Shin Splints, Medial Tibial Stress Syndrome, And Stress Fractures: What’s The Difference?
Shin pain is a common problem for runners. It can range from mild to severe, and managing it well in the early stages is important to prevent it becoming a more serious issue that really disrupts your running or may need more intensive management.
There are several different conditions that cause shin pain in runners. “Shin Splints” is a generic term that refers to pain felt anywhere along the shins. This includes many soft tissue and bony structures, so it’s not really very helpful from a diagnosis point of view.
Medial Tibial Stress Syndrome – The Most Common Cause Of Shin Pain In Runners
Medial tibial stress syndrome (MTSS) refers to pain along the lower two-thirds of the inside edge of the shinbone. Medial means towards the inside, and the shin bone is called the tibia, hence the name Medial Tibial Stress Syndrome.
MTSS is an inflammation of the muscles, tendons, and bone tissue around the shin bone. It is caused by an overloading these tissues, often by increasing your running volume or intensity too quickly (see below). It is the most common cause of shin pain in middle-long distance runners. It is also common in other sports that involve a lot of running like soccer, football, netball and hockey.
In the early stages of the condition MTSS usually gets worse when you run and improves relatively quickly once you stop. However, if not managed well in the early stages, it will often get worse to the point where it limits or stops you running and takes much longer to settle after you stop. A primary goal of managing MTSS is early intervention to prevent the bone from becoming more involved, because this may lead to a stress reaction or a stress fracture.
Bone Stress Reaction Of The Tibia (Shin Bone)
A bone stress reaction is where an area of the bone is showing signs of failure due to being overloaded, however it has not progressed to a stress fracture. The difference between a stress reaction and a stress fracture is that in a fracture, there will be a defined fracture line (i.e. a crack or break through part of the bone) shown by an MRI scan. In a stress reaction, there will be inflammatory changes and swelling within the bone, but it has not developed into a defined fracture line.
It is important to diagnose a bone stress reaction as early as possible because it can help prevent it from developing into a full stress fracture. The management is generally considerably quicker, you are not out of running for as long, and the chance of complications is far lower. For this reason, if you have shin pain that is persisting or recurring with running, you should get it checked out by a running physio before continuing with your running training.
Stress Fractures Of The Tibia (Shin Bone)
A tibial stress fracture is when an MRI shows a defined fracture line (break) through a section of the shin bone. The pain becomes more severe so it makes running impossible. It will usually be sore even with just general walking and weightbearing, and take longer to settle with rest. It can wake you through the night, or be very sore to initially weight-bear in the mornings.
The sharp pain from a stress fracture is often localised to one area on the shin bone, but soreness may still extend along the bone for some distance. It will be sharply sore to touch or push on. If you think you may have a stress fracture then you should not run until you have been professionally assessed. This is because continuing to run will cause further bone damage, delay your recovery, and in some cases may in result more intensive and invasive medical treatment being required.
For more information on bone stress injuries and stress fractures in runners, and how physio can help you manage them, see our blog post on shin bone stress reactions and stress fractures.
Why Do Runners Get MTSS Shin Pain?
MTSS is the most common running-related shin pain that our physios see at Central Performance. There are many potential causes, but the most common cause is a sudden increase in the amount of running a person is doing. Increasing your running training too quickly, either by volume (run duration and/or frequency) or intensity (speed), exceeds the load capacity of the shin structures and causes MTSS.
Poor calf endurance, lack of power and reduced ankle mobility are other factors we often see in runners with shin pain. The calf has such an important role to play in runners and jumpers, and without adequate strength it can lead to excessive loading of structures around the shin, predisposing the runner to developing shin pain.
Causes Of Shin Pain In Recreational Runners – What The Research Says
A study by Menendez et al in 2020 (see below) was the first comprehensive literature review on the causes of shin pain in recreational runners. They identified 7 mains factors that are associated with MTSS;
1.
Increasing Running Volume Too Quickly: this is the most common problem we see as running physios when we work with recreational runners. Load management and increasing tissue capacity through strength exercises are the keys to effective treatment in this scenario.
2.
Being Female: ok, there’s not much we would want to do to actually change this one! However, just being aware that females are more prone to MTSS is helpful because increased awareness may mean that symptoms are picked up more quickly and appropriate changes to training loads are made earlier. Also, research shows that females are more likely to have an increased pelvic drop (see below), so potentially correcting this may help.
3.
Increased Navicular Drop: the navicular bone is on the inside part of your foot, just in front of your ankle. The Navicular Drop test measures how much the bone drops down with weightbearing. It is a measure of foot pronation, or how much your arch drops down as you weight-bear. An increased navicular drop – i.e. having flatter feet when weightbearing – was found to be associated with having MTSS in runners.
4.
Increased Pelvic Drop: pelvic drop means when you land on one leg, how much does the other side of your pelvis drop down? It can be due to weakness or just technique/motor control issues, but excessive pelvic drop was found to be a risk factor for MTSS. Having a running gait assessment will help you see if you have increased pelvic drop.
5.
Apropulsive Gait: This refers to an inability to effectively progress from heel-strike to a strong push-off as your foot leaves the ground. Common movement issues seen in this gait are an early heel lift and an abductory twist, where the foot fails to supinate and so stays in excessive pronation. This can cause MTSS by increasing the load on the tibialis posterior tendon as it attaches to the inside of the shin bone.
6.
Increased Peak Hip Internal Rotation: this is the extent to which the hip rotates internally as you run. It is associated with over-pronation and rolling in of the knees (knee valgus collapse). People with MTSS tended to have higher levels of peak hip internal rotation.
7.
Reduced Knee Flexion: research found that runners with MTSS tended to have less knee flexion during stance phase, i.e. they had a straighter knee when that leg was on the ground.
Treatment For MTSS Shin Pain In Runners
While every runner’s case of shin pain needs to be thoroughly assessed and treated individually, there are 3 main take-home messages from the research;
1.
Running Load Management Is Essential: however great your running biomechanics are, if you push to increase your running load too quickly your risk of shin pain increases. How quick is too quick? Well, that’s a complex question that depends on many factors such as running history, previous injuries, overall strength and fitness, how well you sleep and eat, what other exercise you do etc.. An appropriate starting volume and rate of progression for one person may be really inappropriate for another. A running coach or physio can make sure your running program is the right one for you.
2.
Have A Running Gait Assessment & Work On Your Biomechanics: from the discussion above you can see that many of the risk factors for MTSS are to do with your running gait. This includes an increased pelvic drop, an apropulsive gait, increased peak internal hip rotation, and reduced knee flexion. All of these things can be identified in a running assessment, and then you can start the right management program to fix them if required. This often includes specific exercises or drills to build strength (especially around the core, pelvis, hip and calf) and mobility, as well coaching cues to think about when you are out running. A well-designed strength and conditioning program can really help here, as well as specific running coaching.
3.
Orthotics May Be Helpful: the role of orthotics (shoe inserts) in treating shin pain and other injuries in runners remains a bit unclear. The research overall leans towards positive effects however, other studies do not show significant benefits.
Given that a number of the factors associated with MTSS relate to excessive pronation (flattening of your foot arch), it is reasonable to expect that orthotics will be helpful because this is one of the main biomechanical issues they are used to improve. However, we need to note that orthotics are now thought to work by improving the distribution of force across the foot, rather than by reducing actual foot pronation.
The lack of clear evidence for the effectiveness of orthotics highlights the need for having a personalised assessment and management program. We have had many clients who have gone out and spent good money on orthotics because “their friend had the same problem and orthotics cured it”, only to find a month or so later they were no better off. As the above discussion highlights, so many individual factors are involved in MTSS that what is a miracle cure for one person may be of no help to another.
Our take on orthotics for MTSS in runners is that they are an option that may help in some runners but not all. We tend not to go to them immediately because so many other modifiable risk factors can be addressed through load management, strength and mobility drills, and coaching cues. However if we are not getting the results we want, and if the client’s running gait assessment shows some of the common problems that are associated with excessive pronation, then we will recommend a trial of orthotics.
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Reference: Menéndez C, Batalla L, Prieto A, Rodríguez MÁ, Crespo I, Olmedillas H. Medial Tibial Stress Syndrome in Novice and Recreational Runners: A Systematic Review. International Journal of Environmental Research and Public Health. 2020; 17(20):7457.
