Going through all the MTSS/shin splints research be like:
'There is a fifth dimension beyond that which is known to man…
between science and superstition, and it lies between the pit of man's fears and the summit of his knowledge….
It is an area which we call "The Twilight Zone". '
Am I being a tad dramatic? Maybe.
But at the same, the more research we conduct on MTSS and the more data we gather, the less we know. Which is typically the opposite result of science-ing.
Hence, the Twilight Zone. (I'm sorry in advance for all the weird dreams you might have after watching re-runs.)
But in all seriousness:
It’s interesting that the current literature (within the past 5 years) all gravitate to studying the immediate affected area: the tibia, the general musculature of the lower half of the leg, and the foot. (more blog posts about that here.)
There's been some hopeful findings that have emerged such as:
That a history of having MTSS increases your chance of developing it again by 17%
Over-pronation of your foot/feet can indicate a higher likelihood of developing MTSS
A need to address and strengthen the "foot core"
A muscle strength imbalance may be present between foot invertors and evertors
Possible overactive soleus muscle affecting foot and ankle kinematics
A potential link that poor single leg balance in individuals with a history of MTSS can be indicative of a decrease in postural stability (influenced by neuromotor control)
And lastly, common thought that over striding and affected running form can potential contribute to MTSS
And these are a good start, but...
Largely, these findings still leave us with a big: I DON'T KNOW.
But if we walk through this together, I'd like to ask you to look at that list of facts again
…do you see a pattern with how I've arranged them?
The more I read, the more I noticed how "zoomed-in" the research picture was with occasional moments of "zooming out".
Such as, that list of fact starts with:
specific about foot biomechanics
gradually zooms out from the foot into the lower leg
until it ends in a big picture moment looking at running form.
Where are we going with this?
Right Here.
Our bodies rarely keep a problem isolated to only one area. Compensations will happen when one teammate isn't pulling their weight.
Compensations happen EVEN MORE when pain is involved (duh, shin splints hurt). What we know from years and years of research, is that pain can actually re-pattern our brain AND how our muscles turn on and off (or lack thereof).
Pain also makes it reaallly hard to get an accurate picture of what you can actually do. Because typically, if an action causes pain, you DON'T do it. (duh).
Example: think back to the morning after a really hard work out. You get out of bed, go to take that first step, and start waddling around.
WHY? Because you're freaking sore and you're trying to minimize how much you have to feel the soreness, hence walking weird.
And this seems to be an over-arching theme that is gradually emerging from more and more research:
is that treating MTSS is very individualized, specific, affected by how much pain the runner is in, and may have a larger neuromotor control aspect than first believed.
(what's neuromotor control? Think of it like a mind-muscle connection: when you go to grab a glass of water, you typically don't over-shoot your reach. The reason you don't over-shoot it, is because of neuromotor control.)
So what are you, the average runner, supposed to do then when the science doesn't know, it's all nebulous and vague, and MTSS is super specific to each runner?
We still follow the science. AND….learn from your own body.
You are the expert of your body.
Nobody else knows how it feels after a hard workout, what strength work it responds best to, or how many flaming hot chicken wings you can handle before things go terribly sideways.
Ultimately, YOU are responsible for staying injury-free.
And part of that, is learning how to read your body and then….how to listen to it.
I have amazing tools for you, supported by research, proven to be effective by runner-patients, but at the end of day: you know you're body best.
This means watching your training plan, adjusting it as necessary, strengthening your feet (with the Blueprint for Runners to Stronger Feet Workshop), and working on your running form (with my Running Form 101 Workshop).
But something still might be missing….
And it could be that mind-muscle connection from neuromotor control that's been affected by pain/symptoms.
This is the part where we are definitely in the Twilight Zone.
Because neuromotor control isn't always very objective.
It's like gravity. You know it's definitely there, but you can't hold it, see it, smell it, etc. You can just see (and maybe occasionally, feel) the consequences of gravity.
So, if we follow the science and the facts above….
It's leading us up the chain.
The facts are pointing upward, saying that the foundation (the foot and shins) are carrying more load, doing more work, than is optimal, hence resulting in injury.
(Now, of course, this truly can be because of how your foot is made, possible over pronation, too much speed work too quick, etc)
But think WHY.
Why is it that too much speed work or too much of an increase in mileage has resulted in giving you shin splints?
It might because you haven't earned the right.
You haven't earned the right yet to run fast.
You haven't earned the right yet to run far.
Because you haven't built the engine yet that can handle that load.
You Core strength and control.
Your feet and leg strength and control.
Both need to exist and work together.
This is at least what I can infer from the current literature and glean from working with my current MTSS patients in the clinic.
There's usually a missing link somewhere that's dumping the work into the feet. And a lot of time, it's core neuromotor control in conjunction with the rest of the body.
So if you're up for an experiment…
If you're game to train your core like a runner;
If you're looking for a way to wake it up and help re-establish that mind-muscle connection,
Then let's bust through this core circuit.
2-3 rounds // 30secs or to fatigue // 3x each exercise
High plank knee to same elbow R,L (spiderman plank)
High plank knee to opposite elbow R,L (spiderman plank variation)
High plank, knee to chest, swinging knee between both elbows (I call these "hip swivels")
Bird dog with wall push, knee to chest R, L
(one leg is pushing into the wall, both hands are planted on the floor. Lift the knee on the ground to your chest. Feel that core!)
For all my time in the clinic treating runners, variations of these core exercises above truly seem to have the most impact, on both building core strength like a runner and re-establishing the neuromotor control that runners need the most.
The reason I like these even for MTSS:
they sneakily start working on those calf muscles and foot muscles we talked about at the beginning of this post in a general way that's usually tolerable even for highly symptomatic runners with MTSS.
Because one thing the research has told us:
is that those feet muscles are important, the calf muscles need to re-learn how and when to activate correctly, and that neuromotor control (mind-muscle) connection may be integral to healing MTSS.
Now it's your turn-what exercise seem to work best for you to prevent MTSS from ever coming back? Is it core exercises? Weighted calf raises? Or maybe a certain dynamic stretch?
Leave your holy-grail exercises below in the comments so we can compare exercises!
Until next time,
Dare to Train Differently,
Dr. Marie Whitt //@dr.whitt.fit
P.S. Convinced that it's time to get your shin splints under control or determined to never-ever get them in the first place? Click HERE to get started!
References:
Guo, S., Liu, P., Feng, B., Xu, Y., & Wang, Y. (2021). Efficacy of kinesiology taping on the management of shin splints: a systematic review. The Physician And Sportsmedicine, 1-9. doi: 10.1080/00913847.2021.1949253
Kashi, O., & Minoonejad, H. (2022). The Comparison of Anatomic Alignment of the Shin, Ankle, and Foot in Elite Runners with and without Medial Tibial Stress Syndrome. Journal Of Clinical Physiotherapy Research, 3(2), 89-94.
Mattock, J., Steele, J., & Mickle, K. (2021). Are Leg Muscle, Tendon and Functional Characteristics Associated with Medial Tibial Stress Syndrome? A Systematic Review. Sports Medicine - Open, 7(1). doi: 10.1186/s40798-021-00362-2
Menéndez, C., Batalla, L., Prieto, A., Rodríguez, M., Crespo, I., & Olmedillas, H. (2020). Medial Tibial Stress Syndrome in Novice and Recreational Runners: A Systematic Review. International Journal Of Environmental Research And Public Health, 17(20), 7457. doi: 10.3390/ijerph17207457
Naderi, A., Moen, M., & Degens, H. (2020). Is high soleus muscle activity during the stance phase of the running cycle a potential risk factor for the development of medial tibial stress syndrome? A prospective study. Journal Of Sports Sciences, 38(20), 2350-2358. doi: 10.1080/02640414.2020.1785186
Sievers, M., & Busch, A. (2021). Medial tibial stress syndrome: The relationship between gender and lower-extremity functional performance among collegiate track and field athletes. Internal Journal Of Sports Medicine And Rehabilitation, 4(16). doi: 10.28933/ijsmr-2020-12-0805
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