shin splints, shin splints exercises

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Like so many athletes, you started this year with great intentions. You took your workouts to a higher level, doing more than you had ever done before, and things were great for a couple of weeks. Your fitness began to rise to new heights. Unfortunately, after a series of particularly strenuous workouts, you felt a dull ache on the inside, lower portion of your shin as you began a workout. The discomfort went away once you had warmed up, though, so you were not overly concerned.

You forgot about the little ache, but it didn't forget about you. On the following day, the pain returned - and lasted for a longer portion of your workout. As the days went by, pain was present throughout your training sessions as well as your cool-downs - and even hung around during regular daily activities. When you used your fingers to probe the area near the back, inside edge of the lower part of your tibia (the main bone in the lower leg), you felt tenderness but no major swelling, and the pain seemed to centre in the tissues (muscles and tendons) near the tibia, not the tibia itself. What was wrong?

Running athletes are particularly vulnerable to splints
Of course, you had developed a classic case of 'shin splints', an injury which is technically known as medial tibial stress syndrome (MTSS). Athletes involved in sports that involve running and jumping (including soccer, cricket, basketball, rugby, volleyball, endurance running, sprinting, and triathlons) are particularly vulnerable to MTSS, and many experts believe that shin splints are the most common injury in endurance runners; indeed, research shows that up to one-in-five injured runners are 'on the shelf' because of MTSS(1). MTSS is an especially troubling injury, because it can stop quality training in its tracks, and it also tends to recur, defying conventional treatments. The actual site of injury in the shin area can be muscle, tendon, bone, or the connective-tissue wrappings which surround muscles and bones.
Some sports-medicine experts contend that MTSS is almost inevitable in sports that involve running, since each shin absorbs a force equal to 2-3 times body weight with every footfall - almost 100 times per shin per minute. The cumulative effect of this repetitive stress on the muscles and connective tissues in the shin area is believed to be the origin of MTSS. For that reason, MTSS is often called an 'overuse' injury although, as you'll see, the real problem is not so much overuse as lack of preparation for use. Specifically, MTSS occurs because the ankle dorsiflexors - the shin muscles which, in effect, pull the top surface of the foot towards the shin and also (as part of their eccentric functioning) keep the foot from being pulled away from the shin too rapidly - are not functioning as well as they should.

Slapping sounds on the pavement
The key role of these ankle dorsiflexors during running is, in fact, to control and limit plantarflexion - the movement of the foot away from the shin. During the very earliest part of the footstrike portion of the gait cycle - as the foot first makes contact with the ground - there's a tendency for the foot to slap hard against terra firma. Even in a 'heel-striker' (an athlete who first makes contact with the ground with his heel), forward momentum tries to slap the front-bottom portion of the foot against the ground very quickly and forcefully after heel contact. In either case (heel or forefoot striking), there is a potentially uncoordinated and energy-wasting slap-down of the foot which is resisted by eccentric contractions of the dorsiflexor muscles in the shins (eccentric because the poor shin muscles are trying to contract while they are being rather dramatically stretched).
If an athlete has weak ankle dorsiflexors, you can often 'hear him coming a mile away' if he is running on a road, because his feet actually make fairly loud slapping sounds against the pavement. Of course, such an athlete will be at high risk for MTSS, because the rapid downward movements of his feet which are creating the hubbub will tear at and overstress his dorsiflexors. By contrast, the runner with strong, functional dorsiflexors will seem to pad softly along, even if he is running fast on rock-solid concrete.

The slower the runner, the louder the footfalls
To learn a lesson about the merits of excellent shin-muscle strength, simply go to a 10km road race which has both a large and an elite field. Station yourself about four miles out on the course and listen to the elite runners as they go past. Continue listening as the rest of the field unfolds before you, and note that as the runners slow down their footfalls become louder. This is not just because there are more middle-and-back-of-the-packers than there are elites, and it is the exact opposite of what should occur: ground-reaction force is a function of running speed, so the elites are hitting the ground harder and should be making more sound. Their quietness is a testament to their efficient, coordinated, shin-muscle actions, which make them not only very quiet but also very fast.
Watch some of the elite Kenyans running, for example, and compare their foot-to-ground patterns with those of elite Brits or the 'average Joe'. The Kenyans build up tremendous dorsiflexor strength and functionality because they spend their early years running and walking endless miles barefoot, rather than having their feet clamped onto a fluffy set of midsoles which shield the feet and ankles from hard work (or, worse still, sitting around with legs propped up on soft cushions). As a result, the Kenyans waste very little energy during the stance phase of the gait cycle and seldom hobble off the track or roads with shin injuries. They don't slap the ground; rather their legs react with the ground like tightly coiled springs.

Why many exercises don't work
In addition to controlling plantarflexion, the dorsiflexors must deal with side-to-side motions of the foot and ankle during running, as well as the rotational motions which are a natural part of the gait cycle. Any tendency of the foot to pronate or supinate must be controlled by the shin muscles. If there is relentless, stressful motion in any direction, the shin muscles can be damaged. That's why many of the exercise routines that supposedly prevent shin splints don't work so well; they often emphasise only front-and-back motions, rather than the side-to-side and rotational activities which are routine aspects of the biomechanics of running. The bottom line is that if you want to prevent shin splints, you can't merely develop general strength in your dorsiflexors, or strength that exhibits itself in only one plane of motion: your dorsiflexors must actually be stronger while you are running.

The exercises that do work
That's why the classical mode of treatment for shin splints, RECEIPT (rest, elevation, compression, easy stretching of the muscles, icing, and possibly taping) works fairly well at relieving symptoms but does a very poor job of keeping the injury from recurring. Only by improving the functional strength of the dorsiflexors and the strength and coordination of the entire ankle area can MTSS be held reliably at bay. If your dorsiflexors are strong enough to handle your total training load and are not yanked around too badly by poorly controlled ankle movements, your training year should be unmarked by the pain and disruption of shin splints.

To reduce your risk of MTSS, use the following protective exercises:

1. Wall shin raises
a. Stand with your back to a wall, with your heels about foot-length from the wall. Then, lean back until your buttocks and shoulders are resting against the wall;
b. Dorsiflex both ankles simultaneously while your heels remain in contact with the ground: bring your toes as close to your shins as you can, then lower your feet back towards the ground, but do not allow your forefeet to actually contact the ground before beginning the next repeat;
c. Complete 12-15 reps of the above;
d. Maintaining your basic position with your back against the wall, dorsiflex your ankles to almost their fullest extent, then quickly dorsiflex and plantarflex your ankles 15 times over a very small range of motion.These short, quick ankle movements are called pulses;
e. As you gain strength over time, make the exercise more difficult by progressing from one set of 15 reps (of both basic raises and pulses) to two and then to three, walking around for 15-30 seconds between sets if you wish.

Once you can quite comfortably complete 3 x 15 of the double-leg raises (both basic and pulsing), progress to the single-leg wall shin raise, as follows:
f. Start in the same position as before, but with only one foot in contact with the ground, while the other rests lightly on the wall behind you. Now your full body weight is on one foot - as it is during running - and the exercises are considerably more difficult;
g. Begin with 12-15 reps per foot (both for the basic exercise and pulses) and progress to 3 x 15 on each foot as your strength increases. There's no need to rest between sets; simply carry out 15 reps plus pulses on one foot, shift over to the other foot, and so on until you have completed three sets with each foot.

Although wall shin raises are a great routine for the shins, they are not quite as running-specific as the exercises which follow.

2. Heel step-downs
Simple but devastatingly effective exercises for preventing MTSS.
a. Begin with a natural, erect body position, with your feet about shoulder-width apart, then step forwards with one foot. The length of the step should be moderate, as with normal walking;
b. When your heel makes contact with the ground, stop the foot from fully plantarflexing by using your shin muscles to keep the sole of the foot from making contact with the ground. After heel contact, the ball of your foot should descend no more than an inch towards the floor or ground, held in check by the eccentric contractions of your dorsiflexors (shin muscles);
c. Return your foot to the starting position (back by the other foot), and repeat this basic stepping action a total of 15 times. Then repeat on the other foot;
d. As with the wall shin raises, progress to three sets of 15 reps over time.
Once you have mastered the basic heel step-downs, try the same exercise with dramatically longer steps, which will increase the accelerating forces placed on the dorsiflexors and force them to work more forcefully and quickly, as they must do during running. Start with one set of 15 reps of long steps per foot and progress to 3 x 15 on each foot over time.
Finally, you will be ready to carry out the heel step-downs from a high step, which will increase the forces on your shin muscles to the greatest extent and, of course, build the greatest amount of strength. Use a bench or exercise platform which is about 4-6 inches off the ground. Apart from beginning each step from a bench, your movements are the same as with the basic step-downs, the idea being to land on the heel of the forward foot, then use the shin muscles to prevent the sole of the foot from making contact with the ground (again, don't let the ball of the foot move downwards by more than an inch). The actual length of the step is moderate at first (you can progress to long steps later). As before, begin with 15 reps per foot, and progress to three sets of 15 reps as you gain strength and coordination.
Both the wall shin raises and heel step-downs can be carried out 3-4 times a week, along with your other strength-building exercises. You can perform them more often if you've had lots of problems with MTSS in the past, but not to the point of pain. Once you are an accomplished wall-shin-raiser and heel-step-downer, move on to the next two exercises, which are the ultimate MTSS preventers.

3. Heel hops
a. Using erect but relaxed posture, standing on your right foot, with your right knee just slightly flexed and your left knee flexed to about 90¡ so that the foot is completely off the ground;
b. Hop forwards on your right foot, but instead of landing in the mid-foot area, land on your right heel and hold the position for about two seconds, keeping the rest of your foot off the ground;
c. Repeat on the same foot 14 times more, then repeat on the other foot.

Initially, the hops should be just 4-6 inches in length, but you can increase the hopping distance as your strength and coordination improve. Another key progression is to gradually build up your speed of heel hopping, so that you are moving forwards quite quickly, while remaining on your heels. You can gradually move up to 3 x 15 hops per leg (or even more), but the ultimate progression is to carry out the exercise on a slight downward slope (initially just 1-2%). Using the slope will put severe pressure on your shin muscles, so be careful to begin with a modest number of reps.

4. Heel running
a. Start in a comfortable position, using relaxed and upright posture with your feet roughly beneath your shoulders;
b. Begin jogging slowly, allowing only your heels to make contact with the ground. Stay relaxed as you do this, and avoid the natural tendency to look down at your feet to see what is happening.
At first, keep your movements slow and jog for just 10 metres or so, but as you become more skilled your can speed up your heel running and go for about 3 x 20m, with a short break inbetween reps. Ultimately, you'll want to be able to do some of your heel running on a very modest downward slope. The overall idea is to keep your ankles significantly dorsiflexed as you run and permit just a little plantarflexion with each heel-fall, allowing only your heels to make contact with the ground.

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