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  • Writer's pictureDaniel Selin

Shin splints

Shin splints, stress fracture, medial tibial stress syndrome, compartment syndrome, overuse injury, growth pain, running pain, shin problem, pain, MTSS, tibial internal stress syndrome, children and youth, shin pain

Pain felt on the inner side of the shin (Tibia), which worsens during or after physical activity, is a common problem among those who participate in running sports. This condition is often referred to as shin splints, but this term does not specify the underlying mechanism of the pain or distinguish which tissues are involved. However, there are many different reasons and structures behind the pain, so it's important to differentiate them when creating a treatment plan. This text will identify the different causes of the pain felt on the inner side of the shin, discuss their characteristics, and outline treatment principles.

In general, this is an overuse injury and the tissues are not able to recover fully after physical exertion. It typically occurs among athletes who participate in high-impact activities such as running or jumping. It is more commonly found in children and adolescents in their growing years, but it can also affect adults. During growth stages, the body is in a constant state of change, and the tissues may not have enough time to recover after physical activity. Additionally, bones grow faster than soft tissues, causing an imbalance in the length of the bones and muscles. This increases tensile stress on the muscle attachments and weakens recovery due to constant tensile stress.

 

Differentiation

Gradual onset pain felt on the inner side of the shin can typically be attributed to one of the following: Medial Tibial Stress Syndrome (MTSS), a stress fracture of the shin bone, or Compartment Syndrome. Although these conditions share some similarities, they also have distinct features and may require different treatment approaches.

 

Medial Tibial Stress Syndrome (MTSS) MTSS is an overuse injury of the structures located on the medial side of the tibia, typically seen in athletes who are repeatedly exposed to intensive loading. Pain initially manifests as post-exercise soreness, which progresses to pain during and after loading. MTSS can be thought of as a precursor to tibial stress fracture, but without any bony changes yet. Typical symptoms and findings of MTSS include:

  • Pain located in the middle and lower thirds of the tibia, which worsens during or after exercise

  • Pain that is relieved by rest, after which exercise can often be resumed

  • Pain from exercise may continue for hours or even days after the activity has stopped

  • In the early stages, pain decreases as muscles "warm up," which is in contrast to compartment syndrome and stress fractures, where pain often only worsens with continued loading

  • In later stages, pain is more easily triggered, feels more severe, and short rest no longer reduces the onset of pain

  • Typical findings include tenderness to palpation and percussion along the medial side of the tibia.

Background

The pathophysiological process leading to MTSS is associated with the accumulation of irreparable micro-changes in the structures of the shinbone. These micro-changes develop over time into macroscopic changes that cause pain. The changes typically occur in the fascia surrounding either bone or muscle, but changes in the muscle-tendon unit are also possible.


Risk factors The prevalence of MTSS varies depending on the type of physical activity, with the most common occurrence in sports that involve jumping or running with high impact. The condition is also frequently observed in army recruits who are not used to walking long for distances.

Increased levels of physical load and intensity, high-impact activities, and rapid growth during adolescence can all contribute to the development of MTSS. Other risk factors include:

  • Structural abnormalities in the foot: flat feet or high arches

  • Weakness in the shin and calf muscles, as well as the muscles that support the arch of the foot, which can lead to muscle fatigue, altered running mechanics, and overloading of the shinbone

  • Limited ankle mobility due to joint or soft tissue restrictions

  • Biomechanical challenges affecting lower limb function

  • Previous history of medial shin pain

  • Overweight or obesity

  • Limited hip rotational mobility

  • Muscle imbalance or inflexibility in the shin and calf muscles

  • Running on hard or uneven surfaces or wearing inadequate running shoes

Treatment

The primary treatment approach for MTSS is conservative, focusing on rest and modifying painful activities so that repetitive or aggravating exercises are performed less frequently. The time required for symptom relief varies depending on the duration of symptoms, extent of tissue changes, and individual factors. Adequate rest and reduction of loading form the foundation for rehabilitation nonetheless.


Returning to one's sport after a period of rest should be done gradually over several weeks or even months, gradually increasing the load while simultaneously monitoring one's own sensations. In most cases, a too rapid increase in load or intensity after rest leads to a recurrence of symptoms.


Physiotherapy

Physical therapy for MTSS begins with a thorough assessment of background factors, which serves as the basis for creating a personalized rehabilitation program. The underlying factors must be distinguished and identified to determine which ones have contributed to the development of pain. Any biomechanical challenges should be identified and addressed to prevent further stress on the structures of the inner edge of the tibia.

Strength training aims to improve the muscular support of the foot and increase tissue load tolerance. Manual therapy is used to reduce tissue tension, improve fluid and blood circulation, and alleviate pain.

Orthotics can be used to support the foot structures and reduce stress on the inner part of the shin if there are deviations in foot mechanics such as over- or underpronation. Joint mobility can be improved through a combination of exercise and manual therapy.

Patient education and counseling aim to increase awareness of the condition, symptoms, and underlying factors. Empowering patients with knowledge about their condition and treatment goals can help them take responsibility for their own recovery. Understanding the causes of the condition and treatment goals improves the prognosis and reduces the risk of recurrences.

 

Tibial stress fracture

Tibial stress fracture is typically detected in the lower or upper third of the shin bone, and presents with similar symptoms to MTSS. Initially, pain is only felt during activity, but as the condition progresses, pain may also occur at rest. Fresh stress fractures can only be seen on magnetic resonance imaging (MRI), but later changes in the bone can also be seen on X-rays. With new bone growth, a palpable lump may develop in the bone. Typical symptoms and findings of tibial stress fractures include:

  • Pain in the lower or upper third of the shin bone, which worsens during or after activity

  • Short periods of rest may not be enough to alleviate symptoms

  • Pain typically lasts for hours or even days after stopping the activity that caused it

  • Repeated stress only exacerbates symptoms, and there is no significant improvement in pain when muscles warm up

  • The shin bone is highly sensitive to oscillation, and its inner edge is often tender to the touch

  • The shin bone may be swollen, red, and warm to the touch

Risk factors for tibial stress fractures are similar to those for MTSS. Background

A healthy bone is constantly in a state of balance between micro-damage and repair. Stress fractures of the bone progress gradually in stages: the formation of a crack, the propagation of the crack, and eventually, complete fracture.

The formation of a crack is typically the result of repeated loading of the bone. If the loading intensity or frequency continues and the bone is unable to repair the micro-damage, the crack will continue to propagate. As loading persists, more microscopic changes occur and accumulate, forming a continuum that clinically manifests as a stress fracture. Eventually, these changes lead to a complete structural failure and a visible fracture line on X-rays.

Stress fractures are thus partial or complete fractures of the bone due to submaximal loading. Normally, submaximal forces do not cause fractures, but repetitive loading or inadequate recovery time can lead to stress fractures.


The exact cause of stress fractures is not entirely clear, but it is likely that both increased fatigue of the bone's supporting structures and tension from muscle contractions contribute to their development. Stress fractures of the shinbone are often preceded by medial tibial stress syndrome (MTSS), which is characterized by increased tissue irritation in the bone and muscle sheaths.


Treatment

Most shin bone stress fractures are treated conservatively, and the treatment principles are similar to those of MTSS conservative management. However, painful activity should be avoided for a longer period in the case of a stress fracture compared to MTSS, and simply modifying the load may not be sufficient. In severe and advanced cases, surgical treatment may also be an option. In such cases, the fracture line can be fixed with plating or nailing to speed up the healing of the bone.


Physiotherapy

Similar methods are used for treating a Tibial stress fracture as in the treatment of MTSS, where the cornerstone of treatment is to prescribe sufficient rest and modify loading. These aim to give tissues time to heal and recover.

Treatment modalities include both pharmacological and non-pharmacological pain management methods, as well as a progressively increasing exercise program tailored by a physiotherapist. This program aims to improve any biomechanical challenges, reduce restrictions in motion and muscle tension, and increase load-bearing capacity of supporting structures and muscle strength.

Recommended exercises include aquatic exercises such as swimming, water aerobics, or aqua jogging, cycling, or cross-trainer training. Also strength training that does not exacerbate symptoms in the tibia area are ofter prescribed.


After a sufficient rest period, returning to one's sport should be done gradually, increasing the amount and intensity of loading gradually over several weeks or months. Increasing the load too quickly after a period of rest usually leads to a recurrence of symptoms.

 

Compartment syndrome

Compartment syndrome refers to a condition in which the pressure within a muscle compartment increases, causing a lack of oxygen and reduced metabolic activity in the tissues. This can occur when a rapidly growing and developing muscle grows faster than the surrounding fascia, leading to a volume mismatch in which the muscle is larger than its enclosing membrane. Another mechanism is post-traumatic bleeding within a muscle compartment, resulting in increased pressure within it.

Muscle compartments consist largely of non-elastic collagen, which cannot stretch to accommodate the increased size of the muscle tissue. As a result, swelling of the muscle or bleeding within the compartment can cause increased pressure inside, leading to reduced blood flow to the tissues. This can lead to metabolic challenges and complications associated with reduced oxygen supply, which can eventually result in muscle necrosis if left untreated.

The most typical presentation of compartment syndrome in children, adolescents, and adults is in the inner part of the shinbone, causing similar pain as in medial tibial stress syndrome or a stress fracture of the shinbone. Etiology

Although acute compartment syndrome can occur as a result of intense exercise without prior trauma, shinbone fractures are the most common cause of the syndrome. Approximately 75% of cases originate from a fracture.


Symptoms

Symptoms of compartment syndrome resemble those of MTSS and stress fractures of the tibia, causing pain in the inner edge of the tibia that worsens during exercise. The inner edge of the tibia is typically tender to the touch and the muscles in the calf feel tight or hard. Stretching the calf or shin may worsen symptoms, and numbness or tingling may be present in the area. Redness and warmth of the skin can also occur.


Treatment

The treatment of compartment syndrome depends on the underlying cause. If there is a history of a clear bone or soft tissue injury and quickly worsening symptoms, it is important to seek medical attention as soon as possible. In this case, it is more likely that the internal pressure within the muscle compartment has increased due to bleeding or tissue swelling, which may require an urgent surgical procedure. If the pressure within the muscle compartment continues to rise, there is a risk of tissue oxygen deprivation, which can lead to tissue necrosis. Surgery involves opening the muscle compartment to relieve pressure and restore blood flow.


If on the other hand there isn't an underlying injury and the symptoms have developed gradually, the treatment for shin muscle compartment syndrome is similar to that for MTSS or shin stress fracture.

Physiotherapy

Physical therapy methods for the treatment of compartment syndrome are very similar to those for treating MTSS or shin stress fractures:

  1. Adequate rest from activities that cause pain, as well as modification of exercise routines

  2. Developing a progressive exercise program to optimize muscle function

  3. Treatment of any possible range of motion restrictions through a combination of manual therapy and exercise

  4. Assessment and rehabilitation of biomechanical challenges

  5. Pain management

  6. Guidance and advice regarding the symptom profile, underlying factors, and treatment prognosis

  7. Instruction on alternative forms of exercise.

 

Summary

To summarize, shin splints are characterized by pain in the inner part of the shin that worsens with exercise. A sufficient rest period forms the basis of treatment and recovery. If there is an underlying injury and symptoms begin quickly, it is important to seek treatment immediately as this may indicate an increase in pressure within the muscle compartment.


In addition to a sufficient rest period, it is important to identify underlying factors and address any challenges that increase load on the inner part of the shin. Return to exercise should be done gradually with increasing load and intensity. Returning to activities too quickly predicts the recurrence of the problem and prolongs recovery time.

 

General guidelines for reducing load


Acute phase

At first, a resting period of 2-6 weeks should be aimed for, during which nothing that exacerbates symptoms is done. During the rest period, painkillers are recommended to reduce symptoms and ensure a quick and safe return. In addition, regular use of cold reduces possible swelling and eases symptoms.


Aerobic fitness should be maintained through methods that replace running, such as water jogging, swimming, or cycling. Possible movement restrictions should be treated with self-directed movement training and manual therapy. Treating tense muscles may also be beneficial for improving fluid and blood circulation, as well as reducing pain. Strength training can be increased in the acute phase as long as it does not provoke symptoms. Possible biomechanical challenges should also be addressed and efforts made to improve body- and movement control.


Subacute phase

Return to one's own sport should be gradual and done only when the pain in the shinbone area has subsided and there is no strong tenderness when tapping on the bone. Initially, it is recommended to return with 50% of the training sessions and 50% of the intensity. If this amount and intensity can be achieved without pain or with minimal pain, training volume and intensity can be increased by about 10% per week. However, it is important to listen to the body's signals and monitor any changes in pain. Mild pain that eases within a day is unlikely to worsen the condition, but continuous training against severe pain or pain that does not subside may worsen the prognosis.

During the subacute phase, it is important to continue strength and mobility exercises, as they increase tissue durability and reduce the occurrence of peak loads. It is advisable to use cold therapy after training as long as training increases pain. It would also be beneficial to include exercises that improve posture, control, and agility in one's training routine to reduce the risk of recurrence.

Manual therapy should be continued until any movement restrictions and muscle tension have been addressed.

 

Self care

  1. Rest: The first and most important self-care tip for treating shin splint pain is to take a long enough break that allows the tissues to recover. Avoid activities that worsen the pain and take a break from exercises that strain your legs, such as running or jumping.

  2. Ice: Cold therapy helps reduce pain and possible inflammation. Wrap a cold pack or ice pack in a towel and apply it to the painful area for 15-20 minutes at a time. Repeat cold therapy 4-5 times a day for at least 4 days.

  3. Regular exercise: Exercise promotes blood circulation and reduces muscle tension. Recommended forms of exercise include cycling, swimming, or water aerobics.

  4. Stretching: Gentle and dynamic stretching can promote blood circulation in the muscles and improve the gliding of fascial structures. However, avoid hard and static stretches, which increase tensile load and muscle counter-tension.

  5. Massage: Treating the shin and calf muscles often reduces pain and improves tissue blood circulation. Light massage can be repeated daily, but harder treatment should not be done more than 1-2 times a week.

  6. Avoid walking or running on hard surfaces: Hard surfaces increase shock and can easily exacerbate shin symptoms.

  7. Wear appropriate shoes: Shoes should be comfortable and provide necessary support for the feet and joints. Cushions can also be placed in shoes to reduce the vibration-induced load.

  8. Gradual return to an active lifestyle: When the shin pain begins to heal, gradually return to normal activities. Increase activity levels gradually so that your body has time to adapt to changes in load and recover.

Remember that these self care tips can be helpful in relieving shin splint pain, but it is important to seek help from a healthcare professional if symptoms persist or worsen.


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