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Bone stress injuries in runners

5 Risk factors leading to Bone stress injuries in runners.

Doug James, Physiotherapist, Podiatrist, Marathoner.

A bone stress injury (BSI) is a painful and debilitating problem that affects runners and athletes. It usually occurs as a result of surges in training loads which often coincides with preparing for a competition or a race. Additionally, we’re finding athletes who had to take time off due to Covid-19 quarantine are at greater risk due to a marked reduction in loading during their isolation, and then an overcompensation when returning to running. Depending on the severity of the BSI, the injury may be season ending, or even career ending. The following article will discuss how BSIs develop and the risk factors associated with them.

How they develop

Bone stress injuries occur when the capacity of a bone is unable to deal with the amount of stress it is subjected to [5]. In runners, stress is most commonly generated from running training loads, but any and all physical activity can contribute. If the amount of stress and load is not adequately managed, this can lead to painful fractures developing within the bone. With impact exercises such as running, the bones in our feet, legs, hips and spine undergo stress from compression (jarring from impact when landing), and tension (from muscles absorbing impact, stabilising the body, and creating propulsion). When a healthy bone undergoes sufficient stress that is still within a tolerable level, a process is triggered within the bone to make it stronger. This process involves the removal of part of the bone’s support structure that is then replaced with remodelled and stronger bone.

Symptoms to watch for

In early-stage BSI, symptoms are usually mild – perhaps felt as an ache or light bruising sensation, and might only be felt at the start of physical activity, and/or after the athlete has cooled down. It is thought that at this stage of the injury there is usually only mild damage and a small amount of swelling around the exterior lining of the bone may be evident on MRI. At this stage, the bone’s capacity for loading and stress may be slightly reduced, so caution is needed with any higher risk activities (high-intensity sessions e.g. hills or intervals, or very long runs). If the training load (or other physical activity) continues to stress the bone in its weakened state, swelling within the marrow of the bone begins to develop. At this stage, the injury becomes more uncomfortable during running, but symptoms may still ‘warm up’ as the session continues.

If stress to the bone isn’t reduced sufficiently, the cortical or hard part of the bone begins to degrade and fractures can form within it. By this stage, the injury would be very uncomfortable to run on and is often accompanied by an aching sensation even at rest.

Common BSI sites

80-95% of all stress fractures occur in the lower limbs[1]. The majority of these lower limb BSI are found in the tibia (shin bone) 33[2]-55%[3], metatarsals (long toe bones in the forefoot) 20%[2], and the remainder in the hindfoot and femur (thigh bone).

Who is at risk

Bone Stress Injuries can account for 50% of injuries sustained by runners and military recruits [3]. Female runners are twice as likely as their male counterparts to develop a bone stress injury [3]. Aside from being female, there are a number of factors that have been identified as risks for developing a bone stress injury.

Risk factor: Training load

By their nature, a BSI requires stress to develop [3]. A rapid increase in training load, particularly in poorly conditioned athletes or those new to running will likely bring about sufficient stress to develop a bone injury. A long history of physical activity is protective [6] as this tends to improve bone density over time. Total training volume needs to be monitored over the course of weeks and months to ensure adequate recovery occurs in order for bones to strengthen. For runners that have taken more than 2 weeks off training due to illness and/or quarantine, a gradual return to pre-break levels is advised. Those that are new to running need to be careful if mirroring the training of more experienced runners.

Risk factor: Running technique

Running technique can play a part in the development and likely location of a BSI. Distance runners who land on their heels are more likely to develop a BSI in the tibia. In contrast, sprinters, and runners who land on their forefoot are more likely to develop a metatarsal (toe bones) BSI.

Runners that produce high ground reaction force (impact)[2,3,4] and had increased rearfoot eversion [4] (rolling in) were more likely to suffer tibial stress fractures. Gait retraining can be beneficial in cases of recurrent BSI but needs to be done carefully due to the risk of injury developing from an unaccustomed running style [6].

Risk factor: Footwear

Shoes can play a role in the development of a BSI. It was found that running in old or worn-out shoes increases the risk of BSI[8]. General footwear industry advice is to replace shoes within 600km of running, but keep in mind that shoes will also degrade over time irrespective of use.

A recent study has proposed that running in maximalist (thickly cushioned shoes such as HokaTM) may reduce the risk of tibial stress fractures in female (but not male) runners. By comparison, minimalist (thinly cushioned) shoes were linked to metatarsal stress fractures(10). The use of foot orthotics was found to help reduce the risk of developing BSI in military recruits[9].

Risk factor: Low energy availability

Tracking the amount of energy you consume compared to your daily energy expenditure can help determine if your body is in an energy deficit. This is where the amount of energy consumed is less than the amount expended. Low energy availability reduces the ability of bone to resist load and/or impairs its ability to repair micro-damage [6]. Sustained periods of energy deficit can have negative effects on the body and will compromise performance and recovery. In females, this can lead to disorders in their menstruation cycle [6,7].  

Assessing your attitude towards food can help to identify eating behaviours that may result in low energy availability. The Eating Attitudes Test (EAT-26) questionnaire is a simple screening tool that can help flag problematic eating behaviours [7]. Athletes that score 20 or higher on this test would benefit from professional guidance. The questionnaire can be found easily on google.

Risk factors: Vitamin D and calcium deficiency

Low vitamin D [1] and calcium levels were common findings in athletes that develop BSI [4,5,6]. Ensuring adequate levels via dietary intake or supplementation is an important factor, and a fairly easily achieved goal to help reduce BSI risk. 

  • 600 IU of vitamin D daily is suggested for ages 9 to 70 years
  • 800 IU of vitamin D daily is recommended for > 71 years or older
  • 1300 mg of calcium daily for ages between 9 to 18 years[11].

Conclusion

Bone Stress Injuries are painful injuries that are best avoided. It is important to be aware of the signs and symptoms of a BSI – particularly if you are new to running, have increased your training (especially after taking more than two weeks off running), and/or are at risk of any of the factors listed above. Developing a considered plan for your training load and recovery is crucial for avoiding this potentially season-ending injury.  If you suspect you have a bone stress injury or have had one in the past, contact the intraining running injury clinic for an assessment and to develop a plan on how best to avoid them in future.

By Doug James – Physiotherapist and Podiatrist at intraining running injury clinic.

Doug James Colour 2020

DOUG JAMES

PHYSIOTHERAPIST | PODIATRIST | L1 COACH

Doug James is a qualified physiotherapist and podiatrist with a special interest in running and sports injuries. He combines the two treatment approaches to achieve successful outcomes for clients of all abilities from non-athletes through to elite athletes.

Bachelor of Podiatry (Honours), Master of Physiotherapy Studies.

Doug has undertaken further training in dry needling, Pilates, and Rocktape and may incorporate these as necessary during treatment.

Doug is also a keen runner having completed the New York Marathon.

References:

  1. Alexandra Abbott, Mackenzie L. Bird, Emily Wild, Symone M. Brown, Greg Stewart & Mary K. Mulcahey (2020) Part I: epidemiology and risk factors for stress fractures in female athletes, The Physician and Sportsmedicine, 48:1, 17-24, DOI: 10.1080/00913847.2019.1632158
  2. Tavares, J., Jost, T., Drewelow, G., & Rylander, J. (2020). Do maximalist shoes mitigate risk factors for tibial stress fractures better than stability or flexible (marketed as minimalist) shoes? Footwear Science, 12(1), 63–74. https://doi.org/10.1080/19424280.2019.1708977
  3. Milner, C. E., Ferber, R. D., Pollard, C. S., Hamill, J., & Davis, I. (2006). Biomechanical Factors Associated with Tibial Stress Fracture in Female Runners. Medicine & Science in Sports & Exercise, 38(2), 323–328. https://doi.org/10.1249/01.mss.0000183477.75808.92
  4. Song SH, Koo JH.   Bone Stress Injuries in Runners: a Review for Raising Interest in Stress Fractures in Korea.   J Korean Med Sci. 2020 Mar;35(8):e38. https://doi.org/10.3346/jkms.2020.35.e38
  5. Miller, T. L., Kaeding, C. C., & Rodeo, S. A. (2020). Emerging Options for Biologic Enhancement of Stress Fracture Healing in Athletes. Journal of the American Academy of Orthopaedic Surgeons, 28(1), 1–9. https://doi.org/10.5435/JAAOS-D-19-00112
  6. Warden A, Davis I, Fredericson M. Management and prevention of bone stress injuries in long-distance runners. J Orthop Sports Phys Ther. 2014;44(10):749e765. https://doi.org//10.2519/ jospt.2014.5334.
  7.  Sanderson, S., Raab, S., & Moch, P. (2012). BMI and EAT-26, Predictors for Low BMD? SAGE Open, 2(1), 1–5. https://doi.org/10.1177/2158244012441604
  8. Gardner LI, Jr., Dziados JE, , Jones BH, , et al.. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988; 78: 1563– 1567.
  9. Snyder RA, , DeAngelis JP, , Koester MC, , Spindler KP, , Dunn WR. and Does shoe insole modification prevent stress fractures? A systematic review. HSS J. 2009; 5: 92– 98. http://dx.doi.org/10.1007/s11420-009-9114-y
  10.   Salzler, M. J., Bluman, E. M., Noonan, S., Chiodo, C. P., & de Asla, R. J. (2012). Injuries Observed in Minimalist Runners. Foot & Ankle International, 33(4), 262–266. https://doi.org/10.3113/FAI.2012.0262
  11. Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. 1997.

High Risk vs Low Risk Stress Fractures

High Risk vs Low Risk Stress Fractures

By Steve Manning – intraining podiatrist and coach 

Not all stress fractures are equal.  Low Risk Stress fractures are much more common but they heal quicker and have much fewer complications.  High Risk stress fractures in comparison are at risk of non-union and delayed healing and are much more likely to develop into a complete fracture.
 

HOW COMMON ARE STRESS FRACTURES?

More than a third of distance runners will experience a bone stress injury.  Stress Fractures are thought to make up around 20% of injuries in runners.
 
The most common stress fractures are in the forefoot (Metatarsals) and the leg bones (Tibia and Fibula).  Less often are stress fractures in the midfoot and heel (Tarsals), the thigh bone (Femur), the kneecap (Patella) and even in the big toe (Hallux).
 

WHY DO YOU GET A STRESS FRACTURE?

Bone Stress injuries are usually the result of repetitive chronic overuse.  When you stress your body at a level to which it is unaccustomed, the tissue response is to adapt and remodel so that the body is better able to cope with the same stress in the future.  In your bones, this triggers special cells called osteoclasts to go in and eat away the bone so that other cells called osteoblasts can then lay down new stronger bone with a higher bone density and alignment towards the direction of the force.
 
This process takes around 5 to 6 weeks to occur.  If the stress increases or continues without recovery weeks then the result is that you are stressing a bone that is weaker while it is remodelling.
That is why stress fractures usually occur around 6 weeks after there has been an increase or change in training.  It is also possible to have a stress fracture from a single traumatic like a sprain, fall or contusion but that is rarer. 
 

DIAGNOSIS:

We can often make a clinical diagnosis of a stress fracture from history and palpation.  If the patient is just willing to do the time then we can review it before they return to running.  If it is not clear and the patient has a race they want to do then we will refer for an MRI.  There is an MRI classification system for bone stress injuries that classify by the depth of the swelling and findings on T2 and T1 images.  If the fracture has not healed in the normal time then we will suspect a high-risk fracture and refer to an MRI immediately.  All stress fractures in someone with low bone density or osteoporosis should be considered to be high risk.
 

WHAT IS A HIGH RISK STRESS FRACTURE?

The location of the stress fracture determines the risk classification. When weight bearing different bones or parts of bones undergo either compression or tension.
 
Compression vs Tension in the leg bone (Tibia)
Compression forces are much more likely to lead to a stress fracture especially in long bones.  
In the Tibia the lower half of the inside border undergoes compression during weight bearing so that is where most of the tibial stress fractures occur.
 
The front or anterior border experiences Tension with normal weight bearing. For this reason, normal weight bearing pushes the medial border stress fracture edges together encouraging healing while the anterior border stress fracture is pulled apart leading to non-union.
 
Compression vs Tension in the metatarsal bones  (The long bones of the feet)
The same thing occurs in the metatarsal bones which make up the front part of the arch and foot. 
Stress Fracture Risk by Location cropped scaled 
On normal weight bearing the top of the bone has compression and the bottom of the bone has tension. The vast majority of metatarsal stress fractures occur in the midshaft area.  The treatment for these common low risk fractures is to cease running and jumping activities.  Normal weight bearing with walking will help the healing process so the use of a boot is not indicated.  Long periods in a boot will lead to a loss of bone density, delayed healing and a much longer return to sport.
 
However, if the stress fracture is in the base of the second metatarsal then this is a high risk fracture.  Normal weight bearing will prevent the union of the fracture and a boot is critical to healing despite the loss of bone density.  In some cases even a boot may not be enough and surgery will be required to have a resolution of the fracture.  A recent study found that low running mileage was a factor linked to a greater risk of a high risk fracture in the base of the second metatarsal.
 
Some bones like the navicular, fifth metatarsal and femur are always high risk fractures.  They require a reduction of weight bearing for an extended period with either a boot or crutches.  
 

RECOVERY TIME?

The size of the bone determines the duration of the recovery time.  Metatarsals take the least amount of time – between 4 and 6 weeks off running.  The Tibia and the Calcaneus will take 6 to 8 weeks and the femur will be 12 weeks.  If the fracture is at a high risk location then the recovery period should be at the high end of the range and may take even longer.
 

TREATMENT:

Stress Fractures are an injury that needs you to stop running.  You can do any activity which does not hurt but be careful of not getting another injury from your cross training.  Only high risk fractures should be immobilised.  There are no treatments or exercises that have been shown to make any significant difference in your recovery time.  However, maintaining some non-running activity will help your return to running.  
 
Once you have recovered you should get a review of your training and a return to running training plan.  It also might be worthwhile to investigate other contributing factors like your foot structure and biomechanics, your running shoes and your diet.  
 
At the Intraining Running Injury Clinic, we can help you diagnose your running injuries and create a treatment plan.  We are running coaches as well as being Podiatrists or Physios.  We have extensive experience in helping runners get back on the road as soon as possible.
 

Steve’s Tips for Stress Fractures:

 
1.   Suspect a stress fracture at a high risk location then an MRI must be done.
2.  Do not run or jump during the required recovery phase.
3.  Maintain fitness and activity with cross training.
4.  You can do any activity that does not cause pain.
5.  Avoid the use of crutches or a boot at a low risk location to reduce recovery time and the rehab period.
 

Come and see us at 535 Milton Road, Toowong 

Your Running Injury Helpline

(07) 3367 3088 | [email protected] | Book an appointment 

WORN OUT SHOES OR WORN OUT BODY

WORN OUT SHOES OR WORN OUT BODY!!

How do you know if it’s the shoes, your training, or…   ‘gulp’…   your age. 

With Margot Manning, podiatrist, coach and runner

We all have those runs you slog it out and your body just does not seem to recover.  

While there are many possible reasons for this there are two biggies that you need to check first, and I’m not going to let you use ‘age’ as the excuse!!

Firstly, no one needs to admit that age is the reason for feeling flat and worn out.  We all know how to modify our training to suit the next decade of life.  This means that it’s either training, our shoes, or a combination of both that could be contributing to feeling worn out.  

The important message for you is to recognise when you are not feeling great and take the steps to regain your bounce and keep loving your running.  

Here are 3 signs you need to recognise and act on.  

1.Throbbing feet

Throbbing feet = old shoes…   (usually!!)

That is the most common reason for knowing your shoes are dead.  This usually happens after your long runs or towards the end of them.  You may even have felt a bit flat in your run.   Your feet and legs will have a tender or dull achy sensation.  

Don’t hesitate on this one. Race into you our running shop and get yourself a new pair.   It only leads to more trouble if you don’t change your shoes soon!!  

2. Old injuries resurface or a new niggle starts

Niggles can be signs of fatigue after an increased training load or old shoes that cause pain.   Before you let this one turn into a full-blown injury, check your SHOES and your TRAINING.

Shoes wear out and it’s surprising how fast the months went by since you purchased your last pair.  Combine this with an increase in your training and little niggles just keep popping up.  

Training can have a huge impact on your body, particularly if you have increased the load, or moved into new programs and over different surfaces.  

3. You’re not sleeping or feeling extra tired at work

Failure to launch is a true phenomenon for a runner.  This happens when your body is not recovering as fast from your training as you would like and you struggle to get out of bed.  You will fatigue faster and be less productive during the day.  

If you don’t have a recovery day soon you can even lose your appetite.   Take a day or two off from running if this is you.  You’re worn out body will feel so much better, less cranky and be excited about your next run.  

HERE is an easy check for your running shoes. 

If you answer YES to more than three of these then you need to check your shoes.

My running shoe checklist...

 

If you are still not sure why you are feeling worn out, an easy test is to come into our intraining store and have a run in a new pair of shoes.  Your tired and worn out body will immediately feel that freshness and bounce missing from your runs.   

At intraining we look after your feet, we write programs, and we manage injuries.  Running shoes are our specialty.  You’ll really love our running track because you can feel the difference between new and old shoes when you try them out.  

 

 

Come and see us at intraining for all your running needs or 

CALL us on 07 33673088 for Shoes, Podiatry, Physiotherapy, and Training Programs. 

 

Looking for some help with your running shoes?

Here are 3 ways you can use our services at intraining Running Centre when you need some help with your running shoes:

#1  Come into the store and see our Running Team.  

They will have you try on and run in a range of shoes until you find the right one.  Plus they LOVE to talk running and hear what you are wanting to do with yours

#2  Book a shoe fitting appointment with Steve, Doug or Margot (Our Podiatry and Physiotherapy team).

We are all runners and have worked with runners for years.  This works really well if you have more difficult feet to fit, or you are just unsure.  

#3  For Injuries… 

You’ll need to book in to see our Running Injury Clinic team.  We can help you treat, manage and get you back to running. 

Your Running Injury Helpline 

(07) 3367 3088 | [email protected] | Book an appointment

How to treat shin pain

How to treat shin pain?

Shin splints are a generic term that many runners use to broadly cover shin pain. Sports medicine practitioners have needed to develop more specific terms to differentiate conditions and treatments required when addressing shin pain.

These terms try to reflect the tissues affected and their different causes. Whilst some shin pain may present similarly, it is important to correctly identify the pain and provide appropriate treatment. Below are common shin pain issues we see at intraining Running Injury Clinic.

  • Medial tibial stress syndrome
  • Stress fracture
  • Compartment syndrome
  • Nerve entrapment
  • Muscle and tendon strain

Below we briefly describe; how to diagnose shin pain, common symptoms and how to treat the injury appropriately. If you have shin pain that is holding you back from enjoying your running, click the button below to make an appointment to see one of our podiatry or physiotherapy team.

Make an appointment to see Steve
Steve Manning (podiatrist, coach and runner)

 

MEDIAL TIBIAL STRESS SYNDROME

Diagnosis

The most common cause of shin pain is medial tibial stress syndrome. This pain hurts along the inside of the shin most commonly in the lower half and isolated to the medial border of the shin bone, the tibia. It is an inflammation of the tibial skin, called the periosteum, where the fascia of the leg attaches. The fascia is the stiff layer of tissue that holds all the muscles in place. Little tears occur along this attachment causing inflammation and pain.

MTSS Pain

Symptoms

The pain can sometimes hurt after waking or rest but most commonly hurts at the beginning of a run before warming up. When bad it can begin to hurt again at the end of a run and will hurt a lot afterwards.

Treatment

Treatment involves a direct icing technique for a few days with the addition of a gentle distraction massage after that time. Screening for any underlying biomechanical causes may be necessary if continued running aggravates the injury. Extended rest is not recommended as the scar tissue may become more entrenched and harder to resolve in the long run.

Prognosis

Prognosis is generally quite good with a significant (greater than 50%) reduction of pain within a week and complete resolution within a month.

STRESS FRACTURES

Diagnosis

Medial tibial stress syndrome that goes untreated may lead to more severe injuries to the bone like bone stress or stress fractures. Stress fractures are most commonly found on the inside (medial) border of the tibia but may also occur on the front (anterior) border. It is often overtraining that is the culprit, where it has occurred more than a month prior to injury onset.

MTSS Pain1Symptoms

Pain usually occurs at the start of a run and gets worse without going away. It can ache afterwards and sometimes the pain will wake you at night. Pain is usually localised to a spot on the bone and may hurt on both borders and the shaft. Normal x-rays may pick up a stress fracture after 3-4 weeks but an MRI is the best scan to use.

Treatment

Unfortunately bone injuries are one of the few injuries that require complete rest from activity. If it is bone stress than after a week there will be significant improvement in point tenderness while a stress fracture will take at least three weeks. With bone stress you can return to running when the pain is gone but stress fractures require 6 to 8 weeks of no running. Once the stress fracture has healed adequately there is less chance of recurrence in the same location.

COMPARTMENT SYNDROME

Diagnosis

A compartment syndrome can be defined as the increase in pressure within the limited anatomical space of a fascial compartment which compromises the circulation and function of the tissues within that space. If compartment volume is limited or decreased due to tight or thickened fascia then compartment pressures can increase upon normal muscle swelling during exercise. The anterior compartment muscles are most commonly affected in running.

Symptoms

Generally there is no pain at rest or at the start of a run. Pain comes on at a certain distance of each run and is quickly too severe to continue. The muscle feels tight and may be firm to the touch. Within a few minutes of stopping the pain has gone completely. If the anterior compartment is affected, the foot may ‘slap’ excessively when running. This is because the purpose of the anterior compartment muscles are to control ankle movement as the runner lowers the forefoot to the ground after heel strike.

Treatment

Non-surgical treatment includes changing biomechanics through form modification, change in footwear or orthotics. Avoiding hills or rough surfaces may help as will a reduction of training below the threshold distance of onset of symptoms. Icing and Myofascial release massage techniques can help to release the adhesions between fascia and muscle that may be causing the compartment syndrome.

Prognosis

While immediate improvement can occur complete resolution can take a very long time. In some cases surgical intervention is the only successful treatment.

NERVE AND VASCULAR ENTRAPMENT

Diagnosis

There are more rare forms of shin pain may mimic some of the more common injuries as described above. Entrapment of the popliteal artery has the same symptoms as compartment syndromes but the onset seems to be more related to intensity of activity rather than duration. Neural entrapments can feel like stress fractures but have less consistent symptoms.

Symptoms

Arterial entrapment will give a lack of pulses at onset which does not occur with chronic exercise induced compartment syndromes. The symptoms of neural entrapment can be reproduced by palpation or percussion of the affected nerve.

Treatment

Physiotherapy is the best initial treatment however surgery may be required.

MUSCLE AND TENDON STRAINS

TibialisPosteriorDiagnosis

The posterioral tibialis muscle is the most common strain in the shin. This muscle acts to control pronation in a similar way that the anterior compartment muscles control ankle motion. The peroneal muscles on the outside of leg, control supination of the foot (roll out), to prevent ankle inversion sprains. Peroneal muscles may also be strained. Pain is usually related to activity and may last for a long time after a run. Pain may occur during other activities of daily living.

Symptoms

Damage may just be normal delayed onset muscle soreness (DOMS) caused by unaccustomed activity or it may be more severe rupture of muscle or tendon. More commonly there was a traumatic event that occurred to cause the injury.

Treatment

Treatment requires rest and icing for 72 hours. Massage, stretching or heat during this time will make the injury significantly worse. After the 72 hours then a gradual return to activity with massage, stretching and continued icing should see most strains resolve within a week. If the tendon was damaged, or if it was a chronic strain, then a much longer rehab period will be needed.

Summary

From these brief descriptions of some of the more common injuries you can see how important correct diagnosis and treatment can affect the outcome and subsequent return to exercise. Incorrect diagnosis can prolong the healing period and can also lead to further injury and increased delay in return to activity.

Steve Manning is the owner and CEO of the intraining Running Centre and works as a podiatrist at the intraining Running Injury Clinic in Milton.

If you have shin soreness and want to get back out and running as soon as possible, visit the intraining Running Injury Clinic. Our podiatry and physiotherapy are all runners and understand how important it is to correctly diagnose and treat your injury to ensure you can return, pain free, to running as quickly as possible.

For bookings, please call us at the intraining Running Injury Clinic on 3367 3088, or book online.

 

Is your gait causing shin pain?

Article by Doug James (intraining physiotherapist and podiatrist)
Article by Doug James (intraining physiotherapist and podiatrist)

Gait related shin pain

Running injuries are common. In a given year, runners have a 70-80% likelihood of developing an injury that will prevent them from running pain free for at least a week. While there are many different types of injuries that can occur, some people may be more prone to a particular injury while seemingly resistant to others. There are a lot of different factors that can account for this including age, sex, training history, biomechanics (and more) however of these, running technique is one of the few factors that can be changed.

It needs to be mentioned that no particular running technique can guarantee that you will be injury free. Different, and sometimes worse injuries can develop when people attempt to change their running style. The aim of this article is understand the types of shin injuries that can develop from running, and the factors influencing them.

Shin injuries are commonly lumped under the umbrella term of ‘shin splints’ by some medical professionals. This rather obtuse term neglects the specific location, onset and severity of the injury – all factors required for correct diagnosis and subsequent treatment.

Make appointment

Running can cause injuries to muscle and bone in the shin
Running can cause injuries to muscle and bone in the shin

 Antero-lateral shin pain

Pain on the outside part of the front of your shin is usually related to the Tibialis Anterior muscle. This long muscle is responsible for lifting your foot upwards at the ankle joint. The muscle can become overworked if subjected to more exercise than it is used to and tends to become sore after the run, with pain disappearing a few days later. This injury is frequently seen in those that are new to running, or returning after time off from the sport. People that tend to heel strike (i.e. land heel first) are far more likely to be affected by this injury, and athletes are also more at risk if running in incorrect footwear – particularly if the shoe is too stiff (resulting in foot slapping), or lacks adequate pronation support.

Heel striking occurs when the runner’s heel lands on the ground first – usually in front of their centre of mass – and the further in front, the more of a problem this poses. In this position the Tibialis Anterior muscle is working to have the toes lifted higher than the heel to prevent tripping. The forefoot then rapidly lowers putting further strain on the Tibialis Anterior as it is responsible for the controlled descent of the foot. Once the foot is flat on the ground, the Tibialis Anterior may be subject to further strain if the foot heavily and/or rapidly pronates (rolls inwards).

The Tibialis Anterior can be put under even greater levels of strain when running downhill as this tends to amplify the slapping movement of the heel-to-toe progression.

Key points you should know

  • Your running technique can predict the type of injuries you get
  • “Shin Splints” is a commonly used term but utterly innaccurate
  • A running assessment can help identify faults leading to shin injuries

Postero-medial shin pain

Pain felt on the inside part of the shin along the edge of the tibia (shin bone) is often diagnosed as Medial Tibial Stress Syndrome (MTSS), or more recently known as Medial Tibial Traction Perisostitis (MTTP). Irrespective of the nomenclature, the injury usually begins as a broad area of discomfort along the inside part of the shin. This usually starts as a mild discomfort at the start of the run, but resolves after a few minutes. The pain is usually a response to an increase in loading along the edge of the tibia causing swelling around the periosteum (outer lining of the bone) initially, which can progress to bone damage thereafter. The increased loading is usually from higher running volume or intensity (or both) than is usual. Conjecture exists as to whether damage is due to force generated at foot strike, associated muscle tension from the Posterior Tibialis muscle, or some combination of both.

Training load plays a large role in the development of this injury, however there are certain gait factors that may increase the likelihood of developing it. Over-pronating can play a part in increasing the tension in the Posterior Tibialis muscle, which in turn exerts a traction force on the tibia. Overstriding (landing too far in front of the centre of mass) increases the initial impact forces transferred through the lower limb and shin that can also damage the tibia. Additionally, running in shoes that offer insufficient cushioning (i.e. are worn out, or offer less support than the athlete is accustomed to), and under-pronating can increase shock that also affects the tibia and lower limb.

Worse still…

Overstriding and heel striking are two common factors in shin pain
Overstriding and heel striking are two common factors in shin pain

With both of the injury areas mentioned above, after a sufficient reduction in training (and in some cases complete rest) for a suitable period, the injury will recover and heal. There are two notable exceptions to this however – shin injuries where pain becomes worse with running need to be investigated immediately. Sharp localised pain (on the front or side of the tibia or fibula) can be the sign of a stress fracture and should never be run on as this will steeply increase the injury severity and healing time required. Management usually involves rest (the amount of which can be calculated somewhat more precisely with the aid of an MRI scan), a fracture boot (in some cases), and a considered return to exercise plan.

The other critical shin injury not to miss is compartment syndrome. This is a dangerous injury where pressure builds up in the muscle sheath persisting for hours after exercise and can lead to permanent damage to the muscle and nerves in the leg and foot. This often requires surgery. If you suspect you have a stress fracture or compartment syndrome this should be investigated immediately.

For the injuries mentioned earlier, specific changes in running gait, footwear, and training can help to reduce the severity and reoccurrence of these injuries and possibly lead to better performance as well. If you’ve been dealing with running related shin problems, contact the intraining Running Injury Clinic for an appointment.

600x600-workshops-logoIf you are training more without realising the benefits of increased performance, it may be a simple modification to your running form that will result in the benefits you are looking to achieve. The intraining Running Injury Clinic conduct running form workshops on a regular basis.

If you are interested in improving your running form or reducing your risk of injury, sign up for the Running Form Workshop on 8 October or 3 December 2017.

For more From the Sole injury articles click here.

RunTalk Ep10 – Footwear choice

runtalk-intraining-logoWelcome to RunTalk episode 10 with Steve and Margot Manning.

This week we discuss footwear, footwear development over time and how footwear choice can impact your running enjoyment as well as your risk of injury.

Click here to listen to episode 10 of RunTalk

Episode 10: Footwear choice and how you move.

Running footwear has developed significantly over time, especially since the introduction of EVA (Ethylene vinyl acetate), the foam cushioning, that most shoes use today which help absorb impact. In the modern era further development has ensued encouraging a more natural motion of the foot and how footwear can aid your running gait instead of blocking certain motions. Listen up and learn with Steve and Margot and how you can select the best footwear to suit your running gait.

Podcast10_ImageClick here to find out more about how intraining Running Centre footwear specialists can help you select the right fit for your foot.

About Steve and Margot

  • Steve and Margot have been in the footwear industry since 1979 and 1990 respectively
  • Owners of intraining Running Centre
  • Experienced running coaches
  • Podiatrists and footwear specialists

Click here to view our wide range of running injury, footwear and other related running articles. Remember to check out Footwear – A paradigm shift article mentioned in this week’s footwear edition of RunTalk.

RunTalk Ep06 – Stress Fractures

runtalk-intraining-logoWelcome to RunTalk episode 6 with Steve, Margot and special guests this week – running parents; Aidan and Peta Hobbs and Clay and Michelle Dawson. Aidan Hobbs and Clay Dawson are both intraining sponsored athletes who have both experienced injury set backs and come back stronger upon return. Both Aidan and Clay have recently become parents and have also both been crowned Brisbane Marathon Champions in 2008 and 2013 respectively.

This week together with our guests we discuss stress fractures; how to identify a stress fracture and common areas that stress fractures occur. We also discuss with our guests the changes required to run as a new parent as well as how to create a routine around the rigors of family life.

Click here to listen to episode 6 of RunTalk

Episode 6: Stress fractures and running as a new parent.

AidanHobbs
Aidan Hobbs on his way to 16min 5km

Unfortunately, stress fractures are fairly common in runners and often occurs as a result of overuse, inadequate recovery and even poor footwear choice. Listen up and learn how to determine if you have a stress fracture, where fractures are common and why the occur. We also get some insight from our guests on how to make the most of running as a new parent and ways how to incorporate training sessions with the family.

About Aidan:

  • 2008 Brisbane Marathon Champion
  • 1500m: 3.59 (2016)
  • 3000m: 8.50 (2017)
  • 5000m: 14.59 (2017)
  • 5km with a pram: 16.28 (2016)

About Clay:

  • 2014 Brisbane Marathon Champion
  • Marathon PB: 2.30.44
  • ClayDawson
    Clay Dawson on his way to another Brisbane Road Runners Club title

    Half Marathon: 1:10

  • 10km: 31.20

Article: Interested in finding out more about Stress Fractures and Bone Stress? Click here to view the full article

Stress fractures and bone stress

STRESS FRACTURES and BONE STRESS

What is a Stress Fracture?

A stress fracture is a hairline crack within the bone. Unlike a complete fracture the break is not displaced and does not go across the whole bone. Stress Fractures are usually caused by chronic repetitive stress rather than a fracture event like a fall.  50% of stress fractures in runners are in the shin bone (Tibia) with the bones in the forefoot before the toes (metatarsals) and the heel bone (calcaneus) also common.

What are the Symptoms?

Stress fractures are often preceded by progressing bone stress over a period of a few weeks.  Bone pain can be intense but usually is described as aching.  When running it hurts on impact and gets worse rather than warming up.  There is localised severe pain on palpation commonly with swelling over the bone.  It hurts to hop but often is fine walking.  In some cases there will be pain at night waking you from sleep.StressFracture

What Causes Stress Fractures?

The most common cause of stress fractures is overtraining.  Most runners have increased or changed their training 5 to 6 weeks prior to when pain began.  The increased training stimulates the body to try and adapt and grow stronger to deal with the new training load.  The bone responds by bone turnover involving reabsorption of weak or damaged bone and the laying down of new bone.  While the bone is remodelling it is susceptible to a stress fracture if the training is continued at a high level.  This is because bone formation can not keep up with bone absorption.  Low bone density can increase the likelihood of a fracture as well as running in worn shoes, excessive downhill running and overstriding.  Rigid feet have an increased risk of stress fractures compared to flexible feet.

What Do I Do?

If you suspect you may have a stress fracture you should have it checked ASAP by a Podiatrist.  Clinical diagnosis with history and palpation can identify a stress fracture in most cases however you may need to have an MRI to be definitive.  Bone edema from a stress fracture shows up as a white patch within the body of the bone on a T2. Normal X-rays will rarely show a stress fracture and then only after 2-3 weeks.

Treatment involves complete rest from running.  Early return before it has healed can restart the rehab time.  If you continue to run with a stress fracture it can then lead to a complete fracture with much more severe complications.

When can I get back running?

The size of the bone determines the time required for healing.  It can be as little as 4 weeks for metatarsals to 12 weeks for femurs.  You can do any cross training that does not hurt while it is healing.  After a stress fracture has healed it will be stronger for up to six months with less chance of another fracture in the same place.  A rehab return to training program will then be needed to make sure you do not pick up another injury.  It is worth checking out your biomechanics, footwear and training at the intraining Running Injury Clinic to see what might have caused the injury in the first place.  That way you can reduce your future stress fracture risk.  Treatment to reduce the risk of another fracture can involve changing your running technique, finding the right shoe for your biomechanics and customising your shoe with orthotics.

StressFracture1Common TYPES of Stress Fractures?

•  A stress fracture of the HIP (Pubic Ramus) usually starts as groin pain and can be difficult to differentiate from a muscle strain in the groin.  Sometimes the pain refers into the buttocks. This is the most dangerous type of stress fracture if it goes on to a complete fracture because of the complex network of muscles around the hip.
•  A stress fracture of the Thigh Bone (Femur) is rare in runners.  Because it is such a large bone it can take up to 12 weeks for the bone to heal.  Fractures can occur at the neck or shaft of the femur.
•  Stress Fracture of the Shin (Tibia) is the most common Stress Fracture in runners.  It usually starts with aching shins.  Runners who continue to run with shin pain may lead to a stress fracture.  The most frequent location is on the inside border of the bone of the lower leg.  Fractures of the front border of the bone take longer to heal because standing causes tension rather than compression of the fracture line.  Fractures of the posterior border are often mistaken for calf strains but also will take longer to heal.  The other lower leg bone (Fibula) can also get a stress fracture although it is from muscle tension rather than impact forces.
•  Stress Fracture of the Heel (Calcaneus) was the first type of Stress fracture discovered by a French army physician in the 1900’s.  It can be mistaken for plantar fasciitis but the bone will hurt to squeeze on both sides at the same time.  Hurts on impact and runners will often avoid heel striking when running.
•  Stress Fracture of the Metatarsals are the quickest to heal because they are the thinnest bone. The second metatarsal is the most frequent one damaged because it is the longest metatarsal and takes the most load. Swelling can extend across the top of the whole forefoot.

Keen to learn more about running injuries? Check out our monthly ‘From the Sole‘ newsletter, written by intraining Running Injury Clinic podiatrists, physiotherapist and dietitian.