How To Triumph Over Shin Pain
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. Tell the patient to apply ice for 10 to 15 minutes over the painful area as this will both decrease pain and increase healing time. Immobilization. In some instances, the pain in the legs does not respond to other conventional and conservative modalities. Immobilization with a removable or walking cast/boot or a non-removable fiberglass cast is required. Length of time of immobilization can vary between two to six weeks. Compression. Advise patients that using Ace wraps or tapings prior to or following an athletic event or workout may be extremely beneficial. There are several shin splint wraps available on the market, such as a neoprene sleeve, which also may prove to be useful and help reduce recovery time. Elevation. Encourage patients to elevate their lower extremities above their heart level. Explain that doing so will help reduce the flow of blood to the legs and certainly help reduce the inflammatory process. Remind them that this will help reduce pain and healing time. Tips On Other Helpful Modalities When it comes to antiinflammatory medications, oral drugs such as NSAIDs (ibuprofen, naprosyn, etc.) are very useful for reducing pain and inflammation during the acute stages. However, one should remind patients that most antiinflammatory drugs do have the potential to cause stomach irritation, ulcers or kidney problems. Therefore, patients should limit their use of these medications to the acute phase of the injury. One may also employ oral steroids to reduce painful inflammation. If these injuries go on for several weeks to months without signs of improvement, you should consider other treatment options as the injury is not likely to resolve with antiinflammatories alone. Often, rest pain indicates that a more significant problem may exist. Also keep in mind that deep tissue massage may often prove to be a useful technique for getting rid of shin splints. You may want to refer the patient to a qualified physical or massage therapist. He or she may be able to break down and smooth out knots in muscles or tight areas within the muscle. This will help reduce pain and prevent recurrence. Address Any Biomechanical Issues Correcting any abnormal biomechanics is crucial. If this goes unaddressed, patients will continue to experience recurrence. Emphasizing a good over-the-counter (OTC) arch support or custom orthotic is important for people whose overpronation/excessive flattening is the underlying cause of their shin splints. The choice of footwear is also important since different running shoes and cleats/turf shoes have different degrees of support and motion control. Running shoes typically lose 30 to 40 percent of the shock absorbing capabilities after 450 miles. The tread may look fine but the capacity to prevent injury is not. Uneven wear patterns from one shoe compared to the other may also be an indication of abnormal motion in one leg. You may also consider the use of prescription orthotics. After a short break-in period, patients should wear the orthotics full-time as they can be helpful in reducing acute symptoms of pain and inflammation. Patients can also use custom orthotics to prevent recurrent flare-up episodes from shin splints. Case Study One: When One Resumes Running After A Three-Year Layoff A 33-year-old track coach came into the office. He had once been an avid runner and attempted to get fit after a three-year layoff. Despite minimal training, he recently started running on the old hard cement of the high school track. He notes that he has had lower shin pain for two months and it has gotten progressively worse over the last four weeks. The patient noted that he felt the pain at rest and when he walked. Upon examination, we noted mild swelling on the lower medial tibia. There was pinpoint tenderness but the tenderness was along a 10 cm area. When we applied resistance, the patient experienced pain along the course of the tibialis tendon/muscle at the lower third of the tibia/ankle. We obtained standard X-rays of the tibia and fibula as well as a three-phase bone scan. We found that what began as “shin splints” had progressed into a true tibia fracture. We proceeded to emphasize oral NSAIDs, starting out with COX-1 and then moving to COX-2. We advised the patient to limit his activity and use a removable CAM walker full-time except during bathing. The patient was allowed to ride a bike and do pool workouts to tolerance. He also applied ice to the affected area after exercising. For long-term care, we emphasized the importance of wearing and maintaining proper sneakers, and using custom accommodative orthotics. The patient is doing well as follow-up X-rays reveal bone callus and remodeling. The pearl to take away from this case is using an X-ray, bone scan, MRI and/or CT to confirm the diagnosis of true shin splints versus a potential differential diagnosis such as a fracture. Case Study Two: Addressing A Field Hockey Player’s Upper Shin Pain A 17-year-old female field hockey player presented with upper shin pain. She reported being hit with a hockey stick four months earlier and has had a slowly progressive pain that occurs with daily walking as well as at rest. She noted that she only had the pain while walking. Our examination revealed that there was a very localized tenderness to touch. While X-rays were negative, MRI findings revealed extensive bone marrow changes that were consistent with bone contusion and stress reaction. We emphasized oral COX-1 NSAIDs and a removable CAM walker with an elastic sleeve on the leg. Other recommendations included a protective shin guard for sports. The patient was also referred for physical therapy to tolerance. The patient did improve but she remained sensitive to touch only. We proceeded to recommend wearing running and/or turf shoes for sports. Case Study Three: When A Patient Appears To Be Heading Toward A Tibial Stress Fracture A 32-year-old female presented to the office with pain in both mid tibias that had lasted for six months. She reported no previous injury. The patient said the pain was getting worse and more consistent, with the right leg being worse than her left leg. She noted an increased activity level and a change in the type of exercises she was doing. She reported doing more power aerobics and running in the last six months. She had been wearing old sneakers but switching to new sneakers made the pain worse. On a scale of zero to 10, the patient reported a pain level of seven. She said she only experienced the pain during exercise and not with daily walking or rest. A three-phase bone scan showed uptake that is typical of shin splints. The uptake appeared to be greater on the right leg and looked like it was heading toward a possible tibial stress fracture. Treatment consisted of physical therapy, ultrasound, ionto/phonophoresis, ice, pool therapy and propioception strengthening. In addition, we emphasized a steroid dosepak initially for six days and proceeded to COX-2 NSAIDs. We reminded the patient to watch what kind of shoes she wears and had her make a gradual return to activity. We also gave her a custom orthotic to use for dress and athletic shoes. The patient made a complete recovery. Case Study Four: When There Is Localized Swelling And Warmth A 45-year-old active female who was into cross training came into the office. She reported six weeks of progressive pain starting at the ankle and radiating up the proximal tibia to the mid-shin. She had no history of injury, no changes in training habits and a slow onset of pain. Upon examining the patient, we noticed very localized and distinct swelling and warmth along the medial distal tibia from anterior to posterior. There was no palpable tenderness up the shin but the pain radiated up the patient’s leg when she walked. A positive MRI of the distal tibia revealed a non-displaced fracture. We emphasized COX-2 NSAIDs and placed the patient in a short leg, fiberglass walking cast with a cast shoe. We also recommended that the patient cease working as a nurse for 26 days. The patient proceeded to use a removable CAM walker for four weeks while walking. Between the cast changes, we casted the patient for a sport-type orthotic. The patient saw much improvement. She is now going back to work part-time and will eventually go back full-time with running/walking sneakers. We reminded her to avoid going barefoot and doing any cross training. One may ask why we opted for the MRI in this case. The three-phase bone scan is sensitive but not as specific as a MRI. A three-phase bone scan wouldn’t provide any more additional information therefore the MRI was ordered as the initial diagnostic test. Even if the MRI was not available, we would have applied a short leg cast anyway. Sometimes, you may consider obtaining a CT to evaluate the bone further. Final Notes All the above cases emphasize accurate diagnosis with initial treatment based on the short-term acute stage, long-term needs and prevention to decrease recurrence. Early aggressive treatment is the key for shin splints. The primary goal of treatment is relieving pain and inflammation. One can accomplish this via a combination of rest, physical therapy, cold therapy, taping, oral medications, antiinflammatory medications, oral steroids, a change of shoe gear and orthotic devices. During the healing process, patients can maintain cardiovascular fitness via alternative pain-free activities such as cycling, swimming, water therapy or weight training. Dr. Romansky is a Fellow of the American College of Foot and Ankle Surgery and is a Diplomate of the American Board of Podiatric Surgery. He is a team physician for the United States Olympic and World Cup Men’s And Women’s soccer teams. Dr. Erfle is a Diplomate of the American College of Foot and Ankle Surgeons and the American Board of Podiatric Surgery. Drs. Erfle and Romansky are in private practice in Media and Phoenixville, Pa.