Save Yourself from Shin Splints!

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years… plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

I was so sick of reading crappy little articles with the same old advice. Seems like there’s about ten thousand that all say the same useless things. Thanks for the deep dive!

~Sandra Frank, Ottawa, Ontario

A year of shin pain and hardly anything but painkillers and ultrasound from doctors and physios. I was giving up! I thought I’d never have a nice long walk again. Actually I was even more discouraged after reading this book, because so many treatments are apparently bullshit. But then I started experimenting with some of the massage ideas, and bam! The nightmare ended! Unbelievable!

~Alison Fromer, "just a serious walker"

My shin pain has been very stubborn. I know as well anyone there’s no easy way to deal with this, and this book confirmed that! But I really appreciate the education. Even after a couple years of dealing with shin splints, I still had a bunch of nagging questions that this book really helped to clear up. That alone was worth the price, but there were also a couple rehab ideas I’d never come across. Totally worth it.

~Andy Flaco, New York runner

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

• Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
• Too negative specifically. Some are offended by about a treatment option that they personally use and like. Or sell.
• Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
• Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

This document and all of PainScience.com was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 44 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

July — New section: A new standard chapter for most PainScience.com tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

June — Science update: A small but good update giving some good scientific support to the rationale for reducing tibialis anterior loading. That was already recommended, but it’s on firmer foundations now. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2017 — New section: No notes. Just a new section. [Section: No pressure! Not compartment syndrome, but “biomechanical overload” syndrome.]

2017 — Like new: Rewrote discussion of shoes, surfaces, impact, etc. Several new references; recommendations haven’t changed much, but the explanation for them is greatly improved. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2016 — New section: Added a great, practical new tip for diagnosing and predicting medial tibial stress syndrome. [Section: Two really easy tests to both diagnose and predict medial tibial stress syndrome.]

2016 — Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2016 — Minor science update: Citation of Collins 2008, a review of icing evidence (or the lack of it), plus related editing. [Section: Icing for MTSS and compartment syndrome.]

2016 — Update: Careful and thorough editing/update of NSAID recommendations, especially with regards to safety. [Section: You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.]

2015 — New section: Made a new section dedicated to other causes, after adding a science update about a fascinating example of a rare cause of stubborn shin pain. [Section: Other causes of shin pain.]

2014 — Correction: Reduced confidence in the results of a major study of special footwear (Knapik, the subject of the last update). Later removed the citation altogether. [Section: The great pronation fizzle.]

2014 — New item: Added a brief but very well-researched review of platelet-rich plasma injection. [Section: Brief debunkery of several other therapies that you should be skeptical of.]

2014 — Minor update: Added a fun sidebar about a bizarre source of shin pain. [Section: Diagnosis: How do you know which kind of shin splints you’ve got?]

2014 — New section: A new section mostly based on a particularly striking new treatment story from a reader. [Section: A couple trigger point stories.]

2013 — Science update: Added another bad-news citation, and type of evidence. [Section: The great pronation fizzle.]

2013 — Science update: I didn’t really ever expect a science update about tuning-fork diagnosis. But here it is! See the concluding footnote. [Section: From high-tech to low-tech: the tuning fork test!]

2013 — Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.]

2012 — Expanded: Added much more detailed self-help information for trigger points. [Section: Confirming the role of muscle knots in shin pain by treating them.]

2012 — Science update: Weak but interesting new evidence on natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2011 — Minor update: Addressed some common fears about the threat of getting out of shape while resting. [Section: The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.]

2011 — Updated: Added new references to fascia science, regarding the alleged relevance of fascial contractility to compartment syndrome. This is also supported by a substantial new free article, Does Fascia Matter? [Section: Stripping: a popular massage techique for the shins.]

2011 — Minor update: Added reference to Kong et al, about the effect of shoe wear. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011 — Update: Now cautiously endorsing Oesh shoes. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011 — Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman. [Section: Introduction.]

2011 — Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

2011 — New section: Another substantial addition to the tutorial, the third in recent history. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2011 — New section: Another beefy new section for this tutorial, the second addition lately. [Section: Stripping: a popular massage techique for the shins.]

2011 — New section: Finally, long overdue, a new section on this topic (for all the running injury tutorials). [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2011 — Important new info: Where’s the fire? Recently I published a major new article about repetitive strain injuries, in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

2010 — Minor upgrade: Upgrade to the description of popliteal artery entrapment syndrome (PAES), which is often confused with compartment syndromes. [Section: A more detailed looked at the four most common types of shin pain.]

2010 — Minor upgrade: Repaired an alarmingly large batch of typographic errors. Amazing what slips through!

2010 — New cover: At last! E-book finally has a “cover.”

2010 — Minor update: Added results of a study of surgery for stress fractures in elite dancers. [Section: Surgery for shin pain.]

2009 — New section: An important new section on anti-inflammatory medications, notably including discussion of Voltaren® Gel, a worthwhile treatment option for shin splints only recently got into my radar. You can read about Voltaren in a free article as well as here in the tutorial, but the tutorial covers the topic specifically as it relates to each of the different kinds of shin splints. [Section: You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.]

2009 — Major upgrade: Major miscellaneous improvements to the section today. [Section: Stretching is probably mostly ineffective for all kinds of shin splints.]

2009 — Minor update: Added nutraceuticals to the section. [Section: Brief debunkery of several other therapies that you should be skeptical of.]

2009 — New section: Starting off with just a few items. More will be added in time, but there’s four good ones to start. [Section: Brief debunkery of several other therapies that you should be skeptical of.]

2009 — New section: No notes. Just a new section. [Section: Diagnosis: How do you know which kind of shin splints you’ve got?]

2009 — Huge upgrade: About a dozen new sections, many more footnotes, and widespread editing for clarity and thoroughness. Today this tutorial is now officially “extremely detailed,” like the other advanced tutorials on PainScience.com, and went up for sale.

2009 — New section: New section to explain and highlight evidence from Gaeta about the high prevalence of microscopic bone damage found in long-distance runners. [Section: MRI and CT scanning may be helpful.]

2009 — New section: No notes. Just a new section. [Section: Bone tired: medial tibial stress syndrome is probably about bone fatigue, not inflamed soft tissue.]

2009 — New section: No notes. Just a new section. [Section: Strengthening is probably also a completely ineffective therapy.]

2008 — Major upgrade: Several major revisions and corrections.

2008 — Update: Added colorful anecdote from the Canadian wilderness to illustrate the seriousness of acute compartment syndrome. [Section: Danger! Please do not try to run through shin splints! Acute compartment syndrome can be extremely dangerous!]

2007 — Major update: Clarified diagnostic information significantly by integrating important information gleaned from Edwards et al [Section: A diagnostic algorithm (you know it’s good if it’s an “algorithm”).]

1. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
2. Estimates run as high as 35% in some studies (see Yates), which found shin pain in more than a third of naval recruits at the end of basic training. This is the highest figure ever reported, but other studies have also reported quite high numbers. Shin pain clearly ranges anywhere from “pretty darned common” to “rather shockingly frequent.” BACK TO TEXT
3. As are all knee injuries from the knee down. Ferber et al estimated in 2009 that about 80% of all running injuries occur in the knee and lower leg. 50% of those are in the knee, while “injuries to the foot, ankle, and lower leg—such as plantar fasciitis, Achilles tendinitis, and medial tibial stress syndrome (also known as shin splints)—account for almost 40% of the remaining injuries.” BACK TO TEXT
4. Back splints, anyone? Shoulder splints? Head splints? I’ve been wondering about this little bit of language oddity for years now, but I still can’t dig up anything about the origins of “splints” and why it’s apparently exclusive to shin pain. BACK TO TEXT
5. Batt ME. Shin Splints — A Review of Terminology. Clin J Sport Med. 1995;5(1):53–57. “Currently the term [shin splints] is used widely and variably, with little consensus of definition. Broadly, it denotes the occurrence of exertional lower leg pain …” BACK TO TEXT
6. Edwards PH, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. 2005 Aug;33(8):1241–1249. PubMed #16061959. The authors of this paper describe several common lower leg pain problems (several of which are covered by this tutorial, and including at least three types of shin splints) and then comment that “symptoms associated with these conditions often overlap, making a definitive diagnosis difficult.” BACK TO TEXT
7. The importance of muscle dysfunction is a recurring theme throughout this website. It’s not relevant to every injury, but it is involved to some degree in most kinds of injuries, either as a root cause or a significant complicating factor. I’ll explore this in much greater detail below. BACK TO TEXT
8. Generally speaking, medical philosophy about overuse injuries is significantly bogged down by a simplistic over-emphasis on “mechanical” risk factors such as various kinds of crookedness. Shin pain is certainly blamed on a variety of common anatomical scapegoats (like excessive foot pronation), none of which have ever really been established scientifically. Much more about all this below! BACK TO TEXT
9. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781.

   Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine…

   BACK TO TEXT
10. Compartment syndromes outside of the calf are rare, because it’s all about plumbing: it’s harder to pump tissue fluid out of the lowest (most distal) large tissue compartments in the body. Once in a while there's a compartment syndrome in the forearm, because it has the same plumbing problem to a lesser degree. Compartment syndromes elsewhere in the body probably only occur in unusual circumstances involving very specific or serious injury. BACK TO TEXT

There are 81 more footnotes in the full version of this book. I like footnotes & I try to have fun with them whenever possible.

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