How to Manage Shin Splints

What are shin splints?
The term "shin splints" has been widely used as a catch-all term referring to a collection of different conditions that cause leg pain. The term medial tibial stress syndrome (MTSS) better defines the injury and separates it from injuries such as stress fractures or compartment syndrome. MTSS is caused by chronic strain, overuse, and microtrauma of the soleus (calf) muscle at its origin on the shinbone (posteromedial tibia) or deep inflammation of the periosteum, which is the connective tissue that covers the bone, of the tibia beneath the posterior tibialis muscle (Fig.). MTSS usually occurs in unconditioned people who begin a new running or jumping activity or conditioned runners who change or increase their speed or distance or change their type of shoe or running terrain. MTSS also affects individuals who have flat feet because the mechanics of the foot increase stress on the soleus muscle.

MTSS or stress fracture?
A patient with MTSS has pain at the inner portion of the tibia in the middle of the lower leg and in the surrounding soft tissue (Fig.). A patient with a stress fracture feels pain around the upper outside portion of the tibia. With MTSS, pain usually disappears once the activity that causes the pain is reduced or stopped. With a stress fracture, however, the patient usually experiences pain that does not go away with rest. The pain often persists with walking and increases when walking up steps or during similar moderate activity. The patient often complains of pain at night. A "one-leg hop test" is a functional test often used to distinguish between MTSS and a stress fracture. A patient with MTSS can hop at least 10 times on the affected leg; however, a patient with a stress fracture cannot hop without severe pain.

An x-ray sometimes show chronic cases of MTSS, where there is a mild thickening or an uneven edge at the end of the tibia in the back. X-rays are also often taken to rule out a stress fracture. However, x-rays may not show a fracture line or a healing stress fracture until several weeks after injury, so a bone scan, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan may be used instead.

How to treat MTSS
To relieve the pain caused by MTSS, ice massage and Achilles tendon stretching are performed 3 to 4 times a day. Nonsteroidal anti-inflammatories such as aspirin are recommended to relieve inflammation and pain. Gentle stretching of the leg muscles that includes the calf, heel cord, and hamstring is essential before and after exercising to treat MTSS. Any anatomic foot variation, such as a pronated (a foot with a low arch) flat foot, should be corrected with a semirigid foot orthosis (shoe insert). Runners should use a running shoe that provides shock absorption and has a firm heel support. Gentle flexibility and strengthening exercises for the muscles involved should also be added to the workout.

The key treatment for MTSS is rest from the activity that causes the pain. Once the pain has subsided, less stressful exercise can begin. For example, for the first week, biking and swimming can be substituted for running. Then the patient can start training again at about half the previous level of intensity (half the distance or pace). The exercise intensity should be gradually increased to the desired level over 3 to 6 weeks. Recurrence of pain is a signal that the level of activity has been resumed too fast.

Active individuals who have recurring MTSS need not stop exercising or running. They should first correct predisposing factors, such as wearing worn-out shoes, running on hard surfaces and pavement, or increasing training too quickly. If the pain does not subside with these changes and a reduction of activity, then a visit to their orthopaedist is warranted. Rarely, if the symptoms do not respond with long periods of rest, a patient may undergo surgery to release the soleus attachment to the tibia. Usually after surgery, the patient may walk as tolerated, and activity is gradually increased over the following 3 months.

MTSS can be painful but is usually easily resolved. If you experience pain in your shin, thoroughly stretch before exercising, reduce your activity level, and check your shoe wear. If you run on a hard surface, find softer ground. Remember, exercising should be fun, not a painful experience.

Steven K. Below, M.D.
Columbus, Georgia

Further Reading: Perrin DH. The Injured Athlete. 3rd ed. Philadelphia, PA: Lippincott-Raven; 1999:423-424.