Shin Splints (Medial Tibial Tenoperiostitis)

(Also known as Periostitis, Medial Tibial Stress Syndrome, Tenoperiostitis of the Shin, Inflammatory Shin Pain, Traction Periostitis, Posterior Shin Splint Syndrome)

What are shin splints?

Medial Tibial Tenoperiostitis (shin splints) is a condition characterized by damage and inflammation of the connective tissue joining muscles to the inner shin bone (tibia).

There are several muscles which lie at the back of your lower leg and are collectively known as the calf muscle (figure 1). Several of these muscles lie deep within the calf (tibialis posterior and soleus) and attach to the inner border of the shin bone (tibia). The connective tissue responsible for attaching these muscles to the tibia is known as the tenoperiosteum. Every time the calf contracts, it pulls on the tenoperiosteum. When this tension is too forceful or repetitive, damage to the tenoperiosteum occurs. This results in inflammation and pain and is known as medial tibial tenoperiostitis – commonly referred to as shin splints.

Medial tibial tenoperiostitis can sometimes occur in combination with other pathologies that cause shin pain such as compartment syndrome and stress fractures.

Causes of shin splints

Shin splints are usually associated with overuse and are often seen in runners and footballers. Shin splints frequently occur in association with calf muscle tightness or biomechanical abnormalities, such as excessive pronation (flat feet – figure 2) or supination (high arch). Patients often develop shin splints early in the season following a period of reduced activity (deconditioning) and when training surfaces are generally harder.

Signs and symptoms of shin splints

Patients with shin splints typically experience pain along the inner border of the shin. Symptoms are usually present upon commencing weight bearing exercise such as running or sprinting, but will normally decrease as they warm up. In more severe cases, patients with shin splints may experience an ache that increases to a sharper pain with activity. A limp may be present although this may reduce as the patient warms up. Athletes with shin splints can often complete their training only to find their shin pain increasing with rest after exercise, particularly the following morning. Patients with shin splints often experience pain on firmly touching the inner border of the shin bone particularly along the lower third of the bone. Areas of muscle tightness, thickening or lumps may also be felt in the area of pain. In severe cases, swelling, redness and warmth may be present and there may be pain walking up and down stairs and with weight bearing in general.

Diagnosis of shin splints

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose shin splints. Investigations such as an X-ray, bone scan, CT scan or MRI may be used to assist with diagnosis.

Treatment for shin splints

Most cases of shin splints settle well with an appropriate physiotherapy program. This requires careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition, with subsequent correction of these factors.

The success rate of treatment for patients with shin splints is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from ANY activity that increases their pain until they are symptom free. Activity resulting in soreness the following morning must also be avoided, particularly excessive walking, running, sprinting, jumping and skipping. Resting from aggravating activity ensures that the body can begin the healing process in the absence of further tissue damage. Once you are pain free, a gradual return to activity can commence provided there is no increase in symptoms.

Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with shin splints is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times.

Activities placing minimal stress on the shin may be performed to maintain fitness. These include hydrotherapy exercises in a pool, upper body weights in sitting or lying, swimming or sometimes cycling.

Patients with shin splints will usually benefit from following the R.I.C.E. Regime. The R.I.C.E regime is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This involves resting from aggravating activities, regular icing (crushed ice or ice massage using a polystyrene cup), the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.

Deep tissue massage to the calf muscles can be an extremely effective way of treating shin splints and should form part of the rehabilitation program.

Patients with shin splints should perform pain-free flexibility and strengthening exercises (particularly of the calf muscles) as part of their rehabilitation to ensure an optimal outcome.

In the final stages of treatment for shin splints, once pain has been controlled and contributing factors have been addressed, a graduated return to activity or sport can occur as guided by a physiotherapist.

Prognosis of shin splints

Most patients with shin splints heal well with appropriate treatment. Recovery time may range from a few weeks to many months depending on the severity of injury, quality of treatment and length of time the injury has been present for. Patients with shin splints that have been present for months may require a considerable period of treatment associated with reduced activity before full recovery occurs.

Contributing factors to the development of shin splints

There are several factors which can predispose patients to developing shin splints. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

• excessive training or activity
• poor foot posture (especially flat feet)
• inappropriate footwear
• training on hard surfaces
• muscle weakness (especially the calf muscles)
• tightness in specific joints (such as the ankle)
• tightness in specific muscles (especially the calfs)
• muscle strength imbalances
• poor lower limb biomechanics
• poor training technique or methods
• leg length differences
• being overweight
• deconditioning
• diet (a lack of calcium intake)

Physiotherapy for shin splints

Physiotherapy treatment for shin splints is vital to hasten the healing process and ensure an optimal outcome. Treatment may comprise:

• soft tissue massage (particularly to the calf muscles)
• mobilization
• dry needling
• electrotherapy
• PNF stretches
• arch support taping
• the use of orthotics or shock absorbing insoles
• biomechanical correction
• ice or heat treatment
• progressive exercises to improve flexibility (especially of the calf muscles), balance and strength
• activity modification advice
• anti-inflammatory advice
• footwear advice
• weight loss advice where appropriate

Other intervention for shin splints

Despite appropriate physiotherapy management, some patients with shin splints do not improve. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may include pharmaceutical intervention, further investigations such as X-rays, bone scan, CT scan, MRI, or compartment pressure testing, or a referral to an orthopaedic specialist who will advise on any procedures that may be appropriate to improve the condition. A review with a podiatrist may also be indicated for the prescription of orthotics to correct any foot posture abnormalities.

Exercises for shin splints

The following exercises are commonly prescribed to patients with shin splints. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

1) Lunge Stretch (figure 3) – With your hands against the wall, place your leg to be stretched in front of you as demonstrated (figure 3). Keep your heel down. Gently move your knee forward over your toes until you feel a stretch in the back of your calf or Achilles tendon. Hold for 15 seconds 4 times at a mild to moderate stretch pain-free.

Figure 3 – Lunge Stretch

2) Calf Stretch (figure 4) – With your hands against the wall, place your leg to be stretched behind you as demonstrated (figure 5). Keep your heel down, knee straight and feet pointing forwards. Gently lunge forwards until you feel a stretch in your calf / knee of your back leg. Hold for 15 seconds 4 times at a mild to moderate stretch pain-free.

Figure 4 – Calf Stretch

3) Kneeling Stretch (figure 5) – Begin in four point kneeling (i.e. on your hands and knees) on a flat surface. Keep your knees and ankles together, toes pointed. Gently take your weight back onto your ankles until you feel a stretch at the front of your ankles or shins. Hold for 15 seconds 4 times at a mild to moderate stretch pain-free. This exercise can be progressed by placing a rolled towel under your feet as demonstrated.

Figure 5 – Kneeling Stretch