Shin Splints / Leg Pain

 

***  Here is a great video link I found demonstrating the in's and out's of shin splints...  enjoy.  http://www.runnersworld.com/injury-prevention-recovery/inside-doctors-office-keep-shinsplints-away?cm_mmc=NL-TrainingExtra-_-1127116-_-12042012-_-Inside-the-Doctor%27s-Office%3A-Keep-Shinsplints-Away

 

 

Shin splints (also known as medial tibial stress syndrome (MTSS) is a familiar pain that most athletes in sports that involve high impact or large amounts of repetition have experienced.  Shin splints refers to pain along or just behind the tibia (shinbone).  This term is often used as a "catch all" phrase for numerous other causes of leg and ankle pain.

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Causes:

Shin splints can happen during any physical activity but normally result from too much force on the shin bone (tibia) and associated connective tissues and  muscles.  Any activity that forces fast stops and stops can create injury to the tibia and connective tissues.  My personal experience with shin splints have been most often with running, playing soccer and occasionally with long hikes.  Most sources will implicate high impact activities and the type of terrain including hills and uneven surfaces.

There are many scenarios that can set you up for shin splints including: muscle imbalance (consider core muscles), tight calf and foot muscles, flat feet and/or over pronation, and sudden increase or excessive duration of physical activity.   Having poor form while running, such as leaning forward or backward too much, as well as landing on the balls of your feet and running with toes pointing outwards all contribute shin splints.  Any athlete who is constantly bothered by this problem should seek out a podiatrist or sports medicine doctor with a treadmill and camera system for gait evaluations.  Currently in the Salt Lake area, I know of only one such system in the office of Trevor Williams DPM.

Poor shoe gear (shoes that either are too flimsy or too thick and padded) can contribute to shin splints.  Shoes that offer too much padding (according to one study) can actually INCREASE the impact forces when running while very thin shoes or no shoes at all require careful changes to running and training techniques to avoid injury and to enjoy the hoped for benefits.

With the new wave of minimalistic shoes and/or barefoot running a lot of anecdotal evidence can be found around the internet supporting or detracting from these "new" running techniques.   A recent extensive scientific literature review performed by Jenkins et al yielded the following results:

"Although there is no evidence that either confirms or refutes improved performance and reduced injuries in barefoot runners, many of the claimed disadvantages to barefoot running are not supported by the literature. Nonetheless, it seems that barefoot running may be an acceptable training method for athletes and coaches who understand and can minimize the risks."

Diagnoses:

Pain associated with shin splints can occur late in a sports season for athletes or after prolonged activity for active individuals. However, onset can occur during the initial rigors of exercise after an individual has been inactive for a long period of time. A typical presentation of this condition involves pain, palpable tenderness, and possibly swelling to the lower leg above the ankle about 5-10 inches. Pain can be described as a dull ache and may show up at the beginning of a workout.  The pain may go away by continued activity and then occur again at the end of the activity.  As the syndrome progresses pain may stay throughout the whole training or during low intensity activity and may continue at rest.  Joint motion in the ankle and foot should not cause pain or another diagnoses should be considered.

There are numerous conditions whose symptoms often mimic those of shins splints.  These can include compartment syndrome and stress fractures (see lecture on metatarsal fractures).   Compartment syndrome is often either caused by significant recent trauma or during strenuous exercise.  This is a serious condition that at it's worst can cause permanent damage to muscle and bone resulting in disability and/or amputation.  Symptoms to look out for are loss of feeling, severe swelling and pain, and loss of pulses in the foot.  The worst cases are usually caused by some type of direct blow to the leg.   Patients should be seen immediately by an emergency room or lower extremity specialist (orthopedic or podiatric).

Stress fractures are much more difficult to differentiate from shin splints early on in the course of the problems because both have similar symptoms.  Often shin stress fractures occur closer to the knee than shin splints and have a very specific and consistent point of pain.  The pain from stress fractures normally progresses into constant  and then severe levels with findings obvious on xray developing.  Shin splint pain can also progress into constant pain if activity levels are not cut down, but xrays will not normally show any significant changes to the bone.  Bone scans, MRI and the new SPECT imaging techniques can offer more information and help the physician tell the difference between these problems.

To complicate things further, there are two different types of shin splints described in the literature.  The first type is called anterolateral shin splints where the pain is located on the front and outside of the shin. It is usually felt during running when the athlete’s heel touches the ground. The second type is called posteromedial shin splints where the pain in the leg is on the inside and lower part of the leg and can be triggered by standing on the toes or inverting (rolling in) the ankle.

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Treatment:

Treatment of shin splints includes rest, ice, and non-steroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen.  It should be treated similar to most soft tissue injuries such as tendon or ligament strains.  Rest is the best way to treat shin splints as this gives the tissues the necessary chance to heal. This can be a couple of weeks in mild cases or up to about three months for severe cases. Acute therapy options for treatment include physical therapy modalities such as ultrasound, whirlpool baths, and electrical stimulation.

Patients may be advised to decrease the duration or intensity of their exercise and then build it up slowly, as well as to exercise caution on high impact surfaces until the muscles re-condition. Depending on the cause of the shin splints, specially fitted footwear or an orthotic may be used to prevent a re-occurrence of shin splints.  Some studies have shown calf stretching and over the counter arch supports to have fairly good value in the treatment of shin splints.

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Longer term considerations for persistent pain must include modifying the training routine until healing can occur. Stretching  and strengthening exercises (click here for a demonstration pamphlet) should be done on a daily basis.  Strengthening of the core hip muscles may also be beneficial.

Again, adequate and appropriate shoe gear is important and also the topic of much debate in the medical and sports world.  Below is demonstration on the basics of a good shoe.  Price is not the answer.  A simple, strong, protective shoe is the key.  If you are the barefoot/minimalistic type you must pay careful attention to the surfaces you are running on and running technique.  Shorter strides, mid-foot striking and soft running surfaces are recommended to reduce injury for all runners.

Other treatment options may include:

  • Extracorporeal shock wave therapy, which is used to treat various tendon problems of the lower extremity.  The evidence is weak at best for this modality at the time of this post.
  • Injection methods, which has been used to treat injuries of the lower extremity, including cortisone.  On a personal note, I have seen very successful podiatrists employ steroid/local injections with very good results.  Care must be taken not to numb up a new stress fracture accidentally and risk further injury.
  • Surgical options are for tough cases only that do not respond to conservative treatment. “Posterior fasciotomy” is the procedure performed. This may include cauterization of a ridge of the tibia, and results may not cause complete resolution but can improve the pain and function.

 

I hope this information is helpful.  Unfortunately anecdotal evidence is rampant with very few solid studies available out there.  Good shoes, simple arch supports, modifying activity levels until healing occurs and slow reintroduction of activities are the name of the game here.  For the persistent pain see a specialist for an injection and imaging to rule out possible stress fractures.

Best of luck to all you shin splint sufferers out there.  Please see a specialist if your pain isn't responding to basic conservative treatments.

Dan Preece, DPM

 

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 430 N. 400 W. Salt Lake City, UT 84103
 
                
     Foot & Ankle Specialists