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Physical Therapy

A Guide to Shin Splints: Symptons, Causes, Treatments

November 9, 2020
By Health Loft

What are Shin Splints?

Most likely you have heard of shin splints. And most likely you have an understanding that shin splints are pain located in your shins. But what are shin splints? Medial Tibial Stress Syndrome is the formal medical diagnosis of shin splints. It is diagnosed when a person has pain along the inside of the shin bone greater than inches, and other conditions have been ruled out.

But what exactly is Medial Tibial Stress Syndrome? Well, the Madigan Army Medical Center defines it as “an overuse condition, specifically a tibial bony overload injury with associated periostitis, that clinicians commonly encounter in participants of recurrent impact exercise, such as running and jumping athletics as well as in military personnel.” Meaning, it is a stress injury to the bone and surrounding soft tissues.

The exact cause of Shin Splints is debated. However, it is theorized that repetitive stress to the tibia (shin bone) can result in tiny injuries that are unable to heal before being compounded by further small injuries. Pain usually occurs along the shin bone or one of its connecting muscles. It is not known if the bone is stressed first causing pain along shin or if the muscles get irritated first and pull on the shin. Either way, the recurring small injuries from the impact of running and jumping can cause inflammation to the bone and adjoining tissue.

Changes in bone and inflammation of tissue can be seen while imaging the lower leg when Shin Splints are present. Common imaging used is CT scan, MRI, and dual energy x-ray. Occasionally, these changes are not noticed on imaging until the pain has been present for two or more weeks.

Conditions mistaken for Shin Splints 

There are a few more serious conditions that need to be ruled out before Shin Splints can be confidently diagnosed. One condition is a Tibial Stress Fracture, which is a small fracture in the tibia. Shin Splints does not include a stress fracture, however, prolonged Shin Splints can lead to a stress fracture.

Compartment Syndrome is another diagnosis that needs to be ruled out before diagnosing Shin Splints. It is “characterized by pain and pressure in one or multiple muscle compartments with repetitive physical activity.” Compartment Syndrome is much more serious requiring intramuscular pressure measurements to diagnose and generally surgery to cure. Like Shin Splints, symptoms of Compartment Syndrome are worse with activity. However, unlike shin splints, numbness and the feeling of pressure can occur with Compartment Syndrome.

Posterior Tibial Tendonitis pain can be felt along the inside of the shin, as well. However, it is also frequently associated with ankle pain on the inside of the foot. Be aware that foot pain is not a common sign of Shin Splints.

Peripheral Artery Disease is when lower leg pain is felt with activity. This condition can cause limited blood supply to the extremities. As your muscles contract more frequently, such as with exercise, the demand for oxygen from the blood is higher. If you have peripheral artery disease, then pain can be felt if the muscles do not get the oxygen needed to keep up with demand. It is important to contact your physician, if you have, or are concerned you have, peripheral artery disease and begin having leg pain during activity.

Shin Splint Symptoms

Shin splints affect 13-20% of runners and 35% of military recruits. Though, it can affect any individual. Usually, the pain begins after repetitive running or jumping and can linger for long periods. Typically, the pain improves with rest and returns with activity or quickly after activity.

Pain is located along the inside of the shin bone, usually in the middle or lower half of the bone. Aching pain is the most common, but it can feel like sharp pain during the activity in some people. The pain should be reproducible by touching the inside of the shin bone. Typically, shin splints don’t cause cramping or burning sensation in the lower leg. Numbness is a sign of a more serious condition, as it is not associated with Shin Splints.

Shin Splint Causes

While research hasn’t agreed on the exact cause of Shin Splints, there are known risk factors and proven non-risk factors.

  • Risk Factors: Many studies have been done to determine which risk factors are most associated with Shin Splints. These studies have given us confirmed and potential risk factors.
    • Confirmed Risk Factors: There are 5 risk factors that have been confirmed by the highest level of research as risk factors for Shin Splints.
      • Higher Weight: When matched to peers, those with higher weight are at a greater likelihood of having shin splints than lower weight peers. Since the research just compared weights between peers and not with an exact cutoff weight, it is unknown at what weight one becomes a higher risk for developing Shin Splints.
      • Greater Navicular Drop: Multiple researchers have agreed that greater navicular drop (greater than 10 mm) is a risk factor for Shin Splints. Navicular drop is how much the arch of the foot flattens when standing compared to sitting. It is also associated with how much your ankle rolls in when standing and walking.
      • Greater Hip External Rotation Range of Motion: Various studies have shown that increased hip external rotation mobility (more than 65 degrees) when measured with the hip and knee bent, is a risk factor for Shin Splints.5-6 Hip external rotation is turning your leg out, causing your toe and knee to point sideways. Furthermore, this motion allows you to place your ankle on your opposite knee. It is unknown why greater hip external rotation is a risk factor.
      • Female Sex: Multiple studies as reported in the Sport’s Health Journal found that being a biological female increases the likelihood of getting Shin Splints when compared to male sex. The reason for this is unknown. One research group theorized that different running mechanics between men and women could be to blame for female sex being a risk factor for Shin Splints.
      • Previous Running Injury: Specifically, a previous lower extremity injury resulting from running increases your likelihood of getting Shin Splints. This is true for most injuries and conditions of orthopedic nature. Once you have an injury, you are more likely to have another injury than someone who has not had an injury.
    • Potential Risk Factors: These circumstances have been shown to be risk factors in some studies. However, the highest level of research (meta-analysis) has not agreed on the importance level of these two factors.
      • Greater BMI: Body Mass Index (BMI) is a controversial risk factor for Shin Splints. In studies where BMI was looked at it was found to be a risk factor. However, in studies where height, weight, and BMI were evaluated separately, BMI was not found to be a risk factor. It is likely based on these studies that increased weight, which leads to increased BMI, is the bigger risk factor.
      • Greater plantarflexion Range of Motion: A study published in the British Journal of Sports Medicine found that the amount of motion a person can achieve when pointing their toes was a risk factor. However, this has not been studied enough to know how much or how it affects Shin Splints risk.
  • Proven Non-Risk Factors: These factors have been thoroughly studied and proven not to be related to shin splints.
    • Age: Shin Splints has not been related to age. There are reports of people young, old, and in between suffering from shin splints.
    • Dorsiflexion Range of Motion: How far a person can raise their toes in relation to their heel is not relevant when it comes to Shin Splints.
    • Ankle Eversion/Inversion Range of Motion or Strength: The amount of motion an ankle moves side to side or how strong the muscles are that perform these motions have not been associated with shin splints.
    • Quadriceps angle: Commonly known as the Q-Angle, the quadriceps angle is the measurement of how much a knee bends inward or outward when standing upright. In regard to Shin Splints, this angle is irrelevant.
    • Walking Speed: This is exactly what it sounds like. How fast or slow a person walks has not been shown to be related to shin splints.
    • Weekly Training Mileage: Runners frequently track and talk about their training mileage to gage their progress. Since Shin Splints is often thought of as an overuse injury it would make sense that the more a person ran the more likely they would be to have shin splints. The research has not agreed. In fact, research has proven that weekly training mileage is not a risk factor for Shin Splints. Although, it is possible that significant change in weekly training mileage could be a risk factor. Meaning, rapidly increasing mileage without proper build up could lead to shin splints. The verdict is still pending if change in mileage is related to Shin Splints.

There are still some risk factors being studied, specifically in the running population, including strength of hip musculature and running postures. However, there is not enough evidence to determine if these factors play a role in developing Shin Splints. It is theorized that if a person’s hips are strong, then there is good support for the rest of the lower limb. Also, the effect of running postures, such as foot strike, are debated regarding injury prevention. But the jury is still out if it matters for shin splints.

Shin Splint Treatment

The biggest question someone has when experiencing shin splints is “How do I stop the pain?” Many treatments have been studied for Shin Splints. A physical therapist or a physician can help you decide which treatment would be best for your individual needs.

  • Relative Rest and Gradual Return to Exercise: The best and most immediate treatment to reduce the pain from shin splints is to stop doing the painful activity. Relative rest is when a person stops performing the painful activity but continues non-painful activity. For example, if a person has shin splint pain while running but not walking, then it would be beneficial for the person to stop running. This person could walk for exercise or enjoyment as long as walking doesn’t become painful. This relative rest has been shown to reduce pain and allow for healing of aggravated tissues in Shin Splints.1

The exact length of time a person needs to rest is dependent on the person’s symptoms. Once the pain is gone with daily activities, then it is time to begin gradual return to exercise. Gradual is the keyword here. To stick with our running example from above, the person needs to be able to walk without any pain before beginning to run. Once the person is ready to run, a short distance should be tried first before long distances. The distance you run should be increased  by no more than 10% each week if there was no pain during running. To progress any distance, there must be no pain with the previous distance.

  • External Foot Support:
    • Orthotics: There are a handful of studies that support the use of orthotics to reduce shin splints. Most of the research has included military personnel and shows that wearing an orthotic inside a shoe/boot decreases pain and reduces the likelihood of getting Shin Splints.9 The theory is that an orthotic will help maintain the shape of the arch throughout activity. Therefore, reducing stress placed on the bone and musculature. Orthotics can be purchased over the counter or custom orthotics can be developed and ordered via an orthotist.
    • Taping: Taping follows the same theory as orthotics, however, it can be applied independently and taken off when not performing painful/demanding activities. A small study reported that kinesio taping was more effective than orthotics at reducing pain in people that had Shin Splints.10 The kinesio tape is a flexible athletic tape that was applied to support the arch and, theoretically, to increase the natural foot stability via muscle activation. A physical therapist can determine if you would benefit from taping. And if needed, a physical therapist can instruct proper application of the tape.
  • Extracorporeal Shockwave Therapy: Using sound waves, Extracorporeal Shockwave Therapy is directed at painful tissues to stimulate healing. There is some evidence supporting the use of this therapy to treat shin splints. Physical therapists and some physicians are able to perform Extracorporeal Shockwave Therapy if you are a candidate.
  • Dry Needling: Periosteal pecking, a type of dry needling, can reduce pain from Shin Splints. In this technique, the dry needle is inserted into the skin and directed to the shin bone to reduce pain signals. It also helps to promote healing within the bone and surrounding tissues. While inserting needles into the body sounds painful, this technique is relatively pain-free and quick to perform. A physical therapist certified in dry needling can determine if you are a good candidate for this procedure.
  • Vitamin D and Calcium: Adding supplements to your routine should always be reviewed with your physician. However, there is research indicating that improving vitamin D and calcium levels can reduce recovery time from Shin Splints. Specifically, this has been shown to be helpful in people that have had prolonged shin splints that did not improve with relative rest. There are side effects to taking these supplements depending on other health conditions and blood levels, so an appointment with your physician is recommended to discuss if this could be beneficial for you.
  •  Address Risk Factors: Earlier we reviewed the different known risk factors for Shin Splints. Well with any condition, if you can change the risk factors then you are able to change your risk of developing the condition. Let’s go through each risk factor again and discuss if and how it could be addressed.
    • Higher Weight: Since the exact weight that increases the risk of Shin Splints has not been reported, we don’t have a cutoff weight to encourage. However, we do know that there are multiple benefits to having a healthy weight. There are two main ways to measure a healthy weight: BMI and waist circumference. A BMI between 18.5 and 24.9 is considered to be healthy. A waist circumference less than 40 inches for men and less than 35 inches for non-pregnant women is considered healthy. If you need assistance in achieving a healthy weight, there are multiple health professionals able to help, including physical therapists.
    • Greater Navicular Drop: A few treatments for reducing navicular drop were already discussed, orthotics and taping. Change in footwear can also help assist with arch support. However, there are other ways to improve navicular drop and foot stability. Strengthening of the natural support system, the posterior tibialis and foot intrinsic muscles, can reduce navicular drop. A physical therapist can evaluate and determine if strengthening is appropriate for you.
    • Greater Hip External Range of Motion: This risk factor is tricky. Having good hip mobility has been shown to reduce risk factors for other conditions, such as back pain. However, in the studies showing that greater hip external range of motion was a risk factor for Shin Splints the participants had much more than the normal range of motion. Therefore, when thinking about reducing this risk factor it is suggested that you don’t try to stretch into hip external rotation past normal ranges (45-55 degrees). Again, an evaluation with a physical therapist can help determine your hip range of motion and any needed stretching modifications.
    • Female Sex: Sorry ladies, there isn’t much that can be changed here. Although, it could be beneficial to have a running assessment performed by a physical therapist to determine if there are any faulty mechanics that can be addressed, as one theory is that running mechanics differ between sexes.
    • Previous Running Injury: You can’t change the past. So, if you have already had a running injury then you are at greater risk. Nevertheless, it is important to treat previous injuries to ensure that you are fully recovered. The possibilities of treatment here are endless and a physical therapist is best suited to determine an individual’s specific treatment protocol.

While there are many factors that play a role in Shin Splints most people recover fully. It is important to understand your risk for shin splints when changing your activity level or exercise routine. And it is equally important to make adjustments and seek treatment if you develop shin splints. Shin Splints can lead to more serious conditions, such as stress fractures, therefore prolonging return to activity if left untreated.

For an individualized treatment plan to help you with your shin splints, consult with one of our physical therapists in Chicago (virtually via our telehealth platform or in person) by calling us at (312) 374-5399 or by scheduling an appointment online. If you have further questions regarding dry needling, we would also be happy to answer them.  Remember to also check out our FacebookInstagram, and Twitter pages for more fun facts and articles on nutrition, physical therapy, and exercise!

 

Submitted by Kellie Stickler
Edited by Alexander Franz
Reviewed by James Caginalp PT, DPT, CSCS, CES, PES

 

REFERENCES

  1. McClure, C.J. & Oh, R. (2020). Medial Tibial Stress Syndrome. Treasure Island (FL): StatPearls Publishing.
  2. Franklyn, M. & Oakes, B. (2015). Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. World Journal of Orthopedics, 6(8): 577-589. doi: 10.5312/wjo.v6.i8.577.
  3. Moen, M.H., Tol, J.L. Weir, A., Steunebrink, M. & De Winter, T.C. (2009). Medial Tibial Stress Syndrome: A critical review. Sports Medicine, 39(7): 523-546. doi: 10.2165/00007256-200939070-00002.
  4. Vajapey, S. & Miller, T.L. (2017). Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature. The Physician and Sportsmedicine, 45(4): 391-398. doi: 10.1080/00913847.2017.1384289.
  5. Reinking, M.F., Austin, T.M., Richter, R.R. & Krieger, M.M. (2017). Medial Tibial Stress Syndrome in active individuals: A systematic review and meta-analysis of risk factors. Sports Health, 9(3):252-261. doi: 10.1177/1941738116673299.
  6. Hamstra-Wright, K.L., Bliven, K.C.H. & Bay, C. (2015). Risk factors for Medial Tibial Stress Syndrome in physically active individuals such as runners and military personnel: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(6):362-369. doi: 10.1136/bjsports-2014-093462.
  7. Newman, P., Witchalls, J., Waddington, G. & Adams, R. (2013). Risk factors associated with medial tibial stress syndrome in runners: A systematic review and meta-analysis. Open Access Journal of Sports Medicine, 4:229-241. doi: 10.2147/OAJSM.S39331.
  8. Becker, J., Nakajima, M. & Wu, W.F.W.  (2018). Factors contributing to Medial Tibial Stress Syndrome in Runners: A prospective study. Medicine and Science in Sports and Exercise, 50(10):2092-2100. doi: 10.1249/MSS.0000000000001674.
  9. Bonanno, D.R., Murley, G.S., Munteanu, S.E., Landorf, K.B. & Menz, H.B. (2018). Effectiveness of foot orthoses for the prevention of lower limb overuse injuries in Naval recruits: A randomized controlled trial. British Journal of Sports Medicine, 52(5):298-302. doi: 10.1136/bjsports-2017-098273.
  10. Kachanathu, S.J., Algarni, F.S., Nuhmani, S., Alenazi, A.M., Hafez, A.R. & Algarni, A.D. (2018). Functional outcomes of kinesio taping versus standard orthotics in the management of shin splint. Journal of Sports Medicine and Physical Fitness, 58(11): 1666-1670. doi: 10.23736/S0022-4707.17.07520-X.
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