Medial Tibial Stress Syndrome (MTSS) or “shin splints” is one of the most commonly reported lower limb injuries by competitive and recreational athletes. Recent research has shown that shin splints affects approximately 20% of the running population, with the majority of sufferer’s partaking in long distance training/competition.
What causes the pain?
Currently, there is two widely accepted theories on the cause of shin splints:
The bony bending/bowing theory
The traction theory
The bony bending theory suggests that during running, the Tibia (shin bone) bends due to the stress placed upon it. This bending causes small amounts of strain in the bone that enables it to adapt and get stronger (a good thing!!). When this strain exceeds the adaption process the shin bone becomes overloaded (a bad thing!), subsequently leading to injury and pain.
The traction theory states that shins splints is caused by the continual contraction of the muscles (Soleus, Flexor Digitorum Longus & Tibialis Posterior) that attach to the inner border of the shin. As these muscles contract during running, they place a traction stress on the shin bone, which results in inflammation at their attachment onto the bone, causing pain.
Am I at risk?
Current research has identified several risk factors leading to an increased likelihood of developing shin splints. These include:
A previous history of shin splints
Prior orthotic use
High Body Mass Index (BMI)
Female gender
Decreased running experience
Decreased running cadence (step rate)
Excessive pronation
Over striding
Crossover running style
Increased vertical oscillation (ground clearance)
Forefoot running
How do I know if I have shin splints?
To diagnose shin splints accurately, two symptoms must be present:
Exercise induced pain along the distal 2/3 of the medial Tibial border
Recognisable pain produced by pressing the medial Tibial border, which spans a distance of 5cm or more.
If you are experiencing symptoms not typical of shin splints such as cramping, pain spanning less than 5cm, burning pain, numbness or pins and needles, you should seek a thorough assessment by a physiotherapist to properly diagnose and treat your condition.
Treatment – Technique Technique Technique!!!
Arguably one of the biggest contributors to the development of shin splints in a runner is their running technique, particularly their lower limb mechanics. One of the quickest ways to reduce shin splints related pain is to address the technical aspects of running that can contribute to increased stress across the Tibia and associated musculature. What you should focus on is:
Cadence – Normal cadence should be between 165-185steps/min. Decreased Cadence causes increased ground contact time resulting in prolonged pronation and excessive tibial torsion stress.
Over striding – Excessive stride length results in poor tibia positioning upon heel strike, increasing Soleal traction and reducing force absorption ability.
Cross Over Gait– Landing across the midline of the body causes excessive tibial torsion and pronation, reducing proper force attenuation.
Vertical Oscillation– Increased vertical oscillation during running increases Tibial impact forces and often results in a loud foot strike.
How do I improve my technique?
Increase your cadence!! – This is by far the biggest bang for your buck. Increasing your cadence by approximately 10%:
Reduces lower limb impact forces by 20%
Reduces vertical oscillation
Reduces ground contact time
Reduces stride length
The best way to achieve an increase in your cadence is by using GPS watches, phone applications or by simply running on a treadmill.
Eliminate a crossover running style – On a track, run straddling a line across 2 lanes or alternatively, try and maintain a space between your knees with every stride.
How to beat shin splints using strength
Strength exercises for shin splints should aim to improve the localised muscular capacity of the calf complex as well as the bone load capacity of the Tibia. This is best addressed with weight bearing functional exercises that mimic running postures.
One of the most important and often forgotten muscles of the calf complex is the Soleus. The soleus muscle is vital for absorbing excessive loads placed on the Tibia during running by minimising excessive pronation as well as resisting the bending forces experienced by the Tibia due to ground impact.
The best Soleus exercise that runners can do is the Bent Knee calf raise (pictured above). To perform the exercise correctly:
Bend your knee as far forward as possible, keeping your foot flat on the floor
Keeping your knee bent, raise yourself up onto your toes
Lower your heel back to the ground
Perform 3 sets of 15 repetitions in a slow and controlled manner.
As always, if you are having problems, please do not hesitate to contact one of our experienced physiotherapists.
Patellofemoral Pain Syndrome (PFPS) or “Runners Knee” is one of the most common overuse injuries amongst the active population. PFPS accounts for approximately 15% of all knee pain, with females and young adults being 2 times more likely to develop symptoms due to PFPS (Boling et al, 2010).
What is the Patello-Femoral Joint?
The Patello-femoral joint is one of two joints that make up the knee (see figure 1). It is comprised of the kneecap (patella) and the thigh bone (femur) and provides the attachment sites for our quadriceps and patella tendons.
How do I know if I have PFPS?
PFPS is characterised as “pain experienced around or behind the knee cap, which is aggravated by weight bearing activities that require a flexed knee such as squatting, running, jumping and hopping” (Crossley et al, 2016). It is not uncommon to also experience symptoms such as:
Creaking/grinding sensations around the knee cap
Swelling around the knee
Pain provoked by pressing the knee cap
Pain bought on by non-weight bearing activities such as sitting
Figure 1. Patello-Femoral Joint
How did I get PFPS?
Runners often develop PFPS due to a combination of several factors such as:
Muscular weakness (Quadriceps/Glutes)
Muscular tightness
Changes to training loads
Inappropriate footwear
Anatomical variations in knee cap shape/position
Changes to running style
Biomechanical abnormalities
What can I do to recover?
Currently, the best treatment supported by research is STRENGTH!!!
Strength interventions have been shown to be most effective in relieving pain and improving function in individuals with PFPS. Exercise selection should be patient specific and target the hip external rotators/hip abductors (Glut Medius) as well as the knee extensor muscles (Quadriceps) due to their roles in knee biomechanics (Martin et al, 2018).
The great news is approximately 90% of individuals suffering from PFPS will be completely symptom free within 6 weeks of starting a strength rehabilitation program guided by a physiotherapist.
What won’t work long term?
Amongst the literature there is a lack of strong evidence, supporting the long-term use of:
Although the majority of these things can help your pain in the short term, none have been shown to be superior to strength exercises of the quadriceps and gluteal musculature.
It hurts to run….what can I do?
Research on running mechanics has shown that stress on the Patello-femoral joint is greatest during mid stance and exceeds approximately 7x your body weight. This can be largely increased with
Slower speeds of running (Increase knee flexion)
Large vertical oscillation
Cross over style running
Excessive body twisting
Excessive body twisting
Ways in which you can alter your running technique to reduce knee joint stress by 15-20% are:
Maintain space between your knees when running (knee window)
Increase running cadence by 10%
Minimise excessive body twisting
How can I prevent getting sore knees?
Currently the best evidence for preventing future patella issues besides maintaining your strength is by assessing and monitoring acute: chronic training volumes in term of distance covered (Km). Acute increases in training volume should be no greater than a factor of 1.5 or you place yourself at an increased risk of suffering a subsequent injury.
We have covered this in depth in our blog titled Our Top 3 injury prevention strategies, which can be accessed by the link below:
Lower back pain is one of the most common musculoskeletal injuries or complaints with approximately 85% of people experiencing back pain at some point in their lives.
Disc bulges are also just as common, but not everyone experiences pain from a disc bulge. In fact up to 50% of people with disc bulges are asymptomatic (i.e. don’t get any symptoms). READ MORE ABOUT THIS IN OUR EARLIER ARTICLE HERE.
Lumbar Spine Anatomy
The lumbar spine consists of 5 lumbar vertebra and 5 corresponding nerve roots. The lumbar nerve roots exit the vertebra through spaces called foramen.
What happens when you do get symptoms from a disc bulge?
This is what is known in the medical world as "radiculopathy".
Radiculopathy is a pathological process where the nerve exiting the vertebra or the spine is being compressed. It can manifest in various signs including pins and needles, numbness, tingling, burning, nerve pain and weakness.
This can be due to changes in bony anatomy, degenerative changes or the dreaded bulging disc, which causes narrowing of the little gap where the nerve exits.
This little gap is called the nerve foramen and narrowing of the foramen is referred to as foraminal stenosis or nerve root impingement on MRI reports.
What exercises can i do if I have a Disc Bulge?
The short answer is lots!
There have been 2 fantastic studies done over the last 7 years which have proved that 2 activities that were thought to be bad for disc bulges are actually good!
Bending (lumbar flexion)
Running
1) Lumbar Flexion: Can I bend or should I keep my back straight?
In 2013, Singh and colleagues conducted Kinetic (dynamic) MRI’s on patients with disc bulges to assess for disc displacement as well as foraminal size which showed that lumbar flexion does not cause displacement of the discs, but actually increases the size of the foramen, which means more room for the nerve!
The take home messages from this study were:
A) Flexion (bending) showed a significant increase in foramen size on dynamic MRIs indicating an increase in size available for the exiting nerve root.
B) The amount of posterior disc bulge was significantly correlated with posterior movement into the foramen with extension not flexion. This indicates that there is greater compression of the nerve and increased posterior disc bulge when you move into extension (arch backwards) not flexion.
2) Running
Yes! You can do that too! A study published in 2017 by Belavy et al found those that ran 30-50kms/week actually had healthier, stronger, juicier lumbar discs compared to their less active counterparts.
What do I do if I have a bulging disc?
That’s Easy….Walk, run and DO NOT AVOID bending! The great news is that disc bulges do heal with time, with even the serious ones healing within 12 months.
There are lots of other options for disc bulge exercises, so if you’re not up to running or if you are have having trouble then please do not hesitate to get in touch with us at clinicalphysiostives.com.au
References
Singh V et al, Factors affecting dynamic foraminal stenosis in the lumbar spine, Spine J. (2013)
Belavý, D. L. et al. Running exercise strengthens the intervertebral disc. Sci. Rep. 7, 45975; doi: 10.1038/srep45975 (2017)
