Shin Splints
What is the medical term for shin splints?
Medial tibial stress syndrome (MTSS), aka Medial Tibial Traction Periostitis, describes exercise-induced pain along the inside of the tibia. The condition is commonly referred to as “Shin splints” and is a familiar malady and affects about 33 % of athletes (1-4).
Are shin splints common in runners?
Yes, shin splints are responsible for approximately 15% of all running injuries (1).
What causes shin splints?
Shin splints are believed to result from repetitive contraction of the deep ankle flexors during running, jumping, or impact loading (5). Repetitive traction on the medial tibial crest results in myofascial strain, inflammation, and bony stress reaction (6-13).
What actually causes the pain in shin splints?
Early theories focused on myofascial strain, but current evidence suggests that a bony stress reaction (called periostitis) is the most likely cause of MTSS (14-20).
Shin splints and stress fractures
Newer research suggests that traction periostitis may be an inflammatory precursor to tibial stress fracture (21) The stress of exercise can weaken bone. Healthy bone responds to this stress by remodeling itself more densely. Stress reactions occur when the normal adaptive remodeling response is unable to keep pace with the loads of excessive training: high demands with inadequate recovery times (22,23). Prolonged insult may lead to tibial stress fracture (24,25).
Shin splints and athletes
The leading mechanism of injury is repetitive eccentric contraction from running or jumping on hard surfaces (the landing portion of each step is eccentric) (26-28). Excessive or improper training is the leading factor for the development of shin splints (2,3,29-33). Common training errors include the terrible too’s (too much, too fast, too long) (31-34). Athletes who run more than 20 miles per week are at increased risk of developing shin splints (35). Inexperienced runners or those with poor technique are at greater risk (4). Running with a narrow or “crossover” gait increases tibial stress (87).
What are the risk factors for shin splints?
Foot hyperpronation is a significant risk factor for the development of shin splints, as a collapsing foot puts additional stress on the suspect tissues (4,10,12,14,28,36).
Interestingly, the use of orthotics is associated with the development of MTSS, although orthotic use should not be viewed as an independent risk factor since those using orthotics are likely to hyperpronate (4).
Females are affected more frequently and have a 150-350% increased likelihood of progressing to stress fracture (4,37).
Other risk factors include a prior history of shin splints and increased BMI (4).
Hip abductor weakness is a common culprit of many lower chain overuse injuries (86). Excessive external rotation of the hip is another known contributor (4,50).
What are the symptoms of shin splints?
The pesentation of shin splints includes vague, diffuse pain over the middle to distal inside of the tibia. Athletes often present following an increase in activity intensity or duration. Symptoms are often worse with exertion – particularly at the beginning of a work-out (38).
Initially, symptoms may subside during training, but as the condition progresses, symptoms may linger throughout activity or even at rest (38). Pain that persists more than five minutes post-activity carries a higher suspicion of stress fracture (49).
Prolonged stress may generate a periosteal reaction detectable as a “rough” or “bumpy” feel (39).
Do I need X-rays or imaging for shin splints?
Imaging of early and uncomplicated MTSS is often unnecessary (53). Imaging is appropriate in the presence of: red flags, focal tenderness, pain at rest, or when the patient fails to improve with a reasonable trial of conservative care (53). Radiographs taken within the first 2-3weeks are not likely to show any change; however, patients with longstanding MTSS may demonstrate periosteal reaction indicating callus formation and stress fracture (55).
Plain films frequently do not demonstrate the signs of tibial stress fracture (42,56,57). Unresponsive patients or those with a higher likelihood of stress fracture (runners) may benefit from advanced imaging, including MRI or bone scan (58). MRI is highly sensitive (74-100%) and is best able to grade the progression of stress reaction (59-61).
What is the best management of shin splints?
No intervention has proven more successful than rest for the management of shin splints.
The successful management of shin splints requires the removal of risk factors, and rest.
Athletes may need to decrease frequency, intensity, and duration of impact activities, including running and jumping. Athletes may need to consider non-weight bearing cross-training like stationary cycling or pool running.
Initially, anti-inflammatory modalities, including ultrasound or e-stim may provide relief. (67) Ice or home ice massage may provide an anti-inflammatory or palliative benefit.
Resolution of shin splints requires correction of any associated kinetic chain dysfunction (68-70). Stretching exercises and myofascial release are appropriate for muscles around the leg and hip. (71) Strengthening exercises may be appropriate for weak hip and ankle musculature. Manipulation may be employed to resolve joint restrictions in the spine, sacroiliac joint, pelvis, and lower extremity (69,70,74).
Arch supports or custom orthotics may be appropriate for patients with fallen arches (75), although at least one contradictory systematic review suggests that orthotics may be causative and are not useful for prevention (76).
Additional possibilities for the management of shin splints include dry needling and acupuncture (74,80).
When can I return to activity with shin splints?
Return to activity should start slowly with a graded running program, beginning with a 1/4 mile run and progressing by 1/4 mile each time the athlete has no pain for two consecutive workouts (82).
Athletes should initially avoid running on hard or uneven surfaces and begin at a lower intensity and distance, increasing by no more than 10-15% per week.
Runners should first increase distance, then pace, and avoid hard or unlevel surfaces, including hills. Runners with a narrow gait may benefit from incorporating a wider step width (87).
Running shoes lose half of their shock absorption capacity after 300-500 miles and should be replaced within that range (83-85).
What other treatment options are available?
Surgical intervention is rarely utilized in this condition (74).
At Creekside Chiropractic & Performance Center, we are highly trained to treat shin splints. We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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