Shin Splints: The What, How, and Why for Treating Medial Tibialis Stress Syndrome

Having pain in the inside of your lower leg? It’s probably shin splints. 

Having pain on the front of your lower leg? It’s probably shin splints. 

Having pain when you touch the bone of your lower leg?

You guessed it. It’s probably shin splints. 

Sounds like almost anything could be shin splints, right? Well, that’s because the term “shin splints” is actually an umbrella term that is used to diagnose a series of aches and pains you can get from playing sports. 

Yes, that does tend to make the injury a bit ambiguous, but it’s not quite as scary as you’d think. (And thankfully, the name “shin splints” is a misnomer; there’s no need to actually splint your leg, despite how the pain may make you feel.)

But then that begs the question — what exactly is a shin splint?

What Are Shin Splints?

Shin splints are a common lower extremity injury that many runners will experience at some point in their careers. Also known as medial tibial stress syndrome, shin splints may affect anywhere between 5% to 35% of runners and may be caused by a variety of conditions.  

Research suggests that shin splints could be any of the following: myofascial strain, periosteal inflammation, or a bone stress reaction. Though the exact tissues and muscle structures that are affected can vary case-to-case, it is believed that the injury primarily affects the calf muscles, the flexor digitorum longus (a calf muscle that bends the toes), or the tibialis muscles.

Shin splints are primarily categorized into one of two types of pain: anterior (front) or posterior (back). The most prevalent shin pain is an anterior shin splint, where you feel pain in the front of your lower leg. Simply identifying where the pain is actually located in your lower leg narrows down what areas are affected, how they may have been injured, and what recovery method will be most effective for healing.

What Causes Shin Splints?

The most accepted theory predicts that shin splints are likely due to high impact forces and/or a sudden increase in mileage during running. But ultimately, because shin splints can present in many ways, it’s hard to pinpoint a singular, specific cause for the injury. Let’s consider both anterior and posterior shin splints, and their potential causes. 

Anterior Shin Splints

An anterior shin splint indicates that your tibialis anterior muscle or tendon is overused, which commonly results from overstriding. An overstride occurs when the foot strikes the ground ahead of the runner’s center of mass. From a biomechanical perspective, an overstride requires the tibialis anterior to contract while in a lengthened position. 

When a muscle contracts while in a stretched position, you’re applying forces to the muscle when it is in a vulnerable position. In other words, the more an athlete over strides, the more likely an athlete can sustain an injury to their tibialis anterior, which causes shin splints. Therefore, it’s important to not overstride while you run! 

Posterior Shin Splints

On the other hand (foot?), a posterior shin splint occurs along the inside and back of the lower leg, and it usually affects — you guessed it — the tibialis posterior. This muscle primarily supports the medial arch muscle (the inner muscle in the arch of your foot) as you put weight on it. Common causes of posterior shin splints are increases in mileage, training intensity, or (unfortunately) having flat feet. 

Researchers believe that the farther or the faster you run, the impact forces the body must absorb can overwhelm the tissues, ultimately causing an injury. 

Adding more mileage increases forces by adding more steps — you’re not landing harder, but you’re landing more often. Running faster creates more impact forces per step. If force is equal to mass times acceleration, then increasing the speed at which you’re hitting the ground is going to increase landing forces.  

Finally, having flat feet can also put you at risk for posterior shin splints. Similar to our anterior shin splint causes, flat feet can overstress the tibialis posterior muscle and tendon by causing the muscle to be lengthened. Without proper activation and strengthening of the foot core muscles, flat feet can also contribute to over-pronation and inward knee collapse, both of which aggravate shin splints. 

Risk Factors for Shin Splints

Flat feet aren’t the only culprits for shin splints. In fact, there’s a wide range of risk factors associated with the condition. A meta-analysis identified several common risk factors for developing shin splints:

1)      Female gender

2)      High BMI

3)      New to running

4)      Increased hip external rotation

5)      Over-pronation

6)      Usage of orthotics

7)      A history of shin splints

Unfortunately, not all of these risk factors can be changed, but being aware of them allows you to know which factors you can modify and improve via training and physical therapy.  For example, if you’re new to running, struggle with your running form, or know your family has a history of shin splints, you can take preemptive measures. Physical therapy can modify your running to improve its efficiency and promote better shock absorption, reducing the amount of stress going through your bones and body. 

Related Injuries: Stress Reactions and Stress Fractures

Although the term “shin splints” covers a wide range of injuries, it’s important not to confuse them with these other tissue- and bone-related injuries. So, let’s start out with some basics.

Bony stress injuries are usually a result of continuous loading. This means that every time your foot hits the ground (which is typically more than one thousand times per run), the body has to absorb your bodyweight in addition to other external forces like gravity. When the body is unable to absorb these forces well, other “passive tissues” (such as bones and ligaments) will step up to do the job. These passive tissues weren’t designed to absorb so much force, and as a result, they can be damaged over time.

Long-term issues can cause microdamage and small cracks in the bone. Several bones in the leg can develop stress reactions or stress fractures. A stress reaction is a pain that may feel tender when touching the bone, but this injury will distinctly lack intense damage to the bone. Stress fractures, however, are small fractures in the bones that are very painful every time you put weight on your leg.

Although stress reactions and fractures aren’t the same as shin splints, unmanaged shin splints can lead to either injury. If left untreated, a small fracture can crack the bone completely and may lead to a full fracture through the entire bone. If you suspect a stress fracture, see your doctor immediately!

An x-ray, MRI, or bone scan can identify a stress fracture (though x-rays aren’t recommended because they are less capable of identifying stress fractures early on). The most common places for stress fractures are the tibia, the navicular (the bone in the middle of the foot), and the second and third metatarsal bones of the foot. 

Prognosis and Treatment for Shin Splints

Once other conditions have been ruled out and a reliable cause has been determined, it’s time to turn your focus to the main goal: eliminating shin splints and making sure they don’t come back. 

Prognosis

Shin splint recovery is entirely feasible, but it can be an achy and long recovery, often taking months to heal. A meta-analysis estimated that in 2 months, most people will be recovered enough to complete an 18 minute run, and up to 90% were able to complete an 18 minute run in approximately 8-10 months. 

But thankfully, a long recovery process doesn’t mean you have to stop running! As painful as shin splints may feel, many people can (and do) still run with them. So don’t worry — as long as you modify the volume, intensity, and hills of your running as needed, those shin splints won’t be stopping you any time soon. 

That being said, there are few cases where it would not be recommended to run (i.e., if you have severe pain, suspicion of a stress fracture, or suspicion of decreased blood circulation). It’s vital to consult with a professional  to make sure it’s safe to run and to manage any symptoms you may feel as you carry on your season. (That’s where physical therapy can come in super handy!)

Treatment

When treating shin splints, the first goal should be to manage symptoms. Using ice, compression, and elevation early on can be a good place to start. This combination is effective for managing pain and swelling. 

“Rest” as a way of managing shin splints needs to be clarified. Complete rest is usually not necessary. Progressive loading (or gradually building up intensity and workload) can be beneficial to promote tendon recovery. 

Restructuring your training plan will likely be necessary, including identifying errors such as sudden increases in mileage or too much speed work. These can be the easiest and most effective way to correct the training-based causes of shin splints.

Once the initial “fire-fighting” is done, the real work begins. It’s going to sound counter-intuitive, but: damage to the contractile tissues (muscles and tendons) of the lower leg can improve the rate of healing. Sounds crazy that you have to damage the tissue to let it heal. What’s happening, though, is that by putting the tissue under a controlled amount of deliberate stress, you’re able to break up some of the tissue adhesions that may have built up, and the process of clearing out “the waste” increases blood circulation and promotes healthier muscles and tendons. 

The way this is done is important, though — it’s carefully implemented, and not just damage for the sake of blood flow. Physical therapists are well trained in soft tissue mobilization, trigger point release, cross friction massage, and sports massages, all of which are ways of stressing the tissue to induce positive results. 

Although they are not the most pleasant massages, they can be very effective for injured muscles and tendons. It is important to include soft tissue techniques at the appropriate time in the rehab process. Including these techniques too early can backfire and cause more pain and swelling.

While tissues are recovering, it’s time to turn the focus on the cause of the shin splints — what is it that’s causing increased impact forces, over-pronation, or one of the other risk factors? Often, the answer lies in form and how you’re running. 

Assessing biomechanics and impact forces can create long-term benefits to improve your performance and limit the number of injuries you get – not just shin splints! As previously mentioned, research suggests that shin splints are caused by high impact forces that accumulate over time. Biomechanical changes include reducing hip drop, limiting the amount of knee collapse, decreasing hip internal rotation, and reducing over-pronation, all of which can lessen impact forces and put your body in a better place to absorb the remaining impact.

Aside from changing yo

ur training plan, improving your running form, functional movement retraining, symptom management, and specialized massage techniques, what else can help with shin splints? You may be saying, “I’ve seen people with tape on their legs or wearing those tight compression socks; do those work?” Well, this next section will dive into the research to provide information on whether you want to wear that cool-looking kinesio tape on your legs. (Spoiler alert: it may not be necessary!)

Debunking Myths: Do Common Treatments Really Work?

compression socks on runnerThere are many recovery techniques, but a majority of them don’t have proper research to support their claims. This section will look into different research studies with evidence suggesting whether or not these interventions are effective in treating shin splints. 

Kinesio-Tape, Rigid White Tape, and TENS + Icing

A recent research article by Sharma and Sinha (2017) compared 30 athletes (divided into three equal groups) to test the benefits of different recovery options based on the TENS method and an ice massage. Group A only received TENS and ice massage, whereas Group B received kinesio-tape in addition to TENS and ice massage, and Group C received rigid white tape in addition to TENS and ice massage. 

In comparing the pain levels, strength testing, leg volume, and performance on a 50 meter sprint between all three groups, researchers found that there was no additional benefit of using kinesio-tape (Group B). While kinesio-tape may provide short-term relief, the use of white tape or TENS + ice combination is just as effective.

Orthotics and Calf Stretching

Loudon and Dolphino looked into whether the use of orthotics and calf stretching had any impact on the symptoms of shin splints. The researchers assigned a calf-stretching program and orthotics to 23 runners. In a follow-up 4 weeks later, they found that 15 runners experienced relief with the combination of interventions. (Interestingly, more men found relief compared to women.)

Unfortunately, people with chronic symptoms of shin splints found the least relief. Essentially, they found that the longer you have shin splints, the less likely they are to go away just by stretching and practicing foot orthotics. The authors concluded that, although orthotics and stretching were helpful to some, they shouldn’t be the only intervention used to fully treat shin splints — a cumulation of interventions would likely be the most beneficial.

Compression Socks and Changing Shoes

A case study suggested that the increase in blood flow and anecdotal statements from members of the running community support compression socks as an added method for treating shin splints. However, recent studies don’t clearly define the benefits of using compression equipment to reduce the symptoms of shin splints. 

There was inconclusive evidence regarding the benefits for both compression socks and shoe brands. That being said, there is some supporting evidence that indicates that worn out shoes can contribute to shin splints, so updating your running gear as it wears out or reaches mileage recommendations is always a healthy habit. 

Until more conclusive research tells us how our footwear may or may not increase our risk of shin splints, stick to paying attention to your own symptoms. Consider trying out a different pair of socks or shoes — if they help, continue wearing them, and if they don’t, switch back to your original pair.

Final Thoughts

That same attitude can be applied to a lot of shin splint management. While there are certainly concrete causes that a practitioner can help you to resolve (such as running form errors), part of symptom management is going to be trial-and-error to find what works. 

Generally, a mix of form correction, training adjustments, and soft tissue work are effective in combating shin splint pain and keeping you running long term. If you suspect you have shin splints (or  more serious conditions), always consult a medical professional before attempting to self-treat — you don’t want to miss something and end up out for the season! 

How to Treat Shin Splints