Shin splints is not a specific injury itself, but are the common name often given to pain at the front of the lower leg of which there may be a number of causes. The most common cause is medial tibial stress syndrome. Here we explain the symptoms, treatment and rehabilitation of medial tibial stress syndrome to cure and prevent it from recurring.
On this page:
- Symptoms & diagnosis
- Causes & anatomy
- Shin splints taping
- Sports massage for shin pain
Symptoms of medial tibial stress syndrome (play video) often come on gradually and consist of pain over the inside lower part of the tibia or shin bone. There may be a pain at the start of exercise which often eases as exercise continues only to come back worse later in the training session or afterward.
Pain in the shin is often worse first thing in the morning but may ease off over time as the tissues warm up, only to become painful again later on in the day. When pressing in (palpating) along the shin, tenderness, swelling, lumps, and bumps may be felt along the inside of the bone, particularly in more chronic cases. This is because new bone growth has occurred in response to repeated trauma. Occasionally in severe cases reddening of the skin over the inside of the leg from acute inflammation may be seen.
Stress fracture - Symptoms of a tibia stress fracture are similar to medial tibial stress syndrome, however, pain is acute or sharp and along the inside of the shin bone and stays the same or gets worse with exercise. Again it will be very tender when pressing in along the inside of the shin bone.
Chronic compartment syndrome - A compartment syndrome occurs when the muscle becomes too large for the sheath that surrounds it causing increased pressure and pain. Typically symptoms will not include pain at rest. An aching type pain gradually gets worse with exercise. Pain comes on at a specific point into a run and is relieved with rest. There will be little or no tenderness at rest unless it affects the large muscle on the outside of the shin.
Popliteal artery entrapment - Symptoms of popliteal artery entrapment consist of pain mostly in the calf muscles at the back of the shin bone. The pain gets worse with exercise, especially going up on your toes or jumping. The athlete's pulse is diminished when plantar flexing the foot (pointing the foot downwards).
The lower leg consists of tibia and fibula bones. The tibia is the larger weight-bearing bone and the fibula is the thinner one to the outside of it. The function of the smaller fibula bones is mostly for muscles attachment to aid movement. The tibia or shin bone bears the bodies weight when running and jumping. Large forces are transmitted through the tibia bone and the soft tissues attached to it.
The tibia bone has a thin sheath on the outside of the bone called the periosteum. Medial tibial stress syndrome or medial tibial traction periostitis occurs when the soft tissues (muscles and tendons) pull on the periosteum or sheath surrounding the shin bone causing pain and inflammation.
It is an overuse injury resulting from too much running or jumping and not enough recovery time. Although too much running, jumping or sprinting is the obvious cause, there are a number of factors which can increase the likelihood of shin pain developing such as increasing running mileage too quickly, excessive training on hard surfaces or running on your toes such as in sprint training. Certain biomechanical factors can also increase the risk of developing medial tibial stress syndrome:
Overpronation occurs when the foot rolls inwards too much flattening the arch of the foot and causing the lower leg to rotate inwards. This, in turn, increases the stress on the soft tissues of the lower leg resulting in pain and inflammation.
Over supination is where the foot rolls outwards too much. If you think you have suspected biomechanical issues then a professional can do gait analysis tests either with a treadmill or using force plates to determine this and whether corrective orthotic inserts for your shoes are needed.
Inadequate footwear such as the wrong type of shoe for your running style or running shoes that are just too old and have lost their support and cushioning can cause injury. Overpronators may require a running shoe with a firmer midsole on the inside to reduce the amount of rolling in (known as a stability shoe or motion control shoe). Supinators usually require a neutral shoe with plenty of cushioning. A specialist running shop can advise.
Increasing training too quickly is one of the more common causes of shin splints. Running on hard surfaces or on your toes as in sprinting and generally doing too much too soon will increase the risk of injury.
Poor flexibility (tight calf muscles) at the ankle can cause increased stress on the soft tissues, muscles, and tendons of the lower leg when running. The calf muscles and in particular the tibialis posterior muscle may need stretching.
Shin splints treatment
Treating shin splints involves reducing pain and inflammation, identifying and correcting training errors and biomechanical problems and restoring muscles to their original condition through stretching, exercises, and massage. The full rehabilitation process may take anywhere from 3 weeks to 12 weeks.
Apply the PRICE principles of protection, rest, ice, compression and elevation to reduce initial pain and inflammation. Apply a cold therapy and compression wrap to the painful area of the shin for 10 minutes every hour initially for the first 24 to 48 hours, reducing frequency to 3 or 4 times a day as symptoms improve. The tissues are very superficial so ice does not need to be applied for longer than 10 minutes. Do not apply ice directly to the skin as it may burn. Either wrap ice in a wet tea towel or use a commercially available cold pack.
Rest is important and often overlooked. This means resting from any activity that makes the condition worse such as running, jumping and other high impact sports. Very severe shin splints may require complete rest for a few days but you should aim to maintain an exercise routine by switching to swimming, cycling, cross trainer, rowing machines, step machines and other nonimpact equipment.
Taping (play video) - as most people have to be on their feet during the day it may not be possible to rest the tissues of the lower leg as much as required. Shin splints taping can instantly relieve symptoms in most patients can be applied all the time until the pain has gone and then occasionally during exercise as activities levels are built up. The simple taping technique supports the muscles of the lower leg by pulling them towards the shin bone reducing traction forces at the most painful part and allowing the soft tissues (muscle, tendon etc) to rest.
Protect and support the area with a shin splint sleeve or compression support. This will help keep the muscles warm and supple as well as providing support to the inflamed tissues. Wearing shock absorbing insoles in shoes particularly if you run or walk on hard surfaces in poorly cushioned shoes will help reduce the shock on the lower leg. Switch to wearing softer training shoes rather than hard leather work shoes if possible until symptoms go.
Stretching exercises - If not painful to do so, stretch the muscles of the lower muscles of the lower leg. In particular calf stretching exercises to release tension in the calf and peroneal muscles.
Identify possible causes - It is a common complaint that athletes will rest until their shin pain goes only for it to return once training resumes again. This is often because the underlying causes are not addressed. Keep a training diary so you can look back and assess if the training load is too high. Get a full biomechanical assessment to identify any problems with the feet which may be contributing and make sure you have the right shoes in good condition.
What can a professional do?
Expert interview (play video): Sports Physiotherapist Neal Reynolds explains professional approach to treating shin splints.
Medication - A doctor may prescribe anti-inflammatory medication e.g. ibuprofen to help reduce pain and inflammation. Although this should not be relied on as a long-term solution or excuse not to rest. Asthmatics should not take Ibuprofen.
Sports massage & myofascial release (play video) - After the first 3 days, massage can be used to reduce tension in the muscles of the lower leg which may be causing traction on the bone. Removing any tight lumps, bumps, and knots as well as encouraging blood flow may aid the healing process. This should initially be quite light and avoid the inflamed periosteum close to the bone. Gradually become deeper over subsequent treatments as pain eases.
Massage techniques (play video) should include sustained pressure along the length of the muscles as well as transverse frictions. It is important the massage therapist avoids the bone as this can make symptoms worse. However, it is important to avoid the bone as massage for shin pain done incorrectly may increase inflammation and pain.
Surgery - If all conservative treatment fails then surgery is an option, although this is rare.
Shin splints exercises
Exercises to stretch the muscles of the lower leg, in particular the tibialis posterior, which is often associated with shin pain are important. Stretching exercises should be done both with the knee straight and bent to target both the gastrocnemius muscle and the deeper soleus muscle.
Straight leg calf stretch (play video)
This is one of the most important shin splints exercises and stretches the larger gastrocnemius muscle as well as the tibialis posterior. Lean against a wall with the back leg straight keeping the heel pushed into the floor. A stretch should be felt at the back of the lower leg. If a stretch cannot be felt then move the heel further back. Hold for 20 seconds then relax and repeat 3 times. If the athlete has particularly flexible calf muscles then a more advanced version of the calf stretch can be done on a step.
Bent leg calf stretch (play video)
To stretch the deeper soleus muscle the knee must be bent to relax the larger gastrocnemius muscle which attaches above the knee. The patient faces a wall with the foot of the calf to be stretched at the back. The knee of the back leg should be bent towards the wall, keeping the heel on the floor. A stretch should be felt in the lower part of the back of the calf. Hold this position for 30 seconds and repeat 3 times. A more advanced version of this stretching exercise is to place the forefoot or the front leg on the wall keeping the heel on the floor and gently push the front knee towards the wall.
Strengthening exercises may also be required although being an overuse injury it is rest and stretching which should be the priority. A gradual return to full fitness is important. Calf raises and toe raise exercises can help get the muscles of the lower leg working again.
When walking has been pain-free for 2 weeks, you can begin running, building up gradually. Apply tape to the shin to support it for the first few runs and apply ice afterward. Stretch properly before and after each training session.
Expert interview (play video): Preventing shin splints
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- Moen MH, Tol JL, Weir A et al. Medial tibial stress syndrome: a critical review. Sports Med 2009;39(7):523-46
- Tweed JL, Avil SJ, Campbell JA et al. Etiological factors in the development of medial tibial stress syndrome: a review of the literature, J Am Podiatr Med Assoc 2008;98(2):107-11
- Bennett JE, Reinking MF, Pluemer B et al. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther 2001;31(9):504-10
- Griebert MC, Needle AR et al. Lower-leg Kinesio tape reduces rate of loading in participants with medial tibial stress syndrome. Phys Ther Sport. 2016 Mar;18:62-67