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.