Shin Splints

(Tibial Periostitis or Medial Tibial Stress Syndrome)

Summary

Patients with shins splints will experience pain at the front of their shins. Symptoms may be worse after certain activities or following prolonged rest (ex. getting out of bed in the morning). Symptoms are often precipitated by an increase in activity level. Treatment often involves rest, icing, anti-inflammatory medication, gentle stretching, and activity modification.

Clinical Presentation

Pain at the front of the shin (tibia) is a key feature of “shin splints.” This pain is typically located over a broad area of the lower inside (medial) aspect of the shin. Shins splints are often associated with a history of an increase in activities, such as extra walking on a hard surface, a new training regiment, or a long hike. Pain may initially improve with activity. However, with prolonged activities, symptoms will be worsened. Start-up pain (pain first thing in the morning or after prolonged sitting) is common.

Shin splints occur when the attachment of the muscles originating from the large lower leg bone (tibia) become irritated. The attachment on the outer layer of the bone site (the periosteum) becomes inflamed (periosteitis), due to the repetitive traction of the muscles pulling on it. The muscles involved are the muscles of the “anterior compartment” and include the tibitalis anterior, the extensor hallucis longus (pulls the big toe up), and the extensor digitorum longus (pulls the smaller toes up). In some patients, one of the muscles (the tibialis posterior) attaching on the inside and back part of the lower leg bone (tibia) may create symptoms.

Shin splints need to be differentiated from a stress fracture of the tibia, which is a microscopic fracture involving the tibia bone itself. Generally, a stress fracture creates more localized pain than shins splints, although sometimes imaging studies are required to differentiate the two conditions.

Physical Examination

Generalized tenderness along the shin is a common finding on examination. Occasionally, there will be swelling or even redness noted in the front of the shins. In addition, many patients will have a tight calf muscle as this will increase the traction forces of the muscle pulling on the front of the bone (tibia).

Imaging Studies

X-rays of the lower leg bones (Tibia and Fibula) may be indicated to rule out any obvious stress fracture. However, in most instances, these x-rays will be negative.

Occasionally, an MRI may be ordered to help rule out a stress fracture. Often there will be a localized area of edema (characteristic of increased blood flow) where the muscle attaches to the bone. In patients with stress fractures of the tibia, a localized area of edema in the bone itself will be seen.

Often a “bone scan” will be ordered instead of an MRI to help establish the diagnosis. A bone scan involves injecting blood that has been tagged with low level radioactive tracers. A bone scan will “light up” in areas where there is a high blood flow. In patients with shin splints, there will be a generally low-level increase in activity that is seen on the bone scan. This differs from a stress fracture of the tibia that will have a very localized high-intensity area of involvement on the bone scan.

Treatment

Once a diagnosis of shin splints has been made, treatment involves a healing phase to let the symptoms settle, followed by a rehabilitation phase to build the area back up and minimize the risk of recurrence.

Healing Phase Treatment

Relative Rest

All precipitating activities should be stopped, and patients should limit their walking and running until the symptoms settle. This condition is essentially caused by repetitive microscopic trauma to the muscles where they insert into the bone. Stopping the inciting activity to allow the body’s healing to catch up is a critical component of treating shin splints. Relatively non-weight bearing activities, such as swimming and cycling, may be substituted at this stage.

Icing

Applying ice to the front of the shin in 10-15 minute intervals can help improve symptoms and decrease the body’s inflammatory response.

Gentle stretching

Gently stretching the muscles at the front of the lower leg (anterior compartment muscles) by pointing the foot downwards should be done for 30-60 seconds at a time, repeated 4-5 times and then again 2-4 times per day. In addition, gentle calf stretching is likely to be helpful.

Anti-inflammatory medications

A short course of anti-inflammatory medications (NSAIDs) can significantly help with symptoms. However, they should not be used to mask the symptoms (i.e. increase the amount of training that can be done), as this can cause the conditions to become more chronic.

Rehabilitation Phase

After symptoms have settled, patients should begin a rehabilitation phase designed to gradually return them to their desired activity level. Shin splints have a tendency to recur, so some element of regular ongoing preventative treatment is often required to keep the symptoms of shin splints from recurring.

Continued stretching

Stretching the lower leg muscle is an important component of controlling the symptoms associated with shin splints.

Heat

Heat applied to the shins may help, particularly in the warm-up phase prior to starting a workout.

Calf support stocking (Shin Splint compression sleeve)

Consider trying a calf support stocking. This device applies gentle compression to the muscles of the lower leg and may help to dampen the forces that muscles exert to the bone. In addition, they will help retain heat in the area. This device may not be for everyone but is probably worth a try for patients who have problematic shin splints.

Taping

Some patients derive benefit from taping their shins. This is done in an effort to dampen the muscle forces on the bone (decrease the whiplash effect).

Shock absorbing shoes and inserts

The use of shoes and inserts with increased shock absorbing capacity may help to decrease the repetitive loads that the shins experience.

Medial arch supports

Patients with flat feet and pain in the lower inner shin may benefit from an over-the-counter (pre-fabricated) medial arch support to help support their arch.

Graduated return to activity

A gradual increase in activity back to pre-injury levels is essential in order to minimize the risk of recurrent symptoms.

Edited October 30, 2017

mf/ 05.14.18