medical second opinion

Shin Splints (Medial Tibial Stress Syndrome)

By Asheesh Bedi, MD

What are shin splints?

The term “shin splints” refers to pain and tenderness along the front and inner side of the bone in the lower leg, the tibia. Shin splints are frequently encountered in athletes and can cause significant pain that limits the ability to compete. The official medical term used to describe shin splints is “medial tibial stress syndrome” (MTSS).

What causes shin splints in athletes?

The exact cause of shin splints remains unknown. It has been attributed to inflammation of the muscles, tendons, and lining of the bone (“periosteum”) in this location that causes pain after repetitive activities. Sometimes the bone is involved as well in more severe cases.

NATA athletic trainers believe that shin splints may result from an imbalance and relative weakness of the anterior compared to posterior compartment musculature of the lower leg. Others believe that forceful, repetitive downward flexion of the foot (“plantar-flexion”) may stretch the anterior muscles of the lower leg and increase risk for shin splints.

What puts me at risk for shin splints as an athlete?

Athletes that perform repetitive, vigorous physical activities are unfortunately at higher risk for developing shin splints. Track and field athletes, particularly sprinters and jumpers, are at high-risk. Vigorous dancers and military cadets (who are often training with running or marching drills) are vulnerable as well.

Flat feet (“pes planus”) or very rigid arches of the foot may also increase the risk of shin splints in athletes. While the precise reason is not known, it is thought that both of these foot conditions increase the stress and transmission of loads to the muscles and bones of the lower leg.

What other problems could be a cause for shin pain in athletes?

Shin splints are a diagnosis of exclusion in athletes, and other conditions must be considered and ruled out to assure the right treatment program is initiated. Some other common problems in athletes that must be evaluated include:

Stress Fracture – Repetitive, vigorous physical activity can sometimes place abnormally high stresses on the bones of the lower extremity. Under these circumstances, “microscopic” fractures of the bone can develop.
Tendon Strain or Muscle Injury – Pain the lower extremity may be secondary to strain or tearing of tendons and muscles. After vigorous exercise, pain in the lower leg can also result from “delayed onset muscle soreness” (DOMS).
Chronic Exertional Compartment Syndrome – In endurance athletes, particularly runners, the muscles of the lower leg can swell with repetitive activities. Sometimes the muscle swelling can exceed the space available for them provided by the surrounding, relatively inelastic envelope (“fascia”). The muscle swelling with increased pressures that limit blood flow can cause significant pain in the lower extremity.

How can the diagnosis of shin splints be made in athletes?

Shin splints can be a tough diagnosis to confirm, and often can be made by excluding the other common causes for lower leg pain in athletes. Athletes will complain on pain along the front and inside (“anteromedial”) aspect of the lower leg during or after physical activity, such as running or jumping. This location is sometimes tender to palpation over the bone and/or muscle.

Imaging studies can be helpful in supporting a suspected diagnosis of shin splints. A bone scan may demonstrate increased tracer uptake in the muscle or bone lining (“periosteum”) of the lower leg. MRI may similarly demonstrate some inflammation and fluid (“edema”) in this location. More importantly, however, the MRI will help to exclude a stress fracture or adjacent muscle/tendon injury in these athletes.

How to get rid of shin splints?

The mainstay of shin splints treatment in athletes is rest and avoidance of activities that cause the pain. This provides time for the inflammation to resolve and for recovery of the injured tissues. Rest is often accompanied by the initiation of anti-inflammatory, nonsteroidal medications (“NSAIDS”), cold therapy, and compressive wraps to alleviate symptoms and reduce inflammation. Some athletic trainers have also found taping of the lower extremities to be of benefit in theoretically unloading the muscles and lining of the bone (“periosteum”). Good orthotics to correct an underlying flatfoot or provide support for a rigid arch are also essential to help address the underlying factors that increase the risk of developing shin splints.

More Information: Read about sports injury treatment using the P.R.I.C.E. principle – Protection, Rest, Icing, Compression, Elevation.

After a period of rest and with complete resolution of pain, a gradual resolution of activities can begin. This should commence at a low-level and avoid prolonged, vigorous running or jumping sports. Consulting an athletic trainer or physical therapist can be very useful to help design a rehabilitation program that strengthens the muscles of the lower extremity and creates staged goals for a slow but steady return to play.

Is there a role for a corticosteroid injection for shin splints?

There is no strong evidence to support that corticosteroid injections are an effective treatment for shin splints. However, anecdotal injections at the edge of the muscular connection to the bone or its lining (“periosteum”) have been reported with variable success. Such treatments, however, should be used with extreme caution as a risk of weaking of tendons and adjacent soft tissues from the steroid is certainly a concern.

The role for surgery in shin splints treatment is very limited, and should only be considered for refractory cases that have failed all nonoperative measures. Given the rarity of this treatment, very limited evidence-based literature is available on the effectiveness of these surgeries on relieving symptoms and allowing athletes to return to competition.

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What can I do as an athlete to prevent developing shin splints?

While certain individuals may be predisposed to shin splints regardless of what they do, certain things can be done to help minimize your chance of developing them. These include:

•  Shin splints stretches  includes both passive stretching that is performed by pulling the foot upward (“dorsi-flexion”), as well as dynamic stretching by actively contracting the muscles to keep it pulled upward, by walking on your heels for example.
Alterations in running style. Heel-striking offers the best shock absorption and natural form when running long distances, and reduces the force transmission to the calf and shin muscles. Running on the toes is efficient for sprinting but hard for long-distance runners.
Choose appropriate footwear. For runners with a heavy heelstrike, make sure that that your shoes have appropriate padding of the heel. “Motion control” shoes with heel padding may be better than “neutral” shoes for the heavy heelstrike runner.
Get orthotics if necessary. Patients with flatfeet (“excessive pronation”) may benefit from arch supports and/or “motion control” shoes with extra support underneath the arch.
Avoid rough or hard terrain. Runners that are sensitive to shin splints may benefit from running on softer surfaces that allow for greater shock absorption and prevent the movement of bones. In this regard, running on a track surface may be better than pavement to prevent this injury.

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