Shin Splits - When to Begin Running Again?

author : AMSSM

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BeginnerTriathlete Member struggles with shin splints and is impatient to run again

Question from user Blastman

"So...I have shin splints. Better than something worse (MRI verified...$$$). I thought I had a stress fracture since I spent days unable to even walk correctly. I took 2 weeks off running last month and then started to run again with some pain the next day. I was trying to run every other day. I did an Oly last week and really pushed myself for my fitness and, well, ...I limped around for 3 days afterwards. So no more running. I'm going to take 2-3 weeks off again but I really want to run but it's hard to know when I should start back up. I still have slight pain walking around. Nothing bad by any means but just enough to let me know it's not 100%. It doesn't hurt when I press on it anymore, which is a good sign. I'm looking for advice on when I should start to run again. I was trying to run every other day, which seemed to be ok-ish but that all-out 10K wasn't ok. Should I slowly add ~3 mile runs in when I'm not 100% or should I be "pain free" for 1-2 weeks first."

Answer from James Suchy, M.D.
Member, AMSSM

Sounds like you’ve been dealing with some bothersome shin (tibia) pain for quite a while. Shin pain is very common in runners and most commonly is due to medial tibial stress syndrome or shin splints. Another common cause of shin pain likely considered by your physician was tibial stress fracture. Both are common running injuries and present with similar symptoms. Shin splints may subsequently develop into a stress fracture if ignored. Shin splints are due to inflammation of the muscle fibers that connect to the periosteum, or thin outer layer, surrounding the tibia. Stress fractures are small cracks in the bone itself, and are more serious. Some more rare causes of shin pain your doctor may consider if you are not improving include exertional compartment syndrome and popliteal artery entrapment. Often times, physicians will make a purely clinical diagnosis, relying on your personal history and an accompanying physical examination. Your physician probably asked about the nature of your shin pain, changes in your running training, the type of shoes you wear, prior history of fractures, nutrition, and personal or family history of bone disease, among other questions.

The history of the pain is often similar in both cases, characterized as an insidious ache at the front of the shin that worsens throughout a run and improves with rest. If the runner persists with training despite these symptoms, the shin pain may even continue at rest. Factors that put you at higher risk for injury include a sudden increase in the volume or intensity of training, poor running form, inappropriate shoes/orthotics, obesity, hip or ankle inflexibility, prior injury, inadequate lower extremity or core strength, poor nutrition, and metabolic bone disease weakening the bone’s strength. The presence of these risk factors make the likelihood of stress fracture more likely. However, an accompanying physical examination of the leg is most revealing. In a tibial stress fracture, there exists a distinct point of swelling, tenderness and reproduction of the pain when pressed upon. Alternatively, in shin splints, the tenderness is more diffuse and no distinct point of tenderness or swelling exists. Additionally, shin splints are more likely to occur in both legs rather than just one.

While often times athletes with shin pain can be managed based on the clinical exam and history; sometimes absolute diagnostic certainty is needed, in order to prevent an unnecessary loss of training time or overtraining on an already fractured bone that would prove detrimental to an athlete’s professional or personal goals. Imaging may be helpful in this regard. The most commonly ordered study is a plain x-ray. A leg with shin splints appears normal on an x-ray, while a stress fractured leg will often show evidence of healing or a linear fracture line within the bone. Unfortunately, often times stress fractures will not show up on x-ray, especially early in the course. An MRI, although more expensive as you pointed out, may be able to definitively distinguish between these two conditions. Other diagnostic tests that may be utilized by a physician to determine the cause of shin pain include CT scan, bone scan, or compartment pressure testing depending on what conditions your physician is concerned for.

Triathletes with tibial stress fractures should strongly consider taking time off running to pursue low impact sports like cycling and swimming as this is safest and allows for the most healing. The running rest period is followed by a progressive and slow increase in running. This allows for a safe but progressive increase in impact bearing that allows for healing while maintaining fitness. By following a graded running program, full training can be resumed over weeks to months. Of note not all tibial stress fractures are equal, some high risk tibial stress fractures may require complete rest or even a surgery, however, these would be uncommon in triathletes.

Alternatively, triathletes with shin splints may be able to continue running, but should decrease the total mileage, though more time spent cross training is preferable. The weekly mileage and intensity of running training should be slowly progressed over a period of weeks to months. Most importantly, running training should not be advanced if you are experiencing pain.

Alternatively, if you are having pain then decrease the level of training until you are pain free. Rarely shin splints may require complete rest from running if you experience pain at rest. Your doctor or a professional trainer can guide you in this regard. To further speed recovery, ice the shins several times daily for 15 minutes, especially after training. You may use ibuprofen, naproxen, or acetaminophen as needed for pain. Identification of factors that contributed to the development of tibial stress fractures or shin splints is also important because if you are not addressing the underlying cause of the problem, you are prone to redeveloping the same issues in the future. This includes an evaluation of biomechanics (foot strike, stride length), your anatomy (arch type), footwear, training regimen (intensity, volume), and potential predisposing conditions (malnutrition, osteoporosis, etc.).

If training error is thought to have been the main contributor, the physician may simply educate you on a slower progression in training. If anatomy is a factor you may be instructed to buy a different running shoe or orthotic. Commonly physical therapy is an important component of management of both shin splints and stress fractures. Calf, leg, and core strengthening exercises are safe and effective ways to reduce tibial stress. Flexibility deficits may also be addressed. If your running gait is thought to contribute, you may benefit from a gait analysis and gait training therapy. It is important that this is done with supervision from a therapist, physician, or athletic trainer who has knowledge of gait training. Taking calcium and vitamin D supplements daily has been shown to be beneficial for both tibial stress fractures and shin splints. A physician or dietician can identify nutrition deficiencies that may be contributing to your leg pain and may recommend additional supplementation. A combination of these approaches is most beneficial in recovering from and preventing future injury. Good luck with your training!

James Suchy, M.D. Family Medicine Resident, PGY-2 University of California, Irvine
Co Author: Caitlyn Mooney, M.D.

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date: August 31, 2016