Medial Tibial Stress Syndrome (Interior Shin Splints) no cure?

[axelator]

First of all I'll apologise, I assume shin splint questions are common but I want awnsers specific to my case if possible.

I first got shin splints training for the army when going on 8 mile marches with 40lb packs and wearing boots. It would be very painful for the first half an hour then go away. It would then be sore after. After this I would get shin splints from running long distances, sprinting, skipping and Kickboxing (my main sport). All of which I had been able to do without pain before the case of shin splints from marching.

I went to a physio and was diagnosed with medial tibial stress syndrome. So I took four - five months off from these exercises until the symptoms went away. I worked on improving my static and dynamic flexability of my ankles, lower leg muscles and quads and hamstrings. I also improved my lower leg strength.

Now I have very good flexibility, and my lower legs are strong. I currently train kickboxing twice a day and this does not cause shin splints any more. Which is used to until I took the time off.

However I cannot skip or run without feeling the symtoms of MTSS coming on. I am confused to what is causing this. I have adressed all the causes. I improved flexibility improved lower leg strength in all ranges, I brought custom insoles for my running shoes to adress biomechanical problems.

Also when I try to skip or run I only do a small ammount so I don't do too much too soon and cause MTSS from overuse but it still comes on every time.

So are there any causes of MTSS that I'm not adressing here? It's very frustrating skipping and running and sprinting are very useful conditioning tools for kickboxing.

Also can anyone tell me why I never got MTSS from sprinting, running or skipping before I got them from marching but now get them all the time? I don't understand this.

Thanks

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[gcoe]

Hi axelator

If what you have is really medial tibial stress syndrome - and it can be misdiagnosed for other problems, then you are actually doing all the right things in getting your leg muscles in better condition. It may be just that skipping, running and sprinting is still overloading the insertions of the muscles involved too much. MTSS is really an overuse injury so you can easily make it worse as you increase your activity.

The pathology can be a bit complex but it includes tendon and fascia problems where the soleus (deep layer of the calf muscle) and the flexor digitorum longus (muscle that bends the toes) attach high up in the shin. the tendons can actually pull on the periosteum - the fibrous tissue that covers the bones and this can be what gives you the pain. the periosteum and the tendons do respond to graded conditioning (ie enough stress to stimulate strengthening of the tissue but not too much to overload and irritate the tissue and make matters worse) However these tissues take much longer to respond than muscle to conditioning and you will just have to be patient and persevere slowly. Muscle has a very good blood supply and is a very responsive body tissue while tendon, fascia and perisoteum have a much poorer blood supply and take much longer to adapt. There is an art to stimulating the tissues just enough to get a good result but not overtraining that will just set you back.

Further strengthening of the ankle and foot muscles including eccentric training (particularly but not limited to the calf muscles) are good. You can gradually add jogging on sprung surface or thin high density mat just working within what is comfortable and slowly increasing the dosage. Then you could add in skipping but keep on a sprung surface. the principle is just gradually increase the stress, always keeping to what is comfortable and so you are not getting delayed soreness. You won't achieve anything by overloading these tissues.

Other things to have checked are your shoes - are they providing adequate support. And you need to be checked for varus of the hind foot and overpronation as these foot problems go hand in hand with MTSS

[roycar]

all the above, very important.

also, you dont mention having any manual therapy to the area of muscle attachment. i've often found that I need to get in quite deep to friction around the posterior aspect of the tibia to release some of the scar/tight tissue around the periosteal attachment. this is often an issue even in someone who can perform most daily tasks painfree like yourself.

[axelator]

Thanks for the replies guys, I really apprecoate it.

I've been strengthening my muscles and stretching consistently for about 6 months now, although I feel it has helped alot (I used to not be able to train at all, now I train twice a day for about 2 and a half hours in kickboxing). Would this suggest it's definitely a problem caused by weak muscles/ligaments as opposed to being some bone density problem?

Also although I train 5 hours a day at the moment and it doesn't make my shins any worse, they won't seem to completely recover. They hurt a tiny bit when I press on the affected area and if I strike the area firmly with the ridge of my hand I feel disperessed pain. I sometimes think I feel them ache in training but it's so slight I'm not even sure it's there. I also wear compression sleeves during training. If I take a few days off the symptoms go completely but when I go back to training they come back, and they get worse if I try skipping or running too much.

My running shoes probably could do with replacement but being in Thailand right now it would be hard to find a proper pair. I also massage my shins myself on the advice of the podiatrist I went to see.

So the advice is continue to strengthen them? I guess it would be good to ease of training and work back up the level Im at now once symptoms subside. However I'm in Thailand and only have a limited ammount of time to train here so want to make the most of it..

[gcoe]

sounds like you have things under control. Keep persevering and you will get there. 6 hours is a lot of training if you are sitting on an overuse problem. If you find the symptoms settle when you rest for a few days it may be that 5 hours a day everyday is a bit too much. What about building some more recovery periods into your training - say training every second day of hard training one day less the next day and none the third day and cycle through that? Make a point of not taking more than two days off.

Pay attention to your body and you should be right - you only get one :-)

[axelator]

Thanks, I think the awnser must be to have more rest days, continue the exercises and slowly work in other activities. Unfortunatly for the next 3 months I'm in Thailand and have to make the most of being able to train here so I'll just do my best to control the symptoms then try and fully recover whe back in the UK.

[cmdo83]

Alright mate I am suffering from the same thing, (i think)

I was in the royal marines and left aprox 4 years ago now. I first went to docs in the corp about this problem and its taken best part of 4-5 years to get somewhere. It got to one stage that when I was running yellow bruises would appear along my shins and the pain was horrific.

I am also a kickboxer and I too do not suffer from the pain during kickboxing.

The nhs is pants and have been passing the book for years with my problem,

Its was only when I moved house and went to a new doctors and got refered to a physio who is massively dedicated and actually cares about her job that I am starting to get somewhere.

Basically the short and small of my injuries that were causing my shin splints were as follows:

Insoles: I have a very high arch which collapses when I run therefore I have insoles to prevent this from happening.

Neurogical: spinal nerve problems caused by compression from carrying weight (an intensive course of pushing very hard on my spine until it cracked lots sorted that) This subsequently gave me a lot more flexibility in my back.

running: I run on my toes with my feet pointing outwards. This is because I have very weak gluts, and the muscle on the inside of my calf is also terribly weak (dont know what its called).

Calf muscles: I have no muscles on my calfs I basically used the anterior compartment muscles to run as a result of the weak inside calf and gluts. Hence this caused the problem.

I have been going through physio for approximatly 5 months now and although physio has eleviated the problem and I do not get the pain I also dont run anymore.

I have to build up my gluts, calf and the muscle on the inside of my calf as well as retrain the way I walk and run.

It is taking an age to solve this problem and although I am making head way I may have to go for an operation. Something my physio is against because results vary massively (it can make the problem worse).

Its just a case of building up these muscles from scratch so I become less dependant upon the anteria compartment.

[cmdo83]

If want my advise mate:

Go to a physio and get them to test all your muscle groups for strength from shoulders to foot.

Get them to look at your running and walking.

Here is a few simple things you can do to check yourself:


Lay on you left hand side. Bend your left knee (ensure the thigh is in a straight line), and straighten your right leg. Make sure there is a straight line from you head to your right leg and keep your hips pushed forward. Lift your right leg as high as you can making sure you hips stay straight forward and your right leg is still straight. Get a friend to apply pressure on your right leg pushing your leg downwards. If this is done fairly easily it means weak gluts. You can test this at different leg heights. Turn over and do the over leg.

Stand on one leg lift the over leg off the floor. On the leg you are standing on raise yourself on your toes (calf raise) do this going right to the top as many times as possible. If you cant do 50 with ease you have weak calves. Failure on this test occurs when your body starts over compensating for the stress on you calf.

I went to physio every week for 2 months and my physio was doing all sorts of tests on different muscles to find out which were weak and which were strong.

[drfoot]

It sounds that you have tried a number of regimes, with ongoing and unresolved symptoms.
I would suggest you alter your training regime but decreasing to a bear minimum. Given the chronicity of symptoms, try ceasation for 4 weeks. I appreciate your Thailand experience and time constraints, but the longer you look for quick fix answers the longer and more chronic it will become.
You mentioned you attended a Podiatrist and "bought" custom insoles. Were these taken form a corrected cast? Was a full biomechanical performed? As advise given muscle group strength assessments are required to exclude imbalances, as is a functional limb length measurement.
Normally for this case I would expect an everted or valgus rearfoot. With nearly all pronatory complaints such as yours, I would see a Gastroc/Soleal Equinus. So, srtretching the calf mucles individually is paramount. If their is a functional difference greater than 0.5 cm, then a 0.5 cm heel raise should be added to the shorter side. Deep tissue massage is uncomfortable, but your physio and his/her fingers deeply working the Pre Tibial would also benefit.
If the Insoles are NOT Orthotics, then have them reviewed. Again I am not an advocate of Rigid orthotics, but an average male approx 80-85kgs would benefit from a semi flexible 4mm polypropylene orthotic witha soft tissue supplument.
Food for thought..interested were you go from here. But do dramatically knock off the training until or allowing for healing.

[axelator]

Well I'm back from Thailand.. I'm still training alot though because I have a fight in two weeks. My shins were not bothering me for a long time, but now they have come back mainly towards the bottom section of my right shin.

When I got my orthotics the podiatrist only asked me to push my foot into this foam cast sort of thing that left an inprint of my foot. I think it's the increased running and skipping that has lead to the return of the shin splints. It's very tender to the touch on my right shin in about a 2cm long area. The left is a little tender but not too bad.

I did have a 2 month break before Thailand but they just return every time even with stretching and strengthening exercises. Is it worth going back to a podiatrist? It's beggining to sound like the last guy ripped me off with the orthotics.

I don't really have the money to see a podiatrist though. Unless I ask my parents, which I'd prefer not to do.

[Trailrunner]

Shin Splints. (I'm not a doctor, just a runner)
I've been running all my life and have battled shin splints until 2 years ago, when I changed my running style. I used to be a heel-to-toe runner. Now I'm a forefoot runner and run 6 to 8 mile trail runs 3 to 4 times per week. I don't have any shin splints or lower back pain anymore.
I believe the best thing you can do is change your running mechanics. Shin Splints come from the abnormal impact of your foot on the ground. When you run heel-to-toe, your leg is completely extended on impact with the ground, causing all sorts of problems (shin splints, knee and back pain). Try shortening your stride and running on the balls of your feet and not extending your leg completely (Kenyan marathon runners are the best at this because they grow up running without shoes, on the balls of there feet). This is actually the way your body was meant to move. Your ankle, knee, hip provides a shock absorber for the body.
It's a bit awkward at first, but you'll find the shin splints start to go away. You're calf muscles will be very tight for a week or so.

Sorry if this has already been covered.
Good Luck.