Shin Splints or Medial Tibial Stress Syndrome is the Leading Cause of Shin Pain

by Adam Brown
avid runner and registered physiotherapist
updated Nov 23, 2020

 

It seems unfair. You finally get around to starting that fitness program, or maybe you increased the intensity of your workouts, and you are hit with intense leg pain. Not only is your new routine impossible, you are feeling pain doing everyday activities. If you are like thousands of other active people every year, you may have developed a case of shin splints.

 

What are shin splints?

Shin splints, or ‘medial tibial stress syndrome’  (MTSS) is a painful condition affecting the shin bone and surrounding tissues. For many years it was thought that the problem develops when the attachment of the muscles (periosteum) at the inside edge of the shin break down in response to increased traction force (1,2). More recently studies have shown that it is actually a stress reaction of the cortical bone on the back and inside edge of the tibia. (2)

 

What causes shin splints?

Medial tibial stress syndrome is one of the most common running injuries and also frequently affects dancers and military recruits. Research has shown that being female or having feet that pronate excessively when standing are risk factors for developing medial tibial stress syndrome. (1,2) But really, anyone who increases their activity or does not support their foot and ankle well enough for the activity they are doing can develop shin splints.

So why you? What caused you to develop this awful shin pain. The answer is usually fairly clear if you understand why shin splints occur. When you do weight bearing exercise, such as running, you place stress on the bone and surrounding tissues of your lower leg.

If the appropriate amount of strain is produced and you allow for adequate time to recover, your bone responds by getting stronger and healthier. If the increase in stress is too intense OR too frequent to allow for proper recovery, the bone will begin to break down. In the case of medial tibial stress syndrome, there is typically an increase in weight bearing activity, coupled with inadequate recovery time. As a general rule, amateur athletes should not increase the volume or intensity of weight bearing training by more than 10% per week to allow your body to adapt..

Some easily changeable factors that contribute to shin splints are inappropriate or worn out footwear, running on uneven ground or running downhill for extended periods of time.

Individuals are more at risk when they have flat feet (overpronation) or rigid high arches (1,2). People who have weak ankles, hips and core muscles may also be at higher risk of developing shin splints.

 

How are shin splints diagnosed?

Medial tibial stress syndrome is diagnosed by a sports medicine doctor or physical therapist with a detailed history and physical examination including a review of your physical and training risk factors. In most cases this is all that’s required to be confident in a diagnosis of medial tibial stress syndrome. In more severe cases, or in patients who have been suffering for long periods of time some testing may be necessary to rule out other problems.

• A bone scan can help to rule out a stress fracture of the tibia.
• An MRI can also help to rule out stress fractures or a larger tear in the local tendons
• A compartment pressure test can diagnose chronic exertional compartment syndrome if it is suspected.
• X-rays are less useful as stress fractures are difficult to detect on x-rays in the early stages of development and the bony reaction that occurs with shin splints is rarely visible.

 

Do shin splints have visible bruising or swelling?

Some severe cases of shin splints will have mild swelling along the medial edge of the anterior tibia. It is uncommon to see tibial bruising or a large amount of swelling. This may be a sign of a larger disruption of tissue and should be examined by your doctor or physical therapist to rule out stress fracture or acute tendon injury.

If you have mild swelling associated with shin splints you may find that a tibial compression garment reduces pain and swelling that develops over the course of a day.

 

Where is shin splint pain located?

To press on the area that is typically painful when you have shin splints start at the hard part of the front of your shin bone near the top, then slowly move toward the outside edge of your leg. When your finger drops off the edge of your shin bone into the softer muscle tissue there is typically pain along the edge of the bone here. Palpate up and down this ridge to see if there is pain where the muscle meets the bone.

 

How do I know if I have shin splints or stress fractures?

Runners injuries are frustrating when you don’t have a clear diagnosis. You can’t always get bone scans quickly and usually one is not required to know if you are at risk for having a stress fracture of the tibia. The pain of shin splints behaves differently. Shin splints usually hurt at the start of an activity, improve several minutes after starting and then pain increases again if you continue for a longer period. If your problem has progressed to include a stress fracture the pain will remain constant or worsen for the entire time you do the activity.

Physiotherapists and doctors may also use a “tap test” or “tuning fork test”. When the bony part of the tibia is rapidly tapped it does not typically cause pain. In someone who has a stress fracture this vibration may cause a pain response that is typically delayed by a second or two. Some clinicians will use the vibration of a tuning fork applied to the bone to test for pain using the same principle.

A stress fracture is a serious problem. It can progress to a full fracture of the tibia if the athlete does not decrease activity. If you suspect you have a stress fracture, see your sports medicine doctor.

 

What other Diagnoses can cause shin pain?

Sciatica

Some patients can present with pain in the lower extremity that is coming from their low back (lumbar spine). In this case you would not expect to find an acute pain along the medial shin bone. If you have lower leg pain coupled with thigh or back pain, tingling, numbness or weakness, see your physician to rule out your low back as the cause of your problem. For more information on Sciatica click HERE

Chronic exertional compartment syndrome

Compartment syndrome is marked by increased pressure inside the lower leg to a painful level when the muscles increase in size due to increased blood flow during exercise. Typically this pain takes some time to ramp up during exercise and feels like intense pressure that resolves quickly after stopping the exercise. In severe cases it may include numbness and tingling. Some sports medicine physicians will perform a test to measure the pressure in the compartments of the lower leg when exercising to confirm this diagnosis. Bone scans and MRI’s are not helpful in diagnosing compartment syndrome. If this condition is severe and does not resolve with therapy a physician may recommend a surgery called a fasciotomy where small incisions are made in the fascia of the lower extremity to relieve pressure. It is worth noting that this condition is quite rare, and it is even more rare for it to be severe enough to require surgery.

 

How long does it take for shin splints to heal?

The length of time it takes to heal from shin splints depends on what the person does, and how much damage was done before altering physical activities. In most cases where the patient treats the problem appropriately and modifies their activity, it will resolve within three months. Return to activity or training should be gradual to allow the tissues to adapt to the increase in stress. If the athlete does not modify their sports activity the bone tissue will degrade. The condition will last for a very long time, and may progress to include stress fractures. If your lower leg pain lasts a long time, and is impacting your fitness, you should have a physical examination by a doctor or therapist to ensure you are doing everything possible to encourage healing.

 

How are shin splints treated?

Rest – you must allow the bone tissue to heal. Activities need to either be stopped or modified to reduce stress on the local tissue substantially.

Ice can be used to reduce pain. 20 minute intervals spaced at least three hours apart are appropriate.

Pain relievers and anti inflammatory medication like ibuprofen (Advil, Motrin IB), naproxen sodium (Aleve) or acetaminophen (Tylenol) can help to reduce pain.

Physical Therapy for Shin Splints involves;

•  Physical Therapists can develop a treatment plan for the surrounding muscles with stretches, exercises and soft tissue manual therapy techniques to ensure you are healing with strong healthy and mobile tissue.
• Targeting weak muscles in the lower extremity around the ankles, hips or core.
• Development of a plan to eliminate factors contributing to the shin splints such as training errors, inappropriate footwear,  poor foot and ankle mechanics, or faulty running technique.
•  Coaching the patient through the gradual return to activity.

Footwear – You must have the right shoe for the right activity. More on that below.

Orthotics – a custom foot orthotic or off-the-shelf arch support shoe inserts have been shown to help reduce pain related to shin splints and prevent them from occurring. (1,2)

Fixing Training Errors – your physiotherapist and coaches can build an exercise routine that includes appropriate increases in training intensity and volume while providing adequate rest. They may also ask you to avoid hard surfaces when you return to your training program.

 

How do you prevent medial shin splints?

Prioritize Rest And Recovery

Every athlete needs to know that the time between training sessions is as important as the training session itself. It is during this recovery time that the body repairs itself and comes back stronger. Every athletes training plan should have at least one rest day a week to allow the body to recover completely.

Fix Your Running Form

Running pain free requires good form. There are a few common errors that beginner runners make that increase the risk of developing shin splints.

Striking in front of your centre of mass (around your belly button) – A runner that places their foot down on the ground well in front of their centre of mass will experience a much higher impact (ground reaction force) than those who have learned to strike directly under them in alignment with their hip joint.

People who strike in front of their centre of mass on the shock absorbing heel of their running shoe require the tibialis anterior muscle to forcefully contract to slow their foot from slapping on the ground under the entire load of the ground reaction force.  (FIGURE 1)

A runner who strikes in front of their centre of mass onto the ball of their foot (fig2)  require the tibialis posterior, soleus muscles and quadriceps muscles to forcefully contract to slow the descent of the heel toward the ground under immense pressure.  (FIGURE 2)

A physiotherapist experienced in treating running injuries can teach you how to alter your running technique to strike under your hip in a position that both reduces the ground reaction force and shares the stress across more muscle groups and joints.  (FIGURE 3)

As a starting point look at your running cadence. Many running form problems can be improved by increasing the cadence (steps per minute) to between 170-190. If you find that your cadence falls well outside this range you may be at increased risk. See a physical therapist with experience treating runners to get some coaching and hear about treatment options.

Get Serious About Your Footwear

1) The RIGHT Shoe – The shoe that you chose must have the right combination of shock absorption and support for the demands of your activity, and your anatomy. If you have flat feet you need to pay particular attention to the running show you choose as well as replacing it before it wears out. Running in shoes that are designed for cross training or court sports increase your risk of developing shin splints. If you have flat or very high arches this must be considered when selecting your shoe. Talk to your physiotherapist about what to look for in an ideal shoe or watch the video below for some tips.

2) Replace Running Shoes Often – One of the most common errors people make is holding on to athletic shoes long past the expiry date. A running shoe lasts for about 800km (500mi). Your shoes are getting too old if the heel cushioning has permanent horizontal folds in it, the heel counter is no longer stiff or the tread has worn through.

3) Runners Need Two Sets Of Identical Shoes – If you run often, you need to have two sets of shoes. It takes about 48 hours for the shock absorbing cushioning in a running shoe to fully recover after a run. Alternate your shoes when you run on successive days to make sure they always provide maximum shock absorption.

4) Arch supports if you have flat feet – If you are someone that has excessive pronation or “flat feet” a set of custom foot orthotics will help prevent shin splints. If your pronation is not severe you may get away with simple off-the-shelf arch supports.

Resistance training

Adding resistance training to your regimen will ensure that the muscles in your lower legs are better able to handle the force associated with your sport or activity and will improve bone density. Exercises that are done in a weight bearing position should be emphasized. Weighted squats and lunges are a good place to start.

Cross training

Our bodies are less likely to break down when we build variety into our physical activity. For example, If you are a runner, use pool running, swimming, cycling or weight training to improve your overall fitness and aerobic capacity while controlling your total mileage.  Training in a variety of settings and on a variety of surfaces has been shown to yield better results.

Train Smarter

Most amateur athletes tend to ramp their sport specific training based on their competitive season rather than making an annual plan that respects how long it takes for their body to adapt. If you are serious about competing in a sport and remaining injury free, have your coach and sports medicine doctor and therapists collaborate to create a plan for your entire year. They can ensure your training volume and intensity will increase gradually and that you will have adequate recovery. This is the first step to ensuring you stay healthy, but it also important for achieving optimal performance.

If you are experiencing tibial pain with activity, do not ignore it. A consultation with a sports medicine doctor or physical therapist to discuss treatment options will ensure you get back to pain free living as soon as possible.

 

 

References:

(1)  Clin Sports Med. 2012 Apr;31(2):273-90. doi: 10.1016/j.csm.2011.09.008.  Medial tibial stress syndrome.  Noam Reshef 1, David R Guelich

(2)  Sports Med. 2009;39(7):523-46. doi: 10.2165/00007256-200939070-00002.  Medial tibial stress syndrome: a critical review.  Maarten H Moen 1, Johannes L Tol, Adam Weir, Miriam Steunebrink, Theodorus C De Winter