Help! I have shin splints. Are my shoes the cause? How do I pick the right shoes to avoid shin splints?
When faced with choosing a new pair of running shoes, we are lucky if the only thing that separates us from those sweet kicks is whether we like the pink with neon green laces or the neon green with pink laces. Choosing a shoe when you have lower leg pain can be much more complicated.
The choices used to be limited to three basic types, or “category” of shoes: neutral, stability and motion control. Now, there are more options. For example, a recent visit to the Saucony website revealed there are 11. 11?! What’s more, the most commonly recommended solutions for shin splints are orthotics and shoes with more cushioning. Despite these changes, some runners still have pain. The answer is far from simple, but the solution may be just a few questions away.
What are shin splints?
“Shin splints” is kind of a catch-all term for tibial pain used by health care professionals. Pain in the inside of your shin or tibia is referred to as medial tibial stress syndrome (MTSS) in the medical community. Tibial stress fractures are a separate condition, but tibial pain is a symptom. It is important to distinguish the difference between the two; stress fractures are a far more serious condition and may warrant a period of immobilization.
To rule out a diagnosis of tibial stress fracture, a physician will use a thorough history and physical to rule out a diagnosis of tibial stress fracture. Another serious condition that affects the lower legs is chronic exertional compartment syndrome. It, too, can be ruled out by a physician.
MTSS used to be considered more of a soft tissue injury, but it turns out that the anatomical muscle insertions did not correspond with the area of pain. Recent research shows that there are subtle and cumulative changes in the tibia bone itself in the case of tibial pain after running. When researchers viewed CT scans of the affected runners, an area of low bone density was present around the painful area.
What’s more, the likelihood of injury seems to be directly related to the amount of stiffness or density present in your tibia itself; if the tibia is less stiff there will be a slight bend in the bone when loaded — or what happens when impact forces are sustained, when your foot strikes the ground while running. This slight bend occurs at the narrowest point of the tibia, which, also tends to correspond with the area of pain. This may be why I tend to see more complaints of tibial pain in new runners; their tibias are generally less dense than experienced runners. Putting in time on the road develops the proper bone stiffness to handle the repetitive pounding of running.
What are the best shoes for shin splints?
There’s no single best shoe or type of shoe that will prevent or treat shin splints. But there are important factors to consider. Unfortunately, there is little consensus in current literature linking shoe selection and injury prevention. It seems the take home message of all the literature reviews on the subject is this: the right shoe for you should not be based solely on your running gait or foot type, I.e., over-pronator or supinator or high or low arch. There are both extrinsic and intrinsic factors that will help to determine what running shoe may be right for you.
Let’s start with three intrinsic factors.
1. Do you heel strike or land on your forefoot when you run?
Have a friend take a quick video of your running form from the side outside or on a treadmill. Also pay attention to your gait after a long run. Does it change when fatigue sets in?
In general, heel strikers will benefit from a shoe with more cushioning in the heel and those who land on the forefoot should lean toward a shoe with more forefoot cushioning. A shoe by itself cannot turn you from a heel striker to a forefoot striker. There are many other factors including ankle stiffness, running cadence, and stride length that affect how your foot hits the ground. Minimalist or zero drop shoes do not necessarily encourage a forefoot strike.
2. How is your lower leg joint mobility?
Try this test to know if you have a stiff leg: Sit with your legs out straight and your feet flat against a wall. Can you bend upward at your ankle, keeping your heel in contact with the wall and pull your entire foot off the wall either actively or passively with a strap? If not, you have limited dorsiflexion of the ankle and may not be a good candidate for the zero drop or low heel-to-toe drop shoes.
If you have a stiffer lower leg, choosing a stiffer shoe with an increased heel-to-toe ratio is a wise choice. Until you develop better mobility in your ankle through stretching of the gastrocnemius muscle stick with the traditional 10 to 15 mm heel-to-toe offset shoes. Otherwise, you run the risk of landing on the ground with a flat foot, rather than at the heel or forefoot, which can increase loading on the bone.
If your ankles are relatively flexible, you have a wider range of options to chose from.
To measure heel-to-toe drop, or “offset,” in a running shoe, subtract the stack height of the forefoot from the stack height of the heel. For example, in the image of a shoe design below, subtract 11 mm from 23 mm: 23 – 11 = 12 mm offset.
3. Are you male or female?
If you are a female you are two to three times more likely to develop tibial pain after starting a running program. Females’ tibias are narrower and less dense than male counterparts. While both men and women’s shoes are designed to handle three to four times of your body weight per foot strike when running, women’s shoes are specifically designed with their unique foot structure in mind.
So stick with gender-specific designs when possible.
Now consider three extrinsic factors that affect tibial pain and whether a certain type of shoe might be best for you:
1. What type of surface do you train on primarily?
The stiffness of your lower leg joints and muscles is inversely related to your training surface of choice. So, if your shoes and the surface you run on remain constant, and you run on a hard surface with a stiffer soled shoe, the leg will adapt by being more compliant — thanks to responsive mechanoreceptors.
The body has an ability to adjust stiffness on demand and the muscles and tendons will assist by absorbing more of the force, cushioning each step.
If you tend to have more muscle or tendon pain in your lower leg, you may chose to run on a softer surface for relief but, if you have more true tibial pain, running on the road may be a better choice. This idea is often contradictory to what is commonly recommended.
Most shoes that don’t include “trail” in the title are ideal for running on roads and hard surfaces.
2. Are you a new runner?
Studies involving both military recruits in poor physical condition and high school cross country runners show up to 12 to 15 percent incidence of tibial pain within three months of starting to run.
On the other hand, experienced runners rarely experience tibial pain because the generally have acquired adequate bone density by training.
Although there’s no single shoe that’s best for new runners, you should purchase running-specific models, which are engineered for the rigors of running.
3. Do you run daily?
You may need to invest in two pairs of your favorite shoes. It could take more than 24 hours for a shoe’s shock absorption material to rebound after a run.
“So, what shoes do I buy?”
OK, so we’re back to the original question. The answer depends on the factors we discussed above and, most importantly, comfort and fit. Answer the above questions, take them to a reputable specialty running store and have a staff member find shoes that match that criteria. Online, running-only sites list factors such as category (neutral, stability, motion control), cushion and heel-to-toe drop. Use the factors discussed to narrow your choices.
If you’re in a running store, run in several pairs of shoes on a treadmill if they have one or outside if they’ll let you. Have someone watch you run in them. Ask for the store’s return policy. Can you run in the shoes outdoors and return them later if they don’t work out?
Once you’re happy with a pair, write the date you purchased your shoes somewhere on the inside of the shoe (on the tag or inside of the sock liner) or write the “new shoes” date into a training log, daily planner, or activity app, like Strava, to keep track of how long you’ve run in your shoes. Depending on your weight, running surfaces and the way the shoes are constructed, it’s generally recommended that you replace running shoes every 250 to miles.
What else can I do to treat and prevent tibial pain from returning?
Rest until the pain subsides with normal daily activities like walking. If it doesn’t subside in two to three weeks, you may want to consult an orthopedic specialist to see if you may need some imaging tests like an MRI or bone scan to rule out a tibial stress fracture. Here are additional tips:
- icing the area for 10 minutes after activity can help with pain and local inflammation
- cross train or rest for a day between running workouts for 2-4 weeks after the pain subsides
- return to running gradually and increase no more than 10-15% of training volume per week
- consider replacing your running shoes after 250 to 300 miles — recent research shows a 60% decrease in shock absorption qualities of shoes after this mileage. At the very least do so after 6 months of use. Shoes also lose shock absorption after 1-2 years even if not worn.
- strengthen the muscles surrounding the tibia to increase both bone density and reduce muscle fatigue. You can work up to 30 reps of the following activities: single leg heel raises, walk on heels, eccentric heel lowers off a stair, single leg hops. Work on activating your hip and core muscles to help prevent this and other injuries.
- reducing stride length and increasing cadence to 180 beats/minute both have shown to decrease overall impact on the tibia. Not sure how to match 180 beats/minute? There are several good apps you can download to both find songs and organize your music by cadence. There is also a metronome app that you can set to a specific cadence.
- have a physical therapist evaluate you for any underlying alignment issues, muscle imbalances, and to see if a custom orthotic may be appropriate to correct foot biomechanics. There is little evidence to support the use of orthotics alone in the prevention of lower leg injury, but they may assist in correcting other movement faults that can result in injury.
I hope this helps shed some light on a very common running injury and how to properly select shoes to prevent MTSS from sidelining you from your next run.
Corey Morris, MPT, COMT