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On today's episode, treatment and prevention of shin splits with Shreen Lasheen. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brodie. I'm an online physiotherapist treating runners all over the world, but I'm also an advert runner who just like you have been through vicious injury cycles and when searching for answers, struggled to decipher between common run... myths and real evidence-based guidance. But this podcast is changing that. So join me as a run smarter scholar and raise your running IQ so we can break through the injury cycles and achieve running feats you never thought possible. It's been a while since I've been unwell. Sounded a bit nasally, so apologies for that. And throughout this interview, but today we have Shereen Lashene, who is a researcher. She's got two amazing papers on shin splints. And one of them being the effects of hip abductor strength on pelvic drop and knee valgus, which is like the caving in of the knee on people with shin splints. And the other looking at the muscle strength. So hip muscle torque in runners with medial tibial stress syndrome, also known as Shinsplints two days ago at the time of recording, she just submitted her PhD. So congratulations on that. And Shreen just talks about an amazing amount of information on Shinsplints. It's a real practical takeaway type of episode. So you're absolutely going to love it. I'll include the links to Shreen's social media in the show notes. If you want to follow her and learn more and let's dive into the interview. Shreen, thank you very much for joining me on the podcast today. Thank you for you. I'm so happy. to be with you today. Happy to discuss all your findings and all your background. So let's get started there. Can you introduce people to yourself and your academic career? Okay. My name is Shreena Sheen and I am a graduated from faculty physical therapy care university in 2012. And at that time I started practicing running as kind of self care and to lose weight. Then I started my master's degree in 2015 and in 2019. Then I started my PhD and I just finished it two days ago. For my career or physiotherapy practice, I spent eight years practicing sports medicine in different gyms. FIPERS, REVIVE, and the Gold Gym in Egypt, in parallel with being a musculoskeletal disorder physiotherapist senior in an outpatient clinic in the Faculty of Physical Therapy, Cairo University. Then I started my job as clinical physiotherapist in one of the medical international organization, Medicine Sam Frontiers, Project of Egypt. It's an international organization that provides medical support for refugees in Egypt. Then, because the project has been closed, I transferred to my current job as an academic instructor. So, currently, my position is assistant lecturer of orthopedic physical therapy. Insha'Allah after getting the PhD degree, I will be a lecturer of orthopedic physical therapy. Excellent. And I saw you have a couple of papers on medial tibial stress syndrome or shin splints. So what got you interested in that? Because when I started practicing running, I had a chest plant at that time, in 2012. And when I asked my running coach, Albir Sobhi, what is this injury, because it stopped me to continue my run. I started to run two kilos, then I can't continue. and my target was 7 to 10k. So he told me that this kind of pain, every beginner in the running experienced this kind of pain, but because this area of the leg, there is no muscles over it, over the middle or the last third of the medial border of the tibia. we can't explain this pain as a kind of muscle injury or muscle strain. It's something related to the bone itself. But if you do an x-ray for this bone, the result will be normal findings. There is nothing. So at that time, it's a kind of, we don't know what is that, but we can't continue to run. And he told me that this injury may be an injury that called the chin splint, but he doesn't know much about it and because he is a running coach and me is a physiotherapist, I should know more about it. Then he asked me to search about this point. At that time, this is the main point why we are searching about this point and when I started my Master degree my supervisor, Professor Dr. Ibsim, she asked me to choose a point which related to clinical practice It will be more real and we can be More curious about it because we have it in clinical practice not just something related to research That's why I am really into HNS plan What's your understanding now, like based on your years of looking at this pathology? I know that's what the therapist was saying at the time when you very first started running, but has your understanding of shin splints changed? Like if you were to try to explain to a runner now who has shin splints exactly what's going on, how would you best describe it? There are two theories that explain the pathology of a shin splint. Firstly, let me define what is a chest plant according to the literature now and according to my clinical practice, it's a running related injury. It's an overused injury due to excessive weight bearing in activities such as running, especially when you hit the ground strongly in each step, not each running cycle. It's each step you hit the ground strongly. the ground reaction force on your limb, how your limb will be affected with this ground reaction force and the balance distribution of this ground reaction force going upward and how your body weight transmission, is it balanced or not balanced, going down through your leg. This is the point. So the two theories which explain the basophysiology or the basology of this injury, pain is secondary to inflammation of the periosteum of the tibia, which means inflammation of the outer layer of the bone itself. And this is due to excessive traction of the posterior muscular compartment which is soleus or tibialis posterior. And the second theory is that overloading of the bone itself which lead to micro damage and it affects the remodeling of the bone itself. This is the two theories. So you need rest. You need to take medications like anti-inflammatory medications. The running program that you will follow, it will be good designed and graduated. You can't increase your distance suddenly. You should gradually increase your training distance and you should detect how your body adapts to your training. After how many kilos you... Experience the spin. This is, so like you were saying, there's two, I guess, competing theories of the pathology. Um, not many runners know, but your calf, part of your calf complex actually attaches onto the back of your shin, you might say. And so one of the theories being with the large force of the contraction force of the calf pulling on the bone as it attaches onto it, if that's done excessively can lead to the outer edge of that bone or the outer layer of that bone becoming inflamed as one theory. But like you mentioned, there's another competing theory about why people develop shin splints and it's the actual, I guess, the bone itself is bending or creating some sort of trauma based on the ground reaction force. And therefore the outer border of that bone starts to become inflamed. And so there's still those two competing ideas as to what the pathology entails. Is that correct? Exactly. Okay. And mainly a inflammatory condition with that outer border. Um, that makes sense. The idea with the, the problem with the shin is that there's a lot of other pathologies there as well. Some people are worried about stress fractures commonly on the shin and maybe less commonly, but like compartment syndrome can also be presented at the front of the shin as well. And so. What might help runners in terms of, are there any classic features, signs and symptoms, or, you know, characteristics that will clearly land them into maybe a shin splint category, as opposed to maybe something that might be a stress fracture or some other pathology? As you have mentioned, we need to differentiate a shin splint from two injuries, stress fracture and compartment syndrome. posterior or lateral, any compartment syndrome. And Chenous Plain, it seems to be a simple injury, but it's not that simple because the symptoms are aggravating with activity and subsiding with rest. So it seems to be simple because if I get rest for one week, the symptoms will decrease or relieve. But the point is that when you return to run, you will have the pain again. This is the point. If you have chest pain and you don't treat it, one of the bad complications is stress fracture. So you have to treat it. You can't continue to run with this injury. So to focus on how to differentiate it from stress fracture and from compartment syndrome. stress structure we have functional test which is one leg hop. You hope with one link. A runner with medial tabial stress syndrome can hop at least 10 times, but a runner with stress fracture can't without severe pain. This is the main functional test to differentiate between transplant and stress fracture. For the compartment syndrome, the symptoms of compartment syndrome are five keys. Pain, which is the same with transplant. Pale skin, this is not a symptom of transplant. Pulsillness, which is faint pulse, this is not included in transplant. Paraphysia, abnormal sensation, numbness or tendling, this is not included in transplant. And paralysis, it's not paralysis, but it's weakness with movement, weakness of the muscles, muscle fiber size but chinesis plant it doesn't include a motor sensory or any muscular abnormalities so the symptoms of a chinesis plant it's a diffuse pain and tenderness along the medial border of the which is the medial or internal part of the tibia. And it's related to excessive weight bearing. It induced by poor biomechanics. And the abductor muscle weakness is the main cause for this poor biomechanics as one of the internal factors. and because the hip abductors are the top of the lower limb chain, so if there is any weakness of these muscles there will be a contralateral pelvic drop and femoral internal rotation and consequently all the bones under the femur will compensate and change its position to compensate for this change in the femur which is higher femoral internal rotation, then there will be knee abduction, lateral patellar tracking, then there will be femoral tibial internal rotation, then ankle eversion, then foot pronation or flat foot. When you run with this abnormal biomechanics, this increases the medial ground reaction force on the tibia. which means inflammation of the spoon and overload of... A lot to unpack there. All right. Um, excellent for describing the functional tests. I think if someone has been told to do a single leg hop and they're unable to do one because of severe pain, we'd definitely send them for scans to see if there is a stress fracture. Um, also for the runners who aren't too familiar with the terminology. Shin splints is medial tibial stress syndrome. So we're talking like the inner border as you described, but some people can have pain on the outer border of the shin and think it's shin splints. So we need to be very careful with the location. You also mentioned it's more of a diffuse pain towards like the middle part or the distal third of the shin itself. Because to my understanding, if the pain is not widespread, it's a little bit more focal. That... might indicate more of a bone stress reaction. Would that be fair to say? Yeah, exactly. Okay. And then you mentioned as a factor that might be contributing to shin splints, we're looking at hip abductor weakness. So looking at mainly like the glute medius would be probably the more predominant hip abductor in single leg standing. And if that's not as strong in like stance in the the hip on the other side travels more towards the ground is what we call a contralateral hip drop, which then compensates everything else around. So if you're standing on one leg, we're looking at or if we sort of capture a runner who is at mid stance, we're looking at the opposite side of the hip dropping towards the ground, we are looking at the stance leg, the knee might travel more towards the midline and the femur or thigh itself might like rotate inwards a little bit. And then that just causes a cascade of biomechanical changes further down. So looking at maybe the, the shin internally rotating or the foot pronating or becoming more of a flat foot and therefore causing stresses, um, unevenly into the leg and then maybe leading to higher stress in that inner border of the shin. Is that fair to say? Yeah, and I want to add a point. As a runner, if you participate in a running event and you want to make a specific timing, it's not only related to the pain, it also will affect your performance, your timing, because you take a longer time in each step to allow the hip abductors to eccentrically contract to rise the droped pelvis on the other side. So the timing will be longer in each running cycle. Okay, so their stance phase might be longer, their cadence might be lower, and they're sort of a bit more sluggish, less springy with their action, and therefore, you know, less efficient, therefore slower in terms of performance. Exactly. Okay. And when it comes to having shin splints, you mentioned that it is. Inflammatory driven. Uh, you mentioned rest is the, a good protocol taking some anti-inflammation medication, coming off it, deloading off it, which kind of makes sense if we're looking at it from a bone overload theory, because we know about bone stress reactions is we do need to significantly offload them to let the bone give the bone time to heal. But you know, with other running related injuries, sometimes it's okay just to load manage and still be able to run at, you know, low loads if symptoms are tolerated. So what's your best advice for runners in terms of running if they do have shin splints? When can they run? How much? How do we know when they can run those sorts of things? Okay, according to Sanford guidelines, rest is very important because if you don't have enough rest, it may develop to a stress structure. According to MRI grading, there are four grades. Grade one, you should take rest two to three weeks. Grade two, four to six weeks. a grade three, six to nine weeks and a grade four, it's like race. Would that be, would grade four be like a stress fracture per se? Yeah, before it's a MRI is very objective to detect the transplant. And your physician or your physiotherapist will find a median medial tibial border periosteum reaction and edema. So at that time and in correlation with clinical findings, he will detect that your grade and at that grade, grade four, it's severe pain that may affect not only your running, it will affect your functional day living activities. So at that grade. we advise on leg press. For the previous grade, you can after, for grade one, for example, after two to three weeks, you can return to sports, but gradually. Okay. Like you said, we should almost consider shin splints to be an early stage of a bone Um, if someone has just got a mild onset, early onset of these shin splint characteristics and they get an MRI and there's no periosteum inflammatory phase, should they still be taking time off? Um, maximum one week. Uh, but, uh, we can apply ice. We can take anti-inflammatory medication according to the physician and muscle relaxant for one week or two weeks according to the physician and the clinical correlation. You can also detect your foot and the appropriate choice for it because This is one of the important external factors to which surface you run on and which shoes you run on and is it suitable for your foot. So you can use choke absorbing insoles. If you have flat foot, you can use pronation control insoles or medial arch support. You can change your running surface if you used to run on a road asphalt you can change to pee on a synthetic tracks grass sand which will be more or will be a bedded ground that will absorb your body weight and then the ground reaction force will be less on your wound. Okay. So let's just say we've gone through, you know, stage one, phase one, some like two weeks off running and then things have calmed down, walking's pain-free, hopping, single leg hopping pain-free, we're ready to start running. We might consider some appropriate footwear, you might say, to sort of correct those mechanical changes you were talking about before. We might consider changing the surface. So maybe if you're used to running on road, changing to something that's a little bit softer. What about the running volumes themselves? Do you have any advice or any guidelines as to, should we would be walk running? Can we, you know, are there certain restrictions about the dosage and the timing itself? You can detect after how many kilos you experience the pain. As we know as physiotherapists, when you do rehabilitation for any orthopedic injury or sports injury, you train your patient or your athlete with exercises free range of pain. So the runner should detect after how many kilos he or she gets the pain. For example, if you run... you used to run for 7 or 10k then you get pain after 3. So we can run for one week 3 kilos then we gradually increase while we applying ice and kinesiotape. Kinesiotape will be very effective and there is a less number of researchers on kinesiotape in transplant but in other injuries It's very supportive when you apply it for support or for relieving pain. Using the proper shoes or just changing the insole will help you. So we're applying ice after running. And is that, you know, 15, 20 minutes standard application? Yeah. 20 minutes to 30. Okay. You mentioned kinesio tape. I'm assuming people can just Google kinesio tape, uh, shin splints to know how that's actually applied. Shoes. We've talked about the footwear before, and then just monitoring symptoms based on how much you can tolerate. So. Is it just like a trial and error of starting at a smaller distance, seeing how symptoms are and then based on how symptoms are making adjustments? Guidelines mention that you should decrease your training to 50% of how many kilos you use to run. They advise to run 50% of it. But if you have been, we can't ask you to just continue. Okay. I appreciate you sharing all of those helpful tips. Is there any like gimmicks or treatments out there that might be popular for people managing shin splints, but the research has shown is ineffective or even harmful? The treatment usually for physiotherapy, electrotherapy such as ultrasound, which is anti-inflammatory, shockwave, which will enhance the bone remodeling, ice, exercises such as stretching, which is very important because one of the internal factors are lack of flexibility and the muscle imbalance between anterior tibial group and posterior compartment. or posterior muscular group. So stretching, strengthening of calf muscle, balance exercise, and strengthening for dorsiflexors. This is the most popular exercises for transplant. Also, a kinesiotape or... according to your physician, anti-inflammatory medications, and muscle relaxant. I think all of this will not be harmful, but according to your case, is it or will be effective or not, it's according to your case and your grade and your functional activity. Do you take enough rest or no? Okay, so the interventions you listed, so like ankle, dorsiflexion, strengthening, shockwave, therapeutic ultrasound, stretching, some balance exercises. To my understanding, it seems like you're saying doesn't show great amount of evidence for being effective, but can be worth trialing for the individual to see if they find it personally beneficial. Fair to say? Yeah. Exactly. Okay. Um, what, what strength exercises would you recommend if you had someone with shin splints or if you had shin splints again, um, what sort of strength exercises would you do? Okay. Uh, according to my research, I believe that, uh, if you, uh, are looking for holistic treatment, you should treat the causes and the symptoms, not only the symptoms. So what I just mentioned, it's for symptoms. But if you want to treat the causes, you should add functional hip abduction strength training because the main reason and one of the internal factors are weakness of the hip abductors, which induce poor lower limb pimechanics. So you have to do the exercises for the symptoms. anterior tibial group, the posterior muscular group, a balance exercise because one of phases, the stance phase, you will be supported on one leg even though the floating phase, the post-lumbes are in the air which is 30% of the running cycle. So this exercise is a must. And the other techniques such as ice, rest, kinesiotape and medications, it's for pain and inflammation. So for the cause itself, which is the hip abductor, I advise on the five exercises of functional hip abductor strength training, which is pelvic drop, lateral step up. standing hip abduction with resistance, a side lying hip abduction with internal rotation and single leg bridge. And those five exercises, according to systematic review by Mouri Itel, 2020, who find that those five exercises are the most exercise which generate at least 60% of maximum voluntary contraction of the muscle. And according to the overload principle of training, to increase the muscle fiber size, you need to generate at least 60% of the maximum voluntary contraction so that you can increase the muscle fiber or you can facilitate the hypertrophy of the muscle. Can we go through those again? So the first exercise you went through was a, I think you mentioned like a hip raise or a hip hitch or a hip hike. Like some people might be familiar with those. Yeah. Okay. So we're standing on the, well, we'll do on both sides, but so you stand on one leg and the other leg. Yeah, I will stand. You can stand on a step or a box. Then you just. with one limb outside this box or this step and you just move your pelvis up and down. It's a kind of motor control and to just stimulate the muscles to know the motion itself and to do brain engram and with this movement in your motor cortex. Okay. Yeah. That's one of my favorite exercises to give runners. It is a bit awkward for people to appreciate like the actual movement that we're going for and to try to get the right activation because some people like to hitch with their lower back or something along those lines, but it does take a bit of practice, but I am a very big fan of that exercise. You mentioned standing hip abduction against resistance. So people would be standing and their leg would be straight, but then, you know, brought out to the side. You mentioned side lying hip abduction where people will be sidelining, they're just raising their leg straight leg up towards the ceiling. But you also mentioned internal rotation as well. Can you explain that? Yeah, with ankle internal rotation. Okay. So toes are pointing down. Yeah. Okay, great. And then a single leg bridge. Was that the other exercise? Yeah, it's different from side lying abduction with internal rotation. It's like bridging, but you raise one limb, one limb straight and the other limb hip flexion, knee flexion. So your body, when you go up, your body is supported on your foot and your head. When you do the bridge and one limb are straightened. Yeah. Okay. I think people can. Google a single leg bridge if they're not familiar with that. So you mentioned you have to be as heavy as like 60% of your maximum contraction for that. So how would you recommend people progress this exercise? Like how many sets and reps are we doing? And then how are we progressing? Yeah. Okay. For sets and repetition, it's a three sets, at least three sets, each set 15 repetition. And 15 seconds, wrist in between, to allow the muscle to get nutrition. And this is for the functional strength knee training. And minimum to get hypertrophy of the muscle, you need eight weeks. And for the balance exercise, it's three sets, each set 30 seconds. And you alternate between the two legs. And the normal progression of the balance exercise which is standing on two limbs, then with eyes open, then with eyes closed, then you can do movement forward, backward, side to side on a balance board or a Pusso Pull. Then you stand on one limb with eyes open and doing the same, then with eyes closed, then dual task. For stretching for the calf muscle, it's three sets, each set 30 second hold and between each set 30 second rest. Can you describe the actual stretch for people? You mentioned it was just a calf stretch. Yeah. Uh, while a long sitting, you can touch with your hands, your toes, and just it's static after your training, or you can do from standing position against wool. Uh, you just stand with one limb in front and one limb, uh, back and uh, you go forward with your hand. Uh, and, uh, back leg is a, uh, one that you are doing stretching for it. Okay. So like a standard calf stretch, I guess, bringing your heel down towards the floor. Um, okay. I want to touch base on massage because a lot of people have shin splints. They go to like a massage therapist or a manual therapist of some sort. And some of them might do this like really deep massage into the inner border of the shin. Is that effective at all? Yeah. The literature doesn't mention the massage a lot because it's inflammation, but it's kind of release. if there is tightness but there is not enough literature on it and I'm not sure if everyone will tolerate diffraction massage on inflamed area but we can do the massage for cuff muscle because in this case There is tightness of the tendon achilles and calf muscles and muscle imbalance between the anterior or anterior tibial group which is weak and the posterior group which is tight. So if you want to do massage it's preferable to be for the posterior part not for the inflamed part. Okay seems like that goes into the camp of Not a lot of research out there to show that it's effective, but nothing to, no evidence to show that it's ineffective. So let's just do a trial and error basis, but probably stay away from the inner border deep massage because it is an inflammatory condition. Maybe it's best treating or releasing the calf complex because some calf tightness been associated with shin splints. Yeah, exactly. Okay. If... A runner's listening and they don't have shin splints, but they want to avoid getting it at all costs or try to minimize their risk of developing shin splints as much as possible. What advice would you have for them? Okay. The development of challenge plant includes combination of internal and external factors. The external factors are running on hard surfaces using inappropriate shoes. So my advice to run on... softer surfaces like grass, sand, a synthetic track, then I prefer those surfaces, then treadmill and route. And if you would like to participate in running events or marathons such as the major marathons in the world, Tokyo, Chicago, New York City, London, you should adapt to the same. road you will experience in this marathon. So my optimum training, three times per week on softer surfaces and two days per week on a road or treadmill. If you want to run for seven days per week, it's okay, five days on softer surfaces and two days on road. And for truth, you should... detect or choose the appropriate shoes for you and its individual variations. If you have flat foot, choose pronation control in sole. If you run on hard surfaces, choose shock absorbing in soles. And this is for the external factors, for the internal factors. hip abductor weakness, you should strengthen it using the hip abductor functional strength training for the navicular drop choose the appropriate choice for lack of flexibility, do stretching each time and that's it. Okay, so if we lack in mobility, we'll do some stretches. If we are wanting to run multiple days a week, consider the softer surfaces and I would say definitely if you're wanting to increase your running mileage, make sure that we're taking the ratio of those services into account. I think it would be fair to say that a new runner doing a lot of running on the road is quite an abrupt shift to meet those demands. Um, I think that's very good. And then obviously, like you say, the, um, hip abductor strengthening as, as a good intervention as well. So thank you very much for that. this conversation. Are there any other takeaways, any other bits of advice that we haven't yet mentioned that you think might be helpful? No, that's all what I have. Just be gentle with your body, listen to it. Researches and knowledge is everywhere using the technology. Just read or ask anyone who have... the same experience. Excellent. Well, thank you for coming on and sharing this. Congratulations on submitting your PhD recently as well. I know that's a lot of hard work. It's been great. It's been like we've covered, you know, injury prevention, injury treatment, risk factors and all those sorts of things. And, you know, a lot of runners will take away a lot from this. So thank you very much for coming on. If you are looking for more resources to run Smarter, or you'd like to jump on a free 20 minute injury chat with me. then click on the resources link in the show notes. There you'll find a link to schedule a call plus free resources like my very popular injury prevention five day course. You'll also find the Run Smarter book and ways you can access my ever growing treasure trove of running research papers. Thanks once again for joining me and well done on prioritizing your running wisdom.