Shin pain is a common symptom in competitive and recreational athletes, a recent study found it is the most prevalent injury in runners. There is often confusion  and misinformation about the types, terminology and how to address it. Let’s look at what types of shin pain often present, their aetiology and how to manage it effectively.

Medial Tibial Stress Syndrome

MTSS is commonly referred to as Shin splints, and is probably the more common type as far as I see in practice, in fact, 16% of all running injuries relate to MTSS. The syndrome is described as an exercise-induced pain along the posteromedial tibial border, with recognisable pain with palpation along this area the length ≥5 cm. Importantly, if there is cramping, burning or pressure-like calf pain this could suggest the presence of chronic exertion compartment syndrome (CECS), which could be concurrent with MTSS or be in isolation. CECS is usually present during exercise and quickly subsides with cessation of activity, and query of pins and needles or cold feet pre or post-exercise will help differentiating the two conditions.

Research has shown that the clinician can make the diagnosis of MTSS using history and careful physical examination with almost perfect reliability! This was demonstrated in clinicians with differing backgrounds in medicine and physiotherapy, and a wide range in clinical experience.

When we run or even walk at reasonable pace there is some bowing that occurs in the tibia bone. This is a normal part of movement and is not pathological. However, shin pain can develop for a number of reasons.

There are two main competing theories, bone overload injury (1) and the shearing of the fascia connected to the soleus and lower limb musculature or fasciopathy(2). Additionally, the presence of micro cracks found in painful sites in athletes with MTSS suggests the impairment of bone repair function by one study. Multiple studies also show the inability to differentiate athletes with or without MTSS on all types of imaging modalities.

It is proposed that in (1) there is insufficient periosteal bone laid down to protect the tibia bone from the ground reaction forces of movement during a movement like running. As mentioned earlier, we experience a mild bowing of the tibia, a normal bone stress, that is usually below a threshold to create any bone injury. However, in this case, the tibia is unable to handle this stress and we start to develop bone bruising or small fractures in the tibia. This can come about because of excessive activity in a short amount of time, or poor prepatory phase of training that inadequate prepares the bone for the activity. The absence of strong evidence for these theories mean MTSS is considered a clinical pain syndrome.

Anterior Shin Pain (Tibialis Anterior Overload)

This is sometimes referred to as upper shin splints, where in fact it is the Tibialis anterior muscle that is overly worked leading to cramping or tightness and pain. The Tibialis anterior muscle attaches from the knee onto the medial aspect of the medial foot and so its role is dorsiflexion and deceleration of the foot during ambulation.

Interestingly, this is also a muscle that gets affected in stroke and CVA patients, where “foot drop” develops and is intrinsically linked to higher risk of falls and impaired balance.

Posterior Tibial Tendon Dysfunction

This can sometimes present similarly to MTSS, where there is pain up the medial aspect of the shin. It actually is a tendinopathy issue, coupled with stretching of the Posterior tibial tendon. This muscle acts as a ‘dynamic stabilizer’ of the foot and so during gait it acts to dynamically support the arch and counteract excessive pronatory forces. If this tendon is stretched or overloaded, the arch can collapse and accompanying symptoms such as medial ankle pain and dysfunction follows.

Location Matters!

Conservative Management

In the initial term, the athlete with MTSS will likely present with severe pain. Reducing pain and managing training load should be the priority in the short term. It is also supported that some pain with loading (under 2/10 pain) may be beneficial versus a loading that induces no pain. The use of patient outcomes such as the MTSS score form a valuable form of objective feedback and a useful resource to refer back to at later stages of recovery to evaluate progress.

A number of treatment strategies have suggested for MTSS. Gait retraining, rest, ice massage, shockwave therapy, stretching and strengthening exercises, graded running programs, lower leg braces and injection therapies are some examples. Unfortunately, none of these interventions has proven high efficacy. Therefore, in the absence of good evidence, one should rely on observational studies and good clinical reasoning.

Patient Expectations, Education and Load Management

A discussion with the patient in regards to their prognosis is essential, some athletes will have overly optimistic expectations to get back to their sport . Some studies suggest it can take up to 90 days to run at moderate pace for 20 minutes with minimal pain, often this level of activity is insufficient to return to a competitive level of play. A timeframe of 9-12 months in an athlete with MTSS for +3 months is likely a realistic prognosis.

Educating the patient on MTSS and its relation to load management is a key step in treatment. MTSS has high variability in terms of presence and severity of pain and disability, and is modulated by how well the athlete balances loading and loading capacity. Changing running pain from 5:00min/km to 4:55min/km pace can be enough to elicit a flare up or re-aggravation.

Consistent and gradual loading eg. Change of load <10% is likely a conservative and logical guideline to expose athletes to increasing training volume, however a 30% increase week to week has been demonstrated to be safe by some recent evidence. Use of running apps and smart wearables can help athletes monitor their loading and avoid excessive spikes. Combining graded tibial loading exercises, with ankle plantar flexor and dorsiflexor strengthening exercises such as calf raises and Tibialis raises could be the best strategy for MTSS.

Adjunctive Therapies & Surgery

Shockwave therapy has demonstrated some promising results in military cadets with MTSS, and could present an effective adjunctive therapy in combination with an individualised strength training and load management program.

Solushin is a novel concept with some promising emerging evidence in the treatment of athletes with MTSS. It combines a compressive sleeve with strategic plastic bracing elements to reduce pain with running and improve the symptoms associates with MTSS. The jury is still out on whether it has long term efficacy, but it is a nice addition to a well rounded and considered load management program.

In terms of surgery there is poor evidence to suggest fasciotomy, or a combination of fasciotomy and periosteal stripping showed excellent improvements for pain (69-92%), with a wide variable with return to sport (29-93%). Given the lack of high quality evidence for the known pathology in MTSS, surgery is seemingly implausible and should never be a first-line therapy.