​In Part I we covered some factors that if present would suggest we shouldn’t be running today. In this Part II, we’ll discuss some factors that may offer at least a glimmer of hope. If any of these conditions are present, it doesn’t automatically mean we’re in the clear but it does give us something to work with.
 
Do your symptoms get better during or after running? Many of you have probably experienced the situation in which you feel pain while walking around or even at rest, but once you start running your symptoms seem to get better. Persistent pain under any situation necessitates caution but the fact you see improvements while moving is a favorable sign. Although this is reason for optimism, we shouldn’t get too greedy because sometimes our bodies can suppress pain signals to get through the physical exertion. Still, any temporary diminishing of pain can help guide us toward a full resolution if we can identify WHY running is making us feel better.
 
Can you run ten minutes with minimal to no symptoms? Ten minutes is long enough to get an honest assessment of our symptoms but not so long that we’re causing any harm if we later find out that we aren’t ready to progress. Also, if you can get through ten minutes or longer of running without symptoms, any reappearance of symptoms later in the run would suggest a training issue related to form or conditioning, not a persistent injury that threatens our ability to run at all.  
 
Do you sometimes forget you were in pain? One of my favorite indications of progress. You go to do something that has been causing pain and afterward you have this realization of “wow…that doesn’t hurt anymore.” Maybe you’ve been having back pain and have dealt with the reality of pain while bending forward. Then one day you reach down to tie your shoes and surprisingly don’t feel pain anymore. Subconscious action is often more reliable for pain perception since it lacks the implicit bias of our conscious mind.
 
Does the pain migrate? If your pain migrates, that leads us to believe we’re dealing with a case of irritation rather than diagnosable structural injury. Think of a fracture at one extreme where your pain is typically centered on the spot of the break. That pain doesn’t migrate. You might experience other secondary pains, but pain remains at the site of the break until healing occurs. Migrating pain, on the other hand, is often a sign of the body trying to work through things subconsciously rather than a structure that we risk damaging if we don’t take the needed rest.  
 
Do changes to training variables lead to changes in symptoms? Maybe it’s different shoes. Or maybe trails or grass help relieve the pain you’ve been experiencing on the road or track. Perhaps your easy runs feel good but running faster provokes symptoms. They might not be permanent at this point, but first things first. HOW to manipulate these variables is a whole discussion unto itself but for now, recognize that having control over these variables also gives us control of our symptoms. 

​One of the main questions I get asked as a Doctor of Physical Therapy and running coach is, “Is it ok for me to run??” Some people will take the easy way out and say “Oh, just take a few weeks off.” But any runner knows that’s an entirely unsatisfactory answer, especially when given in a dismissive tone. True, sometimes we DO need some time off, but it should be the LAST resort, not the first option.
 
Here I’ll go through some “red flags” that can help us determine if we need to avoid running for at least today. Nothing is ever absolute, but if any of these are present, you’d need a very powerful reason to run through the pain…
 
In Part II, I’ll discuss some training factors we can work with to help mitigate the need for excessive time off.
 
Sharp, unrelenting pain - This pain is intense and doesn’t go away, not even when you’re at rest. If it’s that bad, then you probably shouldn’t be running today.
 
Does it hurt when you start running and get progressively worse with running - Rarely does anything good come from trying to push through this situation. If it gets better when we run, then we’re having a different conversation (stay tuned for part II)
 
Do you feel pain with landing AND feel point tenderness in your shin or pubic area - Pain when landing can describe MANY things, so that alone should not automatically take you away from running. But if you’re also experiencing pain that you can specifically pinpoint in one of these two “hot spots,” you’ll want to get imaging to rule out a stress fracture or bone stress injury
 
Does it noticeably change your stride - I recommend a common sense approach for this: if your stride looks painful (meaning the pain is so intense that you can’t even fake your way around it), then we probably shouldn’t be running through the pain.
 
Do you think about it constantly - Think mind-body connection. If the pain is at the forefront of your thoughts and you can’t get your mind off it, your body is telling you something.
 
Have you felt this pain before and unsuccessfully tried to run through it - Use your experience as a guide. Any experienced runner has taken a chance on running through what they consider to be a minor pain. Often it will resolve on its own. But other times we lose our “bet” with our body and the minor pain isn’t so minor. Don’t make the same mistake again (however, the reverse of this isn’t always true…just because you won the bet previously doesn’t give you an automatic free pass…)
 
Do you need a supramaximal dose of pain medication to get through a run – If the pain is that bad, there’s something needing attention. Taking that much pain medication just isn’t a good thing.
 
Look out for Part II where we discuss factors that we can modify to help us work around certain aches and pains…

“Shin splints” is one of those broad terms that many people (doctors included) use to describe a very wide range of conditions. In other words, if someone says “shin splints” what they actually mean can be several different things.
 
Going “by the book,” shins splints is synonymous with “medial tibial stress syndrome” which is basically irritation at the connection between muscle (usually the posterior tibialis) and the tibia (shin bone). Tends to be a repetitive strain condition, but can have underlying causes in mechanics, strength, mobility or training load; or in the case of bone injuries there can be nutrition causes as well.
 
Occasionally, the irritation might be on the muscle itself without any irritation to the bone, in which case it would be some form of posterior tibialis strain or tendinopathy of the posterior tibialis tendon, if closer to the ankle.
 
As for bone injuries, we can have a stress reaction or a stress fracture. The difference is these is basically one of degree. Think of a stress reaction as the beginnings of a stress fracture. Whereas a stress reaction might dissipate within days if given time to heal, a full blown stress fracture can know you out of a solid couple of months. The hallmark sign will be pain/tenderness in a specific spot, whereas many other shin conditions will display pain along a longer segment.
 
On the outside of the shin on the more “meaty” muscle side, we can have anterior tibial tendinopathy or tibialis anterior strain. You may also hear the term “compartment syndrome” which gets tossed around quite liberally referring to pain on the outside of the shin, but full blown compartment syndrome is a true medical emergency, where you’ll experience numbness, loss of circulation and changes to skin texture. The gold standard to diagnose compartment syndrome is to measure the pressure inside the compartment. 
 
Sometimes, shin pain isn’t shin pain at all, but is instead nerve pain from the lower back. You could also experience nerve-like symptoms from irritation at the outside of the knee. But in these scenarios, the symptoms are less likely to be associated with movements or direct stress to the lower leg.
 
High ankle sprain is also slim possibility, but unless you’ve had an acute incident of twisting your ankle or lower leg, it’s safe to rule this one out.
 
Ultimately, these diagnoses are simply descriptive labels. Most important is identifying how and why these are happening, but understanding that many different conditions can exist under the realm of “shin splints” is a good way to start!