Northcoast Footcare

"Shin splints" is a general term used to describe pain on the shin bone. The most common cause for this type of pain is inflammation of the sheath surrounding the shin bone (the tibia). The pain may be directly on the front of the shin bone, or more towards the inside of the shin bone. When the pain occurs on the inside of the shin bone it is called medial tibial stress syndrome (MTSS). When the pain occurs on the outside of the shin bone, it is referred to as anterior shin splints. The term anterior shin splints is a little dated, because this outside area of the shin bone is a more common area for stress fractures and chronic compartment syndrome. Over the years, the term "shin splints" has become a catch-all term for any problem in the leg, including problems with the bone, the muscle and the connective tissue.

The pictures of the runner below show common areas of shin pain. The picture on the left shows the common area of pain for medial tibial stress syndrome and the picture on the right shows the common area of pain for anterior shin splints.

Both conditions are exercise induced, causing inflammation of the the tissue connecting the muscle to the bone, and inflammation of the sheath of tissue which surrounds the bone. The bone is also affected. This is due to traction forces of the muscle on the bone, and typically occurs in runners, those starting a new activity or those changing the intensity of their exercise routine.

Symptoms:

    * pain at the beginning of an activity
    * achy pain is longitudinal along the shin
    * pain may subside as the activity continues
    * pain is generally relieved with rest
    * deep achy pain may return a few hours after the activity
    * tenderness with direct palpation along the shin
    * mild swelling along the area of pain and tenderness
    * pain with forced movement of the foot up or down
    * pain may be increased when walking up or down hills    

Stress fractures occur in a more localized area of the shin and will generally have a more pinpoint region of pain. Any activity tends to cause pain, as opposed to specific activities as listed above. Some believe that medial tibial stress syndrome is a mild form of a stress fracture, or a precursor to a stress fracture. This theory is not yet well accepted. An X-ray and sometimes a bone scan is used to rule out a stress fracture if it is suspected. And MRI may also be used.

Chronic compartment syndrome (CCS) can mimic the pain associated with anterior shin splints or medial tibial stress syndrome. Chronic compartment syndrome is an exercise induced condition caused by increased pressure around the muscles and tissues in the leg, compromising the circulation and function of the tissues and resulting in pain and sometimes numbness. This condition can be difficult to diagnose and distinguish from the more common causes of leg pain. The image to the right shows only one possible, but common, area of pain.

Causes:

• faulty foot mechanics - generally in the form of tight calf muscles and over pronation (discussed below).
• inappropriate shoes - soft, flexible shoes without support .
• lack of shock absorption in the shoes
• beginning a new running or exercise program (too much too soon)
• change in intensity, frequency or duration of training
• running or walking surface - hills, stairs, uneven or hard surfaces

Risk Factors:

• female athlete triad (eating disorders, lack of menstrual period & osteoporosis) - most common in teenagers
• biomechanics - geometry of the foot and leg
• nutritional status - insufficient protein and/or calcium intake
• high BMI (body mass index) - a higher weight to height ratio

A Closer Look at Foot Mechanics

Faulty foot mechanics are a common cause of many foot problems, but are one of the most common causes, in combination with inappropriate shoes, of medial tibial stress syndrome. Even though the pain seems to occur on the front of the shin bone, the affected muscles attached to the shin bone reside in the back and inside of the leg. More on foot mechanics.

The general action of the calf muscles is to flex the foot and toes down and stabilize the arch. When the larger calf muscles are tight, they increase the amount of abnormal pronation and contribute to midfoot collapse.  

When the smaller, deep calf muscles are tight, they increase the traction forces on the tibia. Overpronation causes excess stress on the deep muscle group in the calf, because these muscles attempt to slow and resist pronation. Pronation places excess stress and traction at their attachment, contributing to the development of medial tibial stress syndrome.

Tight calf muscles also cause an imbalance between the muscles on the front of the leg and the muscles on the back of the leg (calf muscles). When the tight calf muscles over power the muscles on the front of the leg, it makes it difficult for the muscles to lift the foot when walking. This aggravates the muscles on the front of the leg and places excess traction force at their attachment, contributing to the development of anterior shin splints.

Treatments

1. Rest:
   A period of rest of 2-4 weeks is recommended. This does not have to be bedrest, this means to eliminate the aggravating activity. If the activity started after increasing the intensity of a run, introducing hills into a training regimen or adding sprints, eliminate these things. Back off on running, or considering cross training with swimming and biking.
   
   
2. Ice:
   Icing for 15-20 minutes 2-3 times a day, and especially after activity (if training continues) may help reduce inflammation and bring symptomatic relief. Freeze a dixie cup of water and then peel the top quarter of the paper down. Place the ice directly on the shin, moving the ice along the area of pain. Icing is particularly helpful during the first 2-3 days after the onset of the shin splint pain.
   
   
3. Calf Stretching
   After icing for 2-3 days, stretching should be started. The most important stretch for shin splint pain is calf stretching. Start with gentle stretching, this should not be painful. The runner's stretch seen on the right is a good stretch to start with. Hold the stretch for 60 seconds, and repeat 3 times. Do this 3 times a day. The stretch should not be painful. Don't hang your heels off a step to stretch the calf, this may overstretch the area. More on stretching.  
   
   
4. Appropriate Shoes:
   Soft, flexible shoes may be comfortable at first, but are the main cause for many common foot problems. Shoes should be rigid and bend only at the toes, which is where the foot bends. A shoe which collapses will contribute to overpronation, stress at the arch and the calf and can contribute to shin splint pain. The shoe should also be wedged at the heel, to add a lift to the heel and take stress off of the calf. Choose a shoe which matches the activity you are participating in. Running shoe for running, walking shoe for walking and hiking shoe or boot for hiking. To test your shoes, take the shoe by the heel and place the toe area on the floor. Press down on the shoe. If the shoe collapses, it is too flexible. The shoe should bend only at the toes. More on choosing a running shoe.
   
   
5. Control overpronation:
   Orthotics are the best way to control overpronation. For those with a considerable amount of overpronation in association with flatfeet, a custom made semi-rigid functional orthotic should be made by a podiatrist. These can be expensive when not covered by insurance. A more affordable option is a prefabricated semi-rigid functional orthotic. Prolab has two types of prefabricated orthotics which are comparable to custom made devices in materials and design. For those who cannot tolerate rigid orthotics, Superfeet or ArchMolds Insoles may be more comfortable. Superfeet Green are designed for runners and walkers. It is recommended to be evaluated by a podiatrist to see what option may be best for you. The pronated foot in a posted Prolab orthotic is shown below.
   
   
   
6. Surfaces Choice:
   Finding the right surface for running or walking can be tricky. Running on grassy areas and sand is general too soft and uneven and may contribute to the development of shin splint pain. Running on surfaces which are too hard, like concrete, cause a "foot slapping" effect, which places excess stress on the muscle group in the front of the leg. These muscles have to work extra hard to keep the foot from slapping down (decelerating plantarflexion). This also happens when running on hills, especially going downhill. The best surface for running is packed dirt or a track surface. Of course, not everyone has access to a nice, packed dirt, running surface or running track. Also, many people who play sports like soccer, tennis, football or basketball are stuck playing on the sport's surface. This is what makes surface choice difficult. If you are recovering from shin splint pain and returning to your activity, it's important to avoid hills, stairs, concrete, uneven and extra soft surfaces. Avoid running on the road's shoulder where the road is slanted. Avoid playing a sport which is on an uneven surface or concrete surface, until you are able to walk and run pain free on a soft, but firm surface.

If you do not improve within 4 weeks, make an appointment with your doctor.

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last updated 6/17/10

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.