass was awesome. Went away after a couple weeks and now I just keep up on my ankle flexibility and calf stretches. Great article OOJ!

  11. BK

    Nice article

    Good point to keep the foot and ankle mobile so that the TA isn´t working against abnormal forces. When stretching the calf, moreover, people should remember to stretch the soleus, not just gastrocnemius. Massage and/or foam rolling the calf is also a good idea. I´m actually working on an article on these different stretches and how to treat a calf that is soar after running. It will be published in the next few days.

  12. Rydman

    Joe, good stuff, as usual.

    In 15+yrs of running, I've oddly never developed shin splints (very mild soreness a few times after a bunch of k2 repeats a year ago). Maybe I can throw out what I think has helped me (and it includes much of what you've already shared).

    – I'm a twig :) (5'10" 140lbs). Less body weight = less "pounding" on the body

    – mid-foot/forefoot strike = no excessive overloading of the knees + shin

    – high running cadence/quick leg turnover = the 2 above pretty much explain it.

    – core strengthening = keeps the body aligned and bio-mechanics intact! (I'm terrible at doing this as much as I should).

    – efficient mechanics. 11+yrs of consistent work on this and it's been (and Joe you would agree and have helped me too!) the single-most definitive reason for staying healthy, I think.

    – avoiding overloading the body with mileage it's either not ready for, or can't sustain (HUGE factor!)

    They all tie in together, but this is what has helped me.

  13. Craig

    When/how does a bone scan play a part in recovery? I've been dealing with posterior shin splints / MTSS for the better part of a year. 6 weeks off of running followed by a very slow ramp up didn't help, but the pain is always general, never acute like I assume a stress fracture would be. X-ray was negative, but would a MRI give me any more specific information about how much time to take off?

    1. OOJ

      MRIs are generally not good at examining bony structures (they're excellent for soft tissues). Bony pathology (e.g. fractures) would show up in a plain film x-ray at six weeks — as even a complete fracture (when rested) will heal 100% in six weeks and the new bone would shine brightly!

      Reading your account, the biomechanist/PT in me thinks, *how* are you running? Anyone who's rested completely (beyond healing parameters for bone), then begins running with the same pain onset tells me that there is a mechanics flaw…in essence, "slamming the thumb in the door", all over again.

      My best advice is to consult w/your MD, but also ask him for a good PT or someone else skilled in gait analysis. Good luck!

  14. OOJ

    Mr Rydman has great mechanics and is extremely light on his feet, with a neutral (in all planes) foot strike. His *only flaw* comes when he's fatigued, and his trunk goes backward (slightly) — that braking could cause a tib issue, but as it's a rare occurrence (and improving this spring?), I think that could account for his streak of good health! :)

  15. Kix

    Perfect timing for this article – thanks. Just did training run Sunday for an upcoming race. I probably pushed my pace and was "braking" on the downhills more than usual. Also, it was a three hour drive to and from the run. I did not notice a problem until Monday when I exited a vehicle and fell on my face. Shin splints/ calves seized up and much pain. I have been running for many years and have not had this happen since I was new! Very humbling. I hope to use some of the tips provided to recover in time to complete my first 50 miler. Thanks.

    Happy Trails!

  16. Daniel

    Joe, this is a fantastic article. I have been struggling with anterior shin pain for just over a year now and have yet to have any doctor or website explain the issues and how to treat them as clearly as your article. I am looking forward to putting your advice into practice and getting back to being pain free (just sore from lots of running!). Thanks.

  17. James @reddirtrunner

    Thanks Joe & Will for the feedback. I have backed off of running for almost 2 weeks and have been cycling like a fool instead. Stretching, rolling, and icing too. I saw the local ART doc for a couple of treatments that really seemed to help as well. My calf was super tight with a couple of nice knots in it. Much improved now, I'd say it is about 90% normal. A few more days and I'll give it a go again. Slowly this time. And for walking around the house I picked up a pair of Sole sandals on clearance from Left Lane Sports. Thanks again, much appreciated.

    Cheers!

  18. Jim Devine

    Truly fantastic article here. I've found that my shin splints flare up mostly after long layoffs (long for me being a week or two without running). I'm wondering if there are any exercises that you would recommend between runs that may help to reduce the flare ups. Thanks again for the great write up.

    1. OOJ

      Jim-

      Thanks for the comment. Here are a couple general things you could do.

      Specific to the tib anterior/front shin muscle: http://www.youtube.com/watch?v=VoC5g4P1RAM

      This is isolated strengthening of the muscle that'll "toughen it up". Go SLOW, especially on the "return" (toe-point)

      Running mechanics: http://runningwellct.wordpress.com/drills-videos/ (Video Drill 1)

      Again, shin splints usually arise from being "too sloppy" with your foot strike. Being "more compact" with your hips (pull straight up, push straight down) reduces the stress upon landing = less shin stress!

      Good luck!

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