Shin pain is a common problem in athletes and “shin splints” is a lay term used to describe a spectrum of disorders that affect the anterior part of the leg (shin bone).
These disorders may affect one (or all) of the following:
- Soft tissue: muscle insertion sites, fascia of the tibia bone.
- Bone: from strain, stress reaction, stress fracture, to fracture.
- Compartment: too much content, too little space.
“Shin splints” are characterised by pain in the front part of the leg and normally are a case of “too much too soon”. We all know that the benefits of exercise come from stressing the body and allowing adaptation to occur from the stresses. But when too much stress is placed on the body before adaptation occurs, overuse injury results.
The diagnosis
Initially, pain may emerge after exercise, for example, running or jumping. In the worst case, it may also be present at rest, at night and/or in the morning. If you have persistent leg pain that worsens, or does not improve, after oral analgesics and modified activity, it is best to seek medical help. An x-ray, MRI or bone scan may then be needed to make a definitive diagnosis of the leg pain. Also note, while the three common causes of the leg pain have been identified above, there are also other causes that must be excluded by a physician. These may include a referred pain from pathologies outside the leg itself, tumours, vascular problems, endocrine and metabolic problems, infections and other musculoskeletal injuries.
Red flags
- Pain at rest, or at night.
- Associated numbness or tingling sensations in the foot.
- Persistent pain despite activity modification and treatment prescribed below.
- Elderly patients and patients known to have other pre-existing medical conditions; for example, kidney disease.
Prognosis
The prognosis of the injury is dependent on the cause. In general, most bony injuries heal completely if given sufficient time. Soft tissue and compartment problems, however, may be more chronic but usually amiable to reduced training loads and modified activities.
Treatment and rehabilitation
General
As mentioned, most shin pain problems are normally the result of doing too much too soon. As such, the initial treatment involves reversing this cycle, which includes relative rest and oral anti-inflammatory analgesics (eg, ibuprofen). Typically, the individual who sustains an overuse injury is likely to be one that is extremely enthusiastic about their exercise. As such, the advice of resting would most likely not be received well and may even be ignored. While it is crucial that you emphasise relative rest, if you insist on exercising, you need to ensure the stressed area remains rested during activity. This can be done through innovative programming; for example, swimming or aqua-based exercise.
Soft tissue
Shin pain associated with soft tissue is usually a result of inflammation. Besides the general measures described above, additional rehabilitation modalities would depend on the stage of the problem. While there is no exact rule dictating the duration of pain during acute, intermediate and chronic phases, a rough rule of thumb is about three weeks for the acute phase, up to three months for the intermediate phase, and more than three months for the chronic phase. If in doubt, simply go slowly.
Acute phase
- Relative rest: do something else! Variety is the key to keeping interested, after all!
- Stretch to increase the flexibility of the anterior and posterior compartments of the leg.
- Assess your shoes to see if there is uneven wear of the sole, indicating abnormal weight-bearing patterns.
- Refer for a podiatric assessment for correction of biomechanical deficiencies that may be contributing to the injury.
- Refer to a physiotherapist conversant with deep muscle massage. They can treat with an ice massage and a gentle deep massage surrounding the painful area, including transverse massage therapy.
Intermediate phase
Chronic phase
Return to play
Bone injury
For people with a known bone injury, relative rest should be strictly enforced. In some instances this may require the use ofcrutches to avoid any weight bearing on that leg. The stress fracture may sometimes require up to 12 weeks before bony tenderness disappears. Some people may be prescribed electrical modalities (eg, interferential therapy, ultrasound) by their physician. Once the bone has been deemed healed by the physician, gradual return to activity is important. The treatment for the four phases above can be used. Note: the acute phase is excluded because this would be when the bone was healing. Sometimes the use of a leg brace may assist in effective training and rehabilitation. It is important that the precipitating cause of the injury be identified. Most commonly it is due to the problem of too much too soon; however, if female always be wary of the “female athlete syndrome”.
Compartment problems
The exact cause for chronic compartment syndrome is unclear. Typically, chronic inflammation and scarring of the compartment of the leg is caused by overuse. The compartment in the leg where the muscle resides becomes restrictive and this prevents muscle expansion during exercise, resulting in pain. Treatment may involve reducing the exercise load, deep massage therapy and flexibility stretches. Correcting any biomechanical abnormality is also important. If conservative measures fail, surgery may be the only treatment option, especially if there is numbness or tingling sensations in the foot.
Final note
While shin problems are relatively common in exercising individuals, and many are responsive to a change in activity or relative rest, oral analgesics and/or stretching exercises, you should always be wary of persistent pain and watch for the “red flags” which can indicate more serious issues. Do not be too proud to seek medical advice.
