Shin Splints in Runners: Why It Happens and How to Recover

Shin Splints, or Medial Tibial Stress Syndrome, is a condition characterized by leg pain along the inner edge of the shinbone (tibia). It is caused by inflammation of the muscles, tendons, and bone tissue around the tibia due to repetitive stress or overuse of foot flexors, often in athletes or individuals who engage in activities involving running or jumping.

Shin splints affect around 20% of recreational runners and can affect as high as 80% of athletes overall. It has an estimated worldwide prevalence of 6% in males and 8% in females.

Risk Factors of Shin Splints (Medial Tibial Stress Syndrome)

Causes of Shin Splints (Medial Tibial Stress Syndrome)

• repetitive high-impact activities
• forefoot contact running
• running on hard, uneven surfaces
• improper footwear
• athlete’s level of conditioning
• frequent changes in activity level
• musculoskeletal abnormalities
• flat feet
• poor biomechanics, including excessive forward lean or an improper stride
• inadequate warm-up or stretching

 

Signs and Symptoms of Shin Splints

• Most runners experience pain around the inner shin boundary, with discomfort that usually resolves in a few weeks, but can become chronic and recurrent.
• Initially, pain subsides with rest but may worsen and persist as the condition progresses.
• Tenderness along the lower leg.
• Mild swelling around the shin area.
• Stiffness is noticed especially in the morning or after periods of rest.
• Weakness or fatigue in the muscles around the lower leg.

 

Diagnosing Shin Splints

Patient History

• Discussing the onset, location, and nature of the pain (e.g., whether it worsens during or after activity).
• Asking about recent changes in physical activity, footwear or surfaces used for exercise.
• Exploring other potential risk factors like flat feet, running mechanics or overtraining.

 

Physical Examination

Palpation is done by gently pressing along the inner edge of the tibia to check for tenderness or soreness. Physiotherapist can use use Ritchie Articular Index (RAI) classification.

• Grading Scale for the Ritchie Articular Index (RAI):
• Grade 0: No tenderness
• Grade 1: Tenderness without grimace or flinch
• Grade 2: Tenderness with grimace and/or flinch
• Grade 3: Tenderness with withdrawal (the patient pulls the joint away from the examiner)

Range of Motion Tests

Mobility of the ankle and foot is assessed to identify any issue.

• knee flexion      
• ankle plantarflexion   
• ankle dorsiflexion
• inversion
• eversion    

 

Muscle Strength Testing: 

Evaluating the strength of the calf and shin muscles to detect any weakness or compensatory issues is also important.

• knee flexors
• knee extension 
• ankle dorsiflexers       
• ankle plantarflexers
• invertors and evertors

Gait Analysis

Observing the patient’s walking or running form to identify biomechanical abnormalities, such as overpronation or poor foot alignment.

Functional Tests

Asking the patient to perform specific movements (like hopping or running) to provoke symptoms and assess their severity.

•  step-up and step-down test

Imaging (if necessary):

X-ray or MRI may be required if the diagnosis is unclear or to rule out stress fractures, which can present with similar symptoms.

 

Differential Diagnosis

• Stress fracture of the tibia
• Compartment syndrome
• Tibial periostitis
• Tibial stress reaction
• Tendinopathy (e.g., posterior tibial tendinopathy)
• Nerve entrapment (e.g., saphenous nerve entrapment)
• Popliteal artery entrapment syndrome
• Deep vein thrombosis (DVT)
• Medial tibial traction periostitis
• Muscle strain (e.g., soleus muscle strain)

 

Physiotherapy Management of Shin Splints

Pain Management

• Advising period of rest from high-impact activities, often requiring non-weight-bearing on crutches is prescribed, to allow the tissues to heal.
• Applying ice packs (Cryotherapy) to the affected area for 15-20 minutes, 3-4 times a day, to reduce inflammation and pain.
• Use of compression sleeves or bandages to reduce swelling and provide support.
• Keep the leg elevated to decrease swelling, particularly after exercise.
• TENS can also be used, with pulse rate: 150 Hz and pulse width of 150 μs along the anteromedial compartments of the lower leg.

 

Activity Modification

• Advising the patient to adjust the running technique, like switching to heel-contact running approach.
• Encouraging low-impact activities such as swimming, cycling, or water running during the recovery phase to maintain fitness without aggravating symptoms.
• Gradually reintroducing running or high-impact activities with modifications, such as using softer surfaces (e.g., grass or a treadmill) and limiting duration/intensity.

Stretching Exercises

The physiotherapist targets the following muscles, gastrocnemius, soleus and tibialis anterior. Avoid excessive stretching in acutely injured patients.  Example of exercises includes:

• Standing calf stretch
• Seated foot stretch

 

Strengthening Exercises

Strengthening of the calf, tibialis anterior and intrinsic muscles of foot is done to improve load tolerance, support the arch and correct biomechanical imbalances. Strengthening exercises should progress gradually to avoid further tissue aggravation. Example of exercises includes:

• Eccentric calf raises
• Toe curls
• Ankle dorsiflexion with resistance bands
• Heel lifts
• Heel walking

 

Manual Therapy

Manual therapy techniques such as myofascial release on the calf muscles and shin to reduce tightness and improve circulation can be performed by the physiotherapist along with use of foam rollers.

Biomechanical Correction

Identifying and correcting any abnormal foot mechanics (e.g., overpronation or supination) that may contribute to shin splints.

• Recommending custom or over-the-counter orthotics to provide arch support and correct foot alignment issues. The use of a pneumatic brace (e.g., Air-Stirrup Leg Brace) has shown to reduce recovery time significantly:
• Advising on wearing appropriate shoes that offer adequate support, cushioning and shock absorption.

 

Kinesio Taping

A single Y-strip of KT (Kinesiology Tape) can be applied starting at the proximal third of the medial tibia. Following steps are followed:

1. The two halves of the Y-strip are positioned anterior and posterior to the medial malleolus.
2. The tape should end under the medial longitudinal arch of the foot.
3. No tension is applied on the proximal and distal ends of the tape.
4. The middle section of the tape is applied with 75% tension.

Once bony tenderness and pain subside, a gradual return to activity should be initiated through a graded, low-intensity program, progressively increasing exercise quality and quantity as symptoms allow, while following the 10% rule to avoid a sudden increase in training. A proper warm-up, cool-down, and stretching routine is critical, along with proprioception and balance training (e.g., single-leg stance) to enhance lower leg stability. 

Educating the patient on injury prevention, gradual training progression, and cross-training is essential. As pain decreases, rehabilitation should progress to sport-specific drills while monitoring symptoms and adjusting exercises accordingly. Regular follow-up and gait re-evaluation ensure proper recovery and help prevent recurrence.

 

Preventing Shin Splints

• Neoprene insoles showed significant protective effects against shin splints.
• Other interventions like heel pads, different boot types, boot inserts can also be used.
• Pre-season conditioning help optimize performance prevent shin splints.
• Strength, agility and flexibility training should be emphasized.