How To Triumph Over Shin Pain

By Nicholas M. Romansky, DPM, and David C. Erfle, DPM

Shin splints are common among runners and individuals who participate in soccer, football, field hockey, lacrosse, etc. This overuse injury usually develops gradually over a period of weeks to months but may occur after a single, excessive bout of exercise. Individuals typically complain of pain in one of two locations: the lower inside half of the tibia and, less commonly, the upper outside portion of the tibia. Shin splints, also known as medial tibial stress syndrome, are an inflammation of the soft tissue surrounding the bone lining of the tibia at the origin of several leg muscles. Excessive running, improper conditioning programs and overpronation (flattening of the arch) are common causes of shin splints because of the stress they cause to the medial structures of the lower leg. This stress may cause microtears and inflammation in the soft tissue (periosteum) attached to the tibia. Muscle weakness, non-supportive shoes, running hard on surfaces and overtraining can also be contributing factors. Patients will usually notice the pain when they start exercising and it decreases or goes away as they continue to exercise. They will usually tell you the pain is worse after they stop exercising or it will hit them the following morning. If strain continues in this area for an extended period of time, it is possible for microfractures (stress fractures) to form along the tibia. There typically isn’t a sudden break of the bone but usually patients will relate a gradual increase in pain until it becomes quite severe. Essential Diagnostic Pointers When patients come in with shin splints, ensuring a proper diagnosis via a thorough history and physical exam is essential. Oftentimes, the work-up may include X-rays. However, be aware that X-rays are often negative and reveal no bone changes. If you suspect a stress fracture, you should obtain a bone scan or MRI. Also keep in mind that shin splint-type pain in the leg may mimic several other problems, including tendonitis, partial muscle tear or growth plate inflammation, which may not respond to the same treatments that one may choose for shin splints. Pain in the shin area may be coming from the lumbar sacral spine, a muscle imbalance, uneven leg length or compartment syndrome. When it comes to posterior shin splints, pain in the lower inside portion of the leg accounts for approximately 75 percent of the problems affecting athletes. Typically, abnormal biomechanics, such as overpronation (excessive flattening of the foot), can cause these posterior shin splints. The excessive work required by the flexor muscles, which arise in the posterior aspect of the leg, causes an inflammation along the muscular attachment to the tibia. Anterior shin splints often occur in both legs. You’ll see this clinical scenario among patients who are just beginning a running program, those who do excessive downhill running or patients engaging in sports requiring rapid starts and stops. Usually you will note an imbalance between the weaker anterior muscle group and the larger and stronger posterior group. Also be aware the tightness of the posterior muscle group may further aggravate this condition. Running on hard surfaces and a flatfoot condition may be initiating factors as well. However, more often than not, this condition is a simple result of over-training or improper training. Emphasizing The RIICE Treatment Plan Conservative treatment for shin splint injuries usually consists of rest, ice, immobilization, compression and elevation. When explaining the RIICE treatment model to patients, be sure to educate them on the following points. Rest. The hallmark of treatment is “relative rest.” You want to have the patient dramatically reduce the frequency, intensity and time of his or her activity/exercise. Usually, this means recommending anywhere between a 50 to 90 percent drop in the duration of the activity/exercise and doubling or tripling the time between workouts. One may often recommend that these patients pursue cross training or doing different types of exercise. Be advised that often patients will make the mistake of taking a few weeks off from their normal routine and then going right back to the same schedule without proper training. Coach them against doing this. In this particular circumstance, the problem will usually return and often become worse. Ice. This is extremely useful for reducing the inflammation following a workout.

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