Orthopaedic Surgery - Shin Splints

Basics

Shin splints, more accurately termed:

Medial tibial stress syndrome

are a common overuse condition characterized by:

Exercise-related pain along the posteromedial border of the tibia.

They usually develop after repetitive:

Running

Jumping

or other high-impact activity, particularly when training volume or intensity increases too quickly.

Synonyms

Common terms include:

Medial tibial stress syndrome

Tibial periostitis

Runner’s leg

and the traditional term:

Shin splints.

Nature of the Disorder

Medial tibial stress syndrome is best considered part of a:

Bone and periosteal stress response

caused by repetitive mechanical loading of the:

Tibia

and surrounding musculofascial attachments.

The condition differs from a discrete:

Tibial stress fracture, although both lie along the same spectrum of repetitive loading injury.

Epidemiology

Shin splints are especially common among:

Adolescents

Young adults

Runners

and athletes undergoing:

Conditioning programs.

Incidence

Reported incidence among runners is approximately:

13.6–20%.

Rates vary according to:

Training population

Running volume

and the diagnostic criteria used.

Risk Factors

Important risk factors include:

Running or jogging

Recent increase in mileage

Recent increase in speed or intensity

Training errors

Foot pronation

Pes planus

Higher body mass index

Female sex

Poor conditioning

Training Errors

A sudden increase in:

Running distance

Frequency

Hill work

or

Intensity

is a common precipitating factor.

The tissues of the leg may not have sufficient time to adapt to the new:

Mechanical load.

Foot Mechanics

Excessive:

Pronation

or a relatively flat foot may increase rotational and bending forces through the:

Tibia.

These biomechanical factors may contribute to repetitive stress along the:

Medial tibial border.

Etiology

Historically, shin splints were attributed mainly to:

Periostitis

at the muscular attachments of the:

Soleus

and

Posterior tibial structures.

Current concepts also recognize repetitive:

Tibial bone stress

as an important component of the disorder.

Muscular Traction

Repeated traction from muscles attaching along the medial tibia, particularly the:

Soleus

may contribute to irritation of the:

Periosteum

and underlying bone.

Repetitive Impact

Repeated ground-reaction forces generated during:

Running

and

Jumping

produce cyclical bending of the tibia.

When these loads exceed the bone’s capacity to remodel, pain may develop.

Associated Conditions

Medial tibial stress syndrome is commonly seen in:

Athletes undergoing conditioning

especially runners and military recruits.

Lower-Limb Deformity

Any biomechanical abnormality that increases stress through the leg may contribute, including:

Pes planus

Excessive pronation

and selected abnormalities of:

Lower-extremity alignment.

Diagnosis

The diagnosis is primarily:

Clinical.

A careful history and examination are important because shin splints can resemble more serious disorders such as:

Tibial stress fracture

and

Chronic exertional compartment syndrome.

Signs and Symptoms

Pain is usually induced by:

Exercise

and is located along the:

Posteromedial border of the distal tibia.

Character of Pain

The pain is typically:

Dull

Aching

or

Diffuse.

In some patients it may become:

Quite intense.

Timing of Pain

Symptoms often appear:

At the beginning of exercise.

Pain may continue during or after the workout but generally:

Improves with rest.

Progression

With continued training despite symptoms, pain may become:

More persistent

and may eventually limit:

Running performance.

Pain at rest or focal severe pain should raise concern for:

Stress fracture.

Physical Examination

The key finding is:

Diffuse tenderness along the posteromedial tibial border.

Distribution of Tenderness

Tenderness generally extends over a:

Relatively long segment

of the tibia rather than being confined to one very small:

Focal point.

This helps differentiate medial tibial stress syndrome from a:

Stress fracture.

Pain With Muscle Testing

Symptoms may be reproduced with resisted:

Plantarflexion

and

Inversion

because these movements recruit muscles attached near the symptomatic tibial region.

Inspection

There is usually little visible abnormality.

Occasionally there may be mild:

Soft-tissue swelling

or tenderness without marked erythema.

Gait and Foot Examination

Examine:

Foot posture

Arch height

Pronation

Ankle motion

and overall:

Running or walking mechanics.

Stress Fracture Concern

A tibial stress fracture should be suspected when tenderness is:

Highly localized

rather than diffuse.

Other concerning features include:

Pain at rest

Night pain

Pain with walking

and progressively worsening symptoms despite:

Activity reduction.

Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome may present with exercise-induced pain but typically has a different pattern.

Symptoms often involve the:

Anterolateral leg

and may include:

Tightness

Neurologic symptoms

or temporary:

Weakness.

Fascial Herniation

Patients with exertional compartment syndrome may occasionally have visible or palpable:

Fascial hernias.

Imaging

Plain Radiographs

Plain radiographs are often:

Normal

in medial tibial stress syndrome.

Their main role is to exclude:

Stress fracture

or another bony abnormality.

Serial Radiographs

Early stress fractures may also be radiographically occult.

Therefore, normal initial radiographs do not completely exclude a:

Bone stress injury.

Bone Scintigraphy

Historically, bone scanning may show:

Diffuse longitudinal uptake

along the posteromedial tibia in medial tibial stress syndrome.

Stress Fracture Bone Scan

A stress fracture more commonly produces:

Focal

or

Transverse increased uptake

rather than a long diffuse pattern.

MRI

MRI is highly useful for distinguishing:

Medial tibial stress syndrome

from

Stress fracture.

It can identify:

Periosteal edema

Bone marrow edema

and, in more advanced stress injury,

A fracture line.

Compartment Pressure Testing

When:

Chronic exertional compartment syndrome

is strongly suspected, compartment pressure measurements before and after:

Exercise

may be considered.

This is most relevant when symptoms are:

Anterolateral

and consistently appear at a reproducible level of exertion.

Pathological Findings

The disorder has historically been associated with inflammation or stress reaction involving the:

Periosteum

and attachment sites of the:

Soleus

and nearby posterior tibial musculature.

Modern evidence also supports an underlying:

Tibial bone stress response.

Differential Diagnosis

The two most important conditions to distinguish are:

Tibial stress fracture

and

Chronic exertional compartment syndrome.

Tibial Stress Fracture

Stress fractures typically cause:

More focal tenderness

and may progress to pain with:

Walking

or

Rest.

MRI is helpful when the diagnosis is uncertain.

Chronic Exertional Compartment Syndrome

This condition typically causes:

Tightness or pain during exercise

that resolves after stopping.

Possible associated symptoms include:

Paresthesia

Weakness

and a feeling of:

Leg fullness or pressure.

Treatment

General Principles

Treatment is primarily:

Nonoperative.

The cornerstone of management is reducing mechanical loading until symptoms improve.

Activity Modification

Training should be reduced to:

Below the level that provokes symptoms.

This may require decreasing:

Mileage

Speed

Running frequency

or temporarily stopping:

Impact exercise.

Relative Rest

Complete inactivity is usually unnecessary.

Athletes may maintain fitness with low-impact activities such as:

Cycling

Swimming

or other exercises that do not reproduce pain.

Ice

Ice may be applied after activity for:

Symptomatic relief.

Physical Therapy

Physical therapy may assist with:

Calf flexibility

Lower-extremity strengthening

Core strengthening

Foot and ankle mechanics

and gradual return to:

Running.

Stretching

Once acute symptoms improve, stretching may focus on the:

Gastrocnemius

Soleus

and other lower-extremity structures.

Strengthening

Rehabilitation may include strengthening of:

Calf muscles

Foot intrinsic muscles

Hip abductors

Core musculature.

Gait Analysis

Running-form assessment can help identify:

Biomechanical abnormalities

or training patterns that increase repetitive tibial loading.

Orthotics and Footwear

Selected patients with excessive pronation may benefit from:

Orthotic inserts

or

Shoe modification.

The goal is to reduce excessive:

Foot pronation

and improve load distribution.

Training Modification

Long-term prevention requires identifying and correcting:

Training errors.

Mileage and intensity should increase:

Gradually.

Extracorporeal Shock-Wave Therapy

Extracorporeal shock-wave therapy has been studied for persistent medial tibial stress syndrome.

Some studies have suggested:

Earlier symptom improvement

but it is not required for most patients.

Medication

NSAIDs

NSAIDs may provide short-term relief of:

Pain

and

Inflammation.

Analgesics

Other simple analgesics, including:

Acetaminophen

may also be used when appropriate.

Medication should not be used to allow continued training through:

Significant pain.

Surgery

Surgery is:

Rarely required.

Surgical Indications

Only patients with persistent symptoms despite a documented course of:

Maximal nonoperative treatment

should be considered for operative management.

Fascial Release

A:

Posteromedial fascial release

has occasionally been used for refractory cases.

Results are variable, and surgery is reserved for:

Highly selected patients.

Follow-Up

Patients should be reassessed if symptoms:

Persist

Become focal

or worsen despite appropriate:

Activity modification.

Return to Running

Return to impact activity should be:

Gradual.

The athlete should first be able to:

Walk pain free

Hop without pain

and perform basic strengthening exercises without significant:

Tibial discomfort.

Training Progression

Mileage and intensity should be increased:

Incrementally

rather than returning immediately to the previous training level.

Prognosis

The prognosis is generally:

Good.

Most patients improve with:

Nonoperative treatment.

Recurrence

Recurrence is common when the athlete returns too rapidly to:

High training volume

or fails to correct the underlying:

Training error or biomechanical problem.

Prevention of Recurrence

Helpful measures include:

Gradual training progression

Appropriate footwear

Correction of excessive pronation when clinically relevant

Strength and flexibility training

and adequate:

Recovery time.

Complications

The most important potential complication is failure to recognize a:

Tibial stress fracture.

Complete Fracture

An untreated stress fracture may progress to a:

Complete fracture

with possible:

Displacement

and substantially prolonged recovery.

Missed Compartment Syndrome

Failure to identify chronic exertional compartment syndrome may result in:

Persistent exercise limitation

and ongoing:

Neurologic or muscular symptoms.

Patient Monitoring

Monitor:

Pain location

Extent of tenderness

Walking tolerance

Running progression

and response to:

Training modification and rehabilitation.

Development of focal pain, rest pain, or worsening symptoms should prompt evaluation for:

Stress fracture or another diagnosis.

Key Principle

Shin splints, or medial tibial stress syndrome, are an overuse injury characterized by diffuse exercise-related pain and tenderness along the posteromedial tibial border.

The most important precipitating factors are:

Rapid increases in running volume or intensity and repetitive impact loading.

Treatment is usually successful with:

Activity modification, ice, stretching, strengthening, gait and footwear assessment, and gradual return to running.

Persistent focal pain or worsening symptoms should prompt investigation for:

Tibial stress fracture, while anterolateral exertional pain with tightness or neurologic symptoms should raise concern for:

Chronic exertional compartment syndrome.