What are shin splints?

Shin Splints (Medial Tibial Tenoperiostitis) is a condition characterized by damage and inflammation of the connective tissue joining muscles to the inner shin bone (tibia).

There are several muscles which lie at the back of your lower leg and are collectively known as the calf muscles (figure 1). Several of these muscles lie deep within the calf (tibialis posterior, flexor digitorum longus, flexor hallicus longus and soleus) and attach to the inner border of the shin bone (tibia). The connective tissue responsible for attaching these muscles to the tibia is known as the tenoperiosteum. Every time the calf contracts, it pulls on the tenoperiosteum. When this tension is too forceful or repetitive, damage to the tenoperiosteum occurs. This results in inflammation and pain and is known as medial tibial tenoperiostitis – commonly referred to as shin splints.

Medial tibial tenoperiostitis can sometimes occur in combination with other pathologies that cause shin pain such as compartment syndrome and tibial stress fractures.

Causes of shin splints

Shin splints most commonly occur due to repetitive or prolonged activities placing strain on the tenoperiosteum. This typically occurs due to excessive walking, running or jumping activities (such as an increase in training or running) and is often seen in runners and footballers. It frequently occurs in association with calf muscle tightness or biomechanical abnormalities, such as excessive pronation (flat feet – figure 2) or supination (high arch) or in those with inappropriate footwear. Athletes more commonly develop this condition early in the season following a period of reduced activity (deconditioning) and when training surfaces are generally harder.

Signs and symptoms of shin splints

Patients with shin splints typically experience pain along the inner border of the shin. In less severe cases, patients may only experience an ache or stiffness along the inner aspect of the shin that increases with rest (typically at night or first thing in the morning) following activities which place stress on the tenoperiosteum. These activities typically include excessive walking, running (especially up hills, on uneven surfaces or in poor footwear such as thongs), jumping and general weight bearing activity. The pain associated with this condition may also warm up with activity in the initial stages of injury. As the condition progresses, patients may experience symptoms that increase during sport or activity, affecting performance. In severe cases, patients may walk with a limp although this may also reduce to some extent as the patient warms up.

Patients with this condition typically experience pain on firmly touching the inner border of the shin bone particularly along the lower third of the bone. Areas of muscle tightness, thickening or lumps may also be felt in the area of pain. In severe cases, swelling, redness and warmth may also be present.

Diagnosis of shin splints

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose shin splints. Occasionally, further investigations such as an X-ray, ultrasound, bone scan, CT scan, MRI or compartment pressure testing may be used to assist diagnosis and rule out other conditions, such as compartment syndrome or tibial stress fractures.

Treatment for shin splints

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Prognosis of shin splints

Most patients with this condition heal well with appropriate treatment. Recovery time may range from a few weeks to many months depending on the severity of injury, quality of treatment and length of time the injury has been present for. Patients with shin splints that have been present for months may require a considerable period of treatment associated with reduced activity before full recovery occurs.

Contributing factors to the development of shin splints

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

• excessive training or activity
• poor foot posture (especially flat feet – figure 2)
• inappropriate footwear
• inadequate warm up
• training on hard or inappropriate surfaces
• muscle weakness (especially the calf muscles)
• tightness in specific joints (such as the ankle)
• tightness in specific muscles (especially the calfs)
• poor lower limb biomechanics
• poor training technique or methods
• leg length differences
• poor balance
• being overweight
• deconditioning
• poor core stability

Physiotherapy for shin splints

Physiotherapy treatment for patients with this condition is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:

• deep tissue massage (particularly to the calf muscles)
• joint mobilization
• dry needling
• electrotherapy
• PNF stretches
• arch support taping
• the use of orthotics or shock absorbing insoles
• the use of crutches
• biomechanical correction
• ice or heat treatment
• progressive exercises to improve flexibility (especially of the calf muscles), balance, strength and core stability
• activity modification advice
• anti-inflammatory advice
• footwear advice
• weight loss advice where appropriate

Other intervention for shin splints

Despite appropriate physiotherapy management, some patients with shin splints do not improve. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may include pharmaceutical intervention, further investigations such as X-rays, bone scan, CT scan, MRI, or compartment pressure testing, or a referral to an orthopaedic specialist who will advise on any procedures that may be appropriate to improve the condition. A review with a podiatrist may also be indicated for the prescription of orthotics to correct any foot posture abnormalities.

Exercises for shin splints

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercises

Calf Stretch with Towel

Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed around your foot as demonstrated (figure 3). Using your foot, ankle and the towel, bring your toes towards your head until you feel a stretch in the back of your calf, Achilles tendon or leg. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free.

Figure 3 - Calf Stretch with Towel

Resistance Band Calf Strengthening

Begin this exercise with a resistance band around your foot as demonstrated and your foot and ankle held up towards your head (figure 4). Slowly move your foot and ankle down against the resistance band as far as possible and comfortable without pain, tightening your calf muscle. Very slowly return back to the starting position. Repeat 10 – 20 times provided the exercise is pain free.

Figure 4 – Resistance Band Calf Strengthening (left calf)