If not a stress fracture, then what?
July 22, 2018 8:25 AM   Subscribe

I have been battling running-related shin pain for 2.5 years and can’t get a clear diagnosis, nor can I seem to make it go away despite extended rest periods. Help? Lots of details inside...

In January 2016 I started experiencing sharp pain in my left shin that seemed associated with running but mostly occurred not when I was running. At the time, I was about 2.5 months out from a half marathon and had ramped down my intensity & distance (3 runs >10 miles in that time, mostly running in the 4-8 mile range at a comfortable pace). I skipped a few runs intermittently but by the beginning of February had decided to take 2 months off completely. The pain subsided significantly but never went away completely. After that I started run-walking and slowly worked my way up to 3-4 miles; the pain came back fairly quickly but I… uh, decided to ignore it I guess.

I went to a sports med doc in May 2016, had an x-ray that showed nothing (common in stress fractures, as I understand it). The doctor’s main diagnostic tests were tapping along my shin bone and identifying a location of sharp pain, and squeezing across my shin (so no pressure on the actual painful area) (working up from my ankle towards my knee). When he squeezed above or below the area that hurt, it was uncomfortable, but when he squeezed directly across the the painful area it was excruciating. He said these findings were very consistent with a stress fracture. For what it’s worth, I was never tuning forked. He put me in a walking cast for 6 weeks (I was a very compliant patient).

When I got out of the cast, he repeated the above tapping & squeezing, and the pain was definitely improved, and he sent me off to rejoin the runners. I again started slowly (one mile run-walks) and slowly increased my distance (was at 4 miles in about 2 months), with the same return in pain. He had me go for a nuclear med bone scan, which did not indicate a stress fracture, or anything else helpful. His team told me maybe it’s shin splints and gave me some exercises to do, which I did fairly regularly until the exercise band they gave me to use snapped. I took another six months off running (save two 3-mile runs in the middle), and the pain improved but never resolved. I got tired of not running and also being in pain, so I started running again, working up from 1-2 miles to 9-10 miles over the course of 6 months. The pain worsened with the running, and improved significantly when I had to skip several days of runs due to other circumstances, so I just stopped again. Took 6+ months off again, and then in May, did two 1-mile easy runs separated by a full rest day, with a significant increase in pain. Gave up. Haven’t done anything since then. The pain now is low-level now but not gone.

About the pain:
-It is definitely associated with running but mostly doesn’t occur when running. If i’m running half an hour or less, I can easily go an entire run without a single twinge. On longer runs I may feel a little pressure in that leg, but I wouldn’t necessarily call anything pain.
-It is 100% in my left leg; I have never had any pain in my right leg.
-The only surefire trigger for pain is something hitting my shin in the right spot (my dog running into me skull first, walking into an open drawer), which is agonizing. It also commonly hurts if I have my ankles crossed with my bad leg in front, so my good leg is putting pressure against the back of my bad leg. It sometimes hurts when I get up and start walking quickly after sitting for a long time.
-Lots of walking doesn’t seem to worsen the pain like running does.

About my running style:
-I generally run max 3-4 days per week, never more than 2 days in a row
-My pace is mostly 8:30-10:30 miles (faster for races)
-I mostly run on asphalt roads or paths, trying to find a level spot
-I have a mid-foot strike
-When measured, my running cadence has always been 170+ steps per minute
-I wear relatively cushioned shoes (Nike Vomero) which I replace within 400 miles
-I’m pretty average weight (high end of normal BMI)

Do you have any other suggestions for what this might be, or what I should try next? Are bone scans ever wrong? Does this actually sound like shin splints? I haven’t by any means ruled out going back to see the same sports med doc (or a new one), but I felt pretty disheartened with the shin splints “diagnosis.” It felt more like “We don’t know so we’re gonna say maybe shin splints,” than an actual diagnosis.

Of note, I’m not seeking advice on alternatives to running. “Runner” is part of who I am, and I have felt incomplete for 2.5 years. If I have to give it up, I will, but if I can have running back, I’ll do just about anything to make it happen.
posted by obfuscation to Health & Fitness (6 answers total) 4 users marked this as a favorite
Did the exercises with the band help?
posted by windykites at 9:37 AM on July 22, 2018

It's usually recommended more for shin splints than for stress fractures, but it certainly can't hurt: here and here are my descriptions of a front-shin stretch that did wonders for me.
posted by notsnot at 9:45 AM on July 22, 2018

Did the exercises with the band help?

Not that I could tell. I'd already been off running for a few weeks by the time they sent me the band, so the pain had subsided a lot (but again, not completely) from rest. I didn't notice any difference with the exercises.

switching from heel-striking to a forefront strike

I'm not sure whether my landing is best described as mid or forefoot strike, but I definitely don't heel strike. As for the rest, I'm already a pretty light lander, and I do run on gravel or dirt when I can, but it's usually not an option (running on grass is begging for a sprained ankle for me). As you can see, I.. did plenty of resting. I could definitely look into a lower drop shoe (my current ones appear to be about 10mm).

Are you feeling pain when pressure is applied across your calf muscle, pressing towards your shin?

Yup, when my right shin is pressing against my left calf, my left shin hurts.
posted by obfuscation at 10:21 AM on July 22, 2018

I had this problem. I changed to Brooks purecadence shoes which have a low heel-to-toe drop as devrim suggested. That fixed the problem 100 percent. It might be worth it to try a few different varieties of shoes if you haven't already done that. I also had the pain for over a year and nothing else including exercises assigned by physical therapist seem to help it.
posted by whistle pig at 3:57 PM on July 22, 2018

Just trying to clear some things up, but there exactly is the pain? Left shin - how high/low on the leg? Is it just slightly lower than middle height of the leg? You mentioned that your right leg touching the left calf muscle can cause pain, so I'm assuming it's on the inner side of your leg (medial side).

If it's this region, you might have what I'm currently fighting. It felt quite similar to a stress reaction I had a few years back (that might not have been a stress reaction), except it was closer to the belly of the muscle than I remembered the stress reaction. It was also a slightly broader location of tenderness unless the stress reacion. The pain is close, but not quite to most of the descriptions for shin splints and stress fracture (research medial tibial stress syndrom (MTSS)). I also had odd occurences when not having run for a bit and it would flare up a bit when walking; especially on odd surfaces in winter. Definitely the getting up after sitting for a while. Oddly getting up after sleeping didn't seem particularly bad.

My physio says the area where my flexor digitorum longus joins in with the rest of the calf muscles is where I'm feeling the pain. In addition to rest, I needed to seriously massage that area (and my foot's arch) to fight the tightness. At the same point, I'm flat footed (read, my arches are crap) and my ankle on my weak leg collapses inward (2 physios have pointed out my ankle issue - the pictures of my ankles from behind when I'm standing relaxed *look* like my ankle is severly injured / should hurt).

I'm doing some band work to strengthen the f.d. longus muscle, and in addition one-legged balance work while keeping my ankle in a good position, and continuing massage even though my pain has lessened / mostly gone in my lower (relative) current volume. My weak leg strongly pronates while running. However my good leg has no issue, and as such both my physio and an orthopedist said stability shoes aren't recommended. I'll soon be trying an ASO ankle brace to help limit over pronation of my weak leg - this was recommended over an orthopedic insert.

Even if you don't have what I do; perhaps it's just my insurance, but I've found that physio's give you much more time for the money and seem more interested in the root cause of the problem, while sports docs look at the symptom only to tell you to stop doing what you're doing and come back in a few months. Ideally find a physiotherapist at a sports medicine clinic, and ask for one who can do a gait assessment for runners. At my place, there's 6 physio's that they'd assign to runners, but only 2 do gait assessments.

You say that you're not a heel striker - have you been recorded and watched this yourself?

(On preview: I'll also note that I'm generally in low-drop shoes. I've got wide feet, so primarily run in Altra or Topo brand shoes.)
posted by nobeagle at 6:53 PM on July 22, 2018 [1 favorite]

I'd say it's just lower than center on my shin. It's not to the side at all, it's right in the front of my shin - when I talk about crossing my legs causing pain, nothing is actually touching the part that hurts. I do also have pretty darn flat feet. I haven't had a gait assessment or recorded my running, but I've seen pictures of myself mid-strike where I'm clearly not heel striking, and my shoe wear patterns bear out that I'm not heel striking.

A lot of what you said definitely did ring true - I'll look into the flexor digitorum stuff. I do think I'll end up seeing my/a doctor again, and I'll be pushier this time about the importance of this to me. I felt like my doc "got it" initially, but ultimately, like I said, felt dismissed. Thanks!
posted by obfuscation at 4:21 PM on July 23, 2018

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