Prevention and Treatment of Shin Splints

shin splint treatment

Shin splint physiotherapy.

Article by Sydney sports physio, Chris El-Hayek.

Medial Tibial Stress Syndrome (MTSS), also more commonly known as ‘shin splints’, is a common overuse injury of the lower limb. This condition is often seen in running based sports, particularly when loading is increased rapidly.

With shin splints, there is often pain induced on exercise that tends to go away at rest. The pain is located at the inside of the tibia (shin bone), and is normally tender on palpation with an area of 5cm or over1.

Shin Splint Injury Incidence (Occurrence)

Shin splints occur in up to 13.6-20% of runners will suffer from shin splints1. Individuals who reported an injury that was running related were x2 more likely to incur shin splints2.

The mechanism of a shin splints injury

There is generally no acute or sudden incident of injury. Rather, pain from shin splints tends to gradually build up over time and can become more and more bothersome if ignored.

Risk factors for suffering shin splints will be explained later in this article.

What is Injured?

Symptoms are normally over the distal aspect of the tibia (lower aspect of your inner shin bone)1. If the microdamage at this cortical bone fails to repair appropriately, it tends to accumulate, and therefore potentially increase symptoms of pain and discomfort1.

A layer of connective tissue surrounding this bone, known as the periosteum can also become inflamed as a result. This is known as periostitis, and is another contributor of pain and discomfort in this area1.

The risk factors of shin splints

Females – It is known that females are more likely to suffer from shin splints. The evidence is limited as to why, but possibilities include differences in running kinematics (motion) compared to men.2

Other factors for increased bone stress is that women have a higher risk of vitamin D and calcium deficiency which is also a separate risk factor in itself for having shin splints.3

High BMI – Excessive load at the lower limb may increase stress at the tibia resulting in an increased risk of shin splints.2

Navicular drop (flat feet) – May reduce ability to absorb ground forces appropriately. A navicular drop of over 10mm can almost double your likelihood of shin splints.2

Previous history of shin splints – Having shin splints once, increases your risk of developing shin splints again in the future, so strategies to reduce risk of it from happening in the first place is important.4

Vitamin D & Calcium deficiency – Being deficient in vitamin D and calcium increase our risk of bone stress injuries. This therefore increases our risk of shin splints!3

Calf/Soleus weakness – Evidence shows a link between shin splints in those with reduced calf/soleus endurance.5

Workload – Sudden spikes in workload are a big risk factor for suffering from shin splints. To put it simple, doing too much, too soon can increase our risk of bone stress and places us at a big risk of these niggling injuries.

Severity and duration of shin splints

The amount of time taken to recover will ultimately depend on your severity of symptoms and how long you have had them for.

If pain levels are quite high, or worsening, medical imaging may be required to rule out a stress fracture.

If there isn’t any true bone stress, and your symptoms are in their early stages, a period of rest followed by gradual return to activity should be enough to relieve symptoms and have you back doing what you love.

Those who tend to ignore the early signs and keep pushing through the pain tend to end up being out of their sport/activity for a lot longer, and unfortunately for some, end up with a potential stress fracture.

Medical Imaging

If there is suspected bone stress or a stress fracture, medical imaging can give a clear picture as to the severity of the injury.

Magnetic Resonance Imaging (MRI) is the most accurate when it comes to picking up bone stress or a stress fracture in this area, however can be a bit more costly.1

A nuclear bone scan is a cheaper alternative, and can still pick up stress reactions or fractures, but is not considered as accurate/reliable.1

Example of MRI showing stress related bone injuries.

Management and prevention of shin splints

Management will ultimately be determined by your severity of symptoms, how long they have been present, what your typical workload is, if there is true bone stress, and if there is a potential stress fracture.

If there is no bone stress on imaging, a period of workload reduction with a gradual build up to usual workload is probably the most important strategy. In that process, risk factors that were mentioned previously in the article can be addressed to see if this improves symptoms and potentially reduces time out from your sport/activity.

If there is clear bone stress on imaging, a similar approach can be taken, but extra care needs to be taken, and a longer period of rest is required to prevent it turning into a stress fracture.

If you unfortunately do have a stress fracture, a period of immobilisation is required to allow the fracture to heal appropriately, and specialist referral to a sports physician/orthopaedic surgeon may be required.

Here are some exercise ideas that may be useful to minimise strength/mobility loss while you are recovering. Remember, this is just a guide and the nature of the exercises will be heavily dependent on the nature and history of your condition.

The exercises below are progressive in nature, starting with a basic calf strengthening exercise, then building into plyometric exercises with higher loading. As you progress in each exercise, consider going from 2 feet to 1, and from on the spot, to multi directional movements for the jump/hop exercises.

Early Stage Shin Splint Rehabilitation Exercises

Heel Raises (Complete 2-3 sets of 8-12 reps, every 1-2 days depending on pain levels):

  • Ensure you push up through your first two toes, and that your feet are pointing forwards to work the calf muscles evenly.
  • Progress to 1 leg heel raises if pain free and you are completing the exercise easily.
  • Try doing it on a step as another progression – you will feel more of a stretch in your calf and have to work a lot harder!

Mid-Stage Shin Splint Rehabilitation Exercises

If you are tolerating strength based exercises such as the heel raises above quite well, and have had a period of reduced workload, skipping is a nice option to re-introduce plyometric based activity.

Skipping is a great way of bringing jumping/hopping back into your routine in a gradual and progressive manner. The great thing about it is that there are so many ways to increase the complexity, by doing it on 1 leg, or jumping/hopping front to back, and side to side.

Skipping (Complete for 3-5 minutes x4 a week):

Late-Stage Shin Splint Rehabilitation Exercises

Further progressions should be made after reintroducing jumping/hopping based movements in the form of skipping.

The aim is to now increase impact/loading with multi directional jumps and hops. As your confidence builds, and if you are of course pain free, the jump/hop height/length can be increased.

Don’t forget to complement your strength/power based exercises, that you should be gradually exposing yourself to jogging again, and slowly building these distances week by week.

Your end goal should be you running similar distances in a week to what you were doing prior to your onset of symptoms. This will obviously vary depending on your level of competition and the sport you are involved in.

As a general rule, when you are progressing your volume, try not to increase your load by more than 10-15% per week.

Hurdle Jump/Hop Variations (4-5 sets of 3-5 reps for each pattern , complete once every 2nd day):

  • This can be done with a variety of patterns. The photo on the left indicates A basic forward jump sequence that can be done over mini hurdles, and can be progressed to a hop.
  • Hops can also be done side to side as seen in the middle photo.
  • In the final photo, is a jump sequence where you jump forwards and back into the space between the hurdles, side to side, and back to forwards.

How a physiotherapist can help treat and prevent shin splints.

If you are suffering from shin splints, a physiotherapist can help guide you with appropriate load management, treatment techniques and a strength & conditioning program to get you back doing what you love pain free.

If you want to optimise your recovery and minimise your risk of worsening your condition, give us a call or reach out through our website to see how we can help you!

Do you need assistance managing, treating and preventing shin splints? 

Sports physiotherapist Chris El-Hayek has extensive expertise in offering physiotherapy services to athletes in a range of high-performance sports. He has been able to assess and treat multiple athletes with a wide range of sport related injuries.  He can successfully implement programs that will minimise injury rates and enhance your athletic qualities.

Speak to a Physio

References

  1. McClure CJ, Oh R. Medial Tibial Stress Syndrome. [Updated 2021 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538479/
  2. Winkelmann ZK, Anderson D, Games KE, Eberman LE. Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. J Athl Train. 2016 Dec;51(12):1049-1052. doi: 10.4085/1062-6050-51.12.13. Epub 2016 Nov 11. PMID: 27835043; PMCID: PMC5264561.
  3. Millward D, Root AD, Dubois J, et al. Association of Serum Vitamin D Levels and Stress Fractures in Collegiate Athletes. Orthopaedic Journal of Sports Medicine. December 2020. doi:10.1177/2325967120966967
  4. Bliekendaal S, Moen M, Fokker Y, et alIncidence and risk factors of medial tibial stress syndrome: a prospective study in Physical Education Teacher Education studentsBMJ Open Sport & Exercise Medicine 2018;4:e000421. doi: 10.1136/bmjsem-2018-000421
  5. Craig DI. Medial tibial stress syndrome: evidence-based prevention. J Athl Train. 2008 May-Jun;43(3):316-8. doi: 10.4085/1062-6050-43.3.316. PMID: 18523568; PMCID: PMC2386425.