Article written by Seth Larsen
Is it possible to limp with both legs at once? I’m not talking about being so sore from a squat workout that your legs just won’t work properly, or doing so many walking lunges that each step makes your knees buckle. I’m referencing the kind of pain that means each step must be taken gingerly for fear of bearing any kind of weight. The walk that causes a wince with each stride, as if the mere act of doing something as menial as taking a step is a struggle. If you’ve ever suffered from shin splints, you have doubtless pondered this question while wishing you could just lie down all day in the hopes that your pain will subside long enough to take the few steps towards the medicine cabinet so that you can continue eating ibuprofen like Skittles. Sound familiar? If not, I envy you. Shin splints, regardless of how innocuous they may sound, can be one of the most painful overuse injuries you will ever experience as an athlete.
While waiting for my first patient to arrive earlier this week, I again saw what I like to call “the shin splint shuffle” firsthand. A young, healthy woman lightly stepped through the doors of the clinic and sat down. She immediately began rubbing her lower legs as if they were going to fall off, her face twisted in pain. While I interviewed her about her current problem, I asked if she was a runner. She said no. As she appeared very fit, I asked her if she had recently lost any weight, which she once again denied. She also could not describe any trauma to her legs that led to her pain. As she daintily pulled off her minimalist running shoes before the exam, she stated that she was a nurse, spending 10-12 hours per day on her feet in said shoes. I immediately had my diagnosis. This woman had developed severe medial tibial stress syndrome (MTSS), one of a few anterior lower leg injuries more commonly known as shin splints. This happened without her running more than a mile in her life!
It has become clear to me, and many researchers in sports medicine, that shin splints are not a problem reserved to the cardio bunnies we strength athletes like to scoff at on a daily basis. It is not the sole purview of the overweight, middle-aged men we see on the side of the road trying to run their way out of a mid-life crisis. Shin splints can affect any one of us, from bartenders to triathletes to strongmen and everything in between. As with any overuse injury, an ounce of prevention is worth a pound of cure. So if it hasn’t happened to you yet, it’s time to make sure that you don’t have to learn my least favorite dance move, the “shin splint shuffle.”
First, what are shin splints? This is an umbrella term coined to describe one of three anterior lower leg injuries: MTSS, tibial stress fractures (TSF), and anterior tibialis tendonitis. Without going into too much detail on their pathophysiology, I will describe all three here. MTSS is an inflammatory process that affects the medial aspect of the tibia, directly anterior to the muscle bellies of the calf. While the exact mechanism is poorly understood at this time, a person suffering from MTSS will generally experience pain along the entire length of the inside of the tibia. MRI studies have shown that edema (tissue swelling) of both the tibial periosteum (the membranous covering of the bone) and tibial bone marrow occurs in most cases of MTSS. While this swelling may not be palpable, it is the likely reason for the pain in this area. Tibial stress fractures are slightly easier to understand. Over time, force on the bone itself can cause both microscopically and radiographically visible cracks. This is more associated with point tenderness in specific areas that refers pain elsewhere with weight-bearing. Anterior tibialis tendonitis is inflammation of the tendon that attaches to the lateral aspect of the tibia. In severe cases, this can cause separation of the anterior tibialis from the tibia and sometimes tendon rupture. Pain in this case occurs on the outside of the shin closer to the knee, but often encompasses the entire length of the tibia as well.
Now that we have an idea of what shin splints are, I will discuss why this injury occurs in the first place. While it is true that running too many miles or being on one’s feet for too many hours are common inciting events for MTSS and its counterparts, they are not necessarily the cause of the injury. It all starts with the functional anatomy of the foot and lower extremity. I won’t belabor you with all the intrinsic muscles and bones of the foot and lower leg, as there are dozens, so we will stick to the basics. The major joints important to shin splints are the knee, hip, and ankle, while the major bones I’ll discuss are the tibia and the fibula, along with the many bones of the foot and ankle. Ensuring proper mobility of these joints and movement of the bones by the muscles that act upon them is paramount in the treatment and prevention of MTSS, TSF, and anterior tibialis tendonitis.
The important muscles here are the fibularis (previously known as peroneus) triad, the anterior and posterior tibialis muscles, the gastrocnemius, the soleus, the popliteus, and the long flexor and extensor muscles acting on the foot. Let’s break this down. First, the fibularis triad. The longus is the most lateral muscle of the lower leg, and functions in eversion of the foot and plantarflexion, along with support of the arch. The brevis is deep to the longus and extends and abducts the foot. The tertius is a small muscle that flips the foot at the ankle and weakly dorsiflexes. The anterior tibialis, while obviously being most integral to its tendonitis, lies directly lateral to the tibia and functions to dorsiflex and invert the foot. Its posterior counterpart is also a dorsiflexor, but mainly functions to stabilize the foot while walking or running. The popliteus is a small muscle behind the knee that assists in knee flexion, but more importantly for our purposes is involved in rotating the lower leg medially. The gastrocnemius is the “calf muscle” that we all normally think of when we are doing calf raises (but seriously, who actually does those?). Other than making Pastor B’s (and my own) legs look tiny, its major function is to powerfully plantar lex the foot and push the body forward during a stride. The soleus lies deep to this and assists it in plantarflexion, especially when the knee is flexed.
I know what’s going through your mind right now: “I’m tired of reading all this science-y bullshit. Can you just tell me how to fix it? Are you done firing a bunch of big words at me to make yourself feel smart?” The answer is yes to both, although I do feel pretty smart. But first let me explain why shin splints happen. The answer is pretty simple. Repetitive trauma to the lower leg without proper foot strike, most often due to muscular imbalance and other anatomic issues, is the number one culprit in the development of shin splints. Whether this is from running distance, walking all day at work, or grinding through sets of yoke walks with 800lb on your back, the mechanism remains essentially the same. When the foot strikes the ground improperly, undue stress is placed on the bones and joints of the lower leg. Not only can this result in knee, hip, and lower back issues, it has caused countless people to experience shin splints. Unfortunately, for a litany of reasons, we develop poor foot strike and gait patterns over time. Imbalance in lower leg musculature is the most common issue, which increases in severity if training continues without treatment due to the strike and the concept of reciprocal inhibition (which I explained here).
Overly tight gastrocnemius, fibularis, and tibialis muscles wreak all kinds of havoc, based on their actions that I detailed above. IT band tightness and increased hip external rotation, which unfortunately often occur together, are also major risk factors for shin splints, as is being female. Sorry ladies, the stats don’t lie. In any of these cases, when the foot hits the ground, it pulls on muscles and tendons in a way they aren’t necessarily intended to move, ultimately resulting in improper force distribution to the bones and muscles throughout the body’s kinetic chain. This is worsened by an increased load, which is why a greater body weight is another risk factor. What do you think happens when that weight hits the ground from the top of a box or with an extra 800lb added to it during a yoke walk? This is one of the many reasons why I am not a fan of jumping down from the box during a set of box squats. Unless it is for time in a competitive setting, step down to the ground or be prepared for pain.
Alright, now it’s time to really get into shin splint prevention. Since running is a major contributor, an easy answer is not to do it. I would in fact argue that unless running more than 100m is integral to your sport, avoid it altogether. Running sucks. It beats you up more than it helps you. Now for you CrossFolk, I know you have to run in some of your WODs. First, I’m sorry for you. That sounds awful. Second, you need to control your foot strike! With the advent of minimalist running shoes, people have bought into the dogma that less is more when it comes to running. This could not be further from the truth. Sure, if you have absolutely no foot pathology, no muscle imbalances, and no foot strike issues, go throw on some toe shoes and hit the pavement. The lack of cushioning notwithstanding, these shoes do absolutely nothing to control your foot strike. If I had a dollar for every shin splint patient I’ve seen walk into the clinic wearing minimalist shoes, I’d still be broke, but my student loans would have a much larger chunk out of them. Before my transition into strength sports, I was part of this crowd too. I wore my Nike Frees like they were the only shoe on the planet, and ran multiple triathlons and obstacle races in them. It just so happens that I developed shin splints, in addition to exacerbating my knee and back problems. Why do you think Vibram is paying out millions for their false claims about barefoot running? So if you are going to run, get a gait analysis. This can be done at most running stores, and they will be able to put you in a shoe that will properly control the motion of your foot strike.
As for those of us who avoid running like the plague, shoe choice is still important. When doing heavy farmer’s walks, yokes, or carries, go for a shoe that has actually less cushioning but still holds your foot firm. Cushioning in these exercises will cause too much movement at the ankle as it compresses down, and can result in lower leg pain due to the muscles and tendons being pulled in different directions. This will be a little more personal, and the right shoe for these events will likely be discovered through trial and error. Unless you can find a store that does yoke walk gait analysis, in which case let me know and I’ll fly there in a hurry.
In both cases, the previously mentioned muscles must also be addressed. Stretching, SMR, and a few basic strengthening exercises are the big weapons here. Never, I repeat, NEVER do any running or loaded movement events without properly warming up your legs. Stretch your calves from every angle you can find, turning your foot in different directions to hit all the intrinsic muscles of the lower leg. You should also stretch your anterior tibialis by placing your toe point on the ground and extending your hips until you feel a nice pull in your ankle and on the outside of your shin. Perform your regular hip mobility circuits to make sure they are rotating properly during your movements. Also make sure to work on your ankle mobility. One way to do this is to sit in a squat and rock your knees forward over each foot individually and hold. As far as total time for this, do what you feel is necessary to improve your mobility, as it will depend on where you are currently at. And for God’s sake, roll! Using a pipe, foam roller, ball, or your torture equipment of choice, roll out the soles of your feet, your anterior and posterior lower legs (including your Achilles tendons; fair warning, this hurts like hell), your quads, your IT bands, and the muscles of the hip girdle. Your shins will thank you.
As far as strengthening exercises, anterior tibialis weakness in comparison to the gastrocnemius helps to contribute to shin splints in a big way, especially in the case of anterior tibialis tendonitis. Because we use our calves in so many exercises, the posterior lower leg is often extremely over-developed in relation to the anterior. This, like any imbalance, is bad news. The fix for this is relatively simple: multidirectional toe raises. To perform these, first anchor a light band to something. Then lay on the ground and loop your foot through the band so that it is just proximal to the base of your toes. Pull your toes towards you, keeping smooth tension in the band throughout. No jerky motions or huge thick bands; you are not going to impress anyone with your toe raise prowess, and will probably wind up having your foot slip out and kick you in the face. If you are going to do it that way, please put it on YouTube so I can laugh at you. Do 15 reps per leg of each of the following: toes pointed in, toes pointed forwards, and toes pointed out. If you do this every day, steadily adding in more sets, you should be able to help reduce the imbalance.
So what if you already have shin splints? My condolences. They suck. No getting around that. There are some solid and essentially free treatments for them, though. First and foremost, rest. Multiple studies and my own clinical experience has indicated that the best way to calm these things down is to stop doing what caused them in the first place. Since I know that nobody wants to take time off, there are other options. In addition to all the preventative measures above (especially getting the right damn shoes!), you can adjust your training to save your shins. CrossFolk, sub out multiple sprints for your longer distance runs to keep your cardio up. You can also replace distance runs with hiking to get a similar muscular and cardivoascular stimulus without the impact. Biking and swimming are also excellent low-impact ways to keep your conditioning while avoiding distance running. For strongmen, lower the weight on your yoke walks and carries. Train them for speed, distance, and proper movement patterns instead. This is why many high level strongmen train heavy yoke walks very sparingly. There is no reason to trash yourself under a heavy implement day in and day out if you do not have a specific competition in mind. Another treatment method is an ice massage. Take a dixie cup, fill it with water, and freeze it. When it is frozen, massage the affected areas with it until it melts to the point that you can no longer do so. This will help to alleviate the pain and reduce inflammation, so do it after every training session and while relaxing on rest days. Epsom salt baths are another great option, and you can actually do some of your stretches in the bath. What runners call “the death stick” can help as well, and also falls into the category of SMR for prevention. It looks similar to a rolling pin, and can be used to roll out the lower legs very effectively, even if it is extremely painful.
Now that you’ve read this, you can probably agree that it’s time to make some changes. So go throw your toe shoes in the trash, grab a roller and some bands, and get to work. Let’s leave the shin splints to those chicken-legged, multiple-trips-for-the-groceries, ET-looking people who think running 26.2 miles is a good way to spend a Sunday.
Seth Larsen has a Bachelor’s of Science in Biology and Neuroscience and is a Doctor of Osteopathic Medicine candidate for 2015 at Midwestern University. He is a former NASM-CPT and student athletic trainer. He currently serves as a reserve officer in the US Navy Medical Corps while he finishes medical school with a specialization in primary care sports medicine. Seth is a former NCAA football player who now competes as a LW (105kg) strongman, Highland Games athlete, and raw powerlifter.
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8. Image sourced from: http://www.doereport.com/generateexhibit.php?A=&ExhibitKeywordsRaw=&ID=690&TL=