1. Signs and symptoms

2. Causes

3. Diagnosis

4. Treatment

5. Epidemiology

6. References

7. Further reading

8. External links

Shin splints is defined as "pain along the inner edge of the shinbone.

(tibia)."^[1] Shin splints are usually caused by repeated trauma to the connective muscle tissue surrounding the tibia.^[2] They are a common injury affecting athletes who engage in running sports or other forms of physical activity, including running and jumping. They are characterized by general pain in the lower region of the leg between the knee and the ankle. Shin splints injuries are specifically located in the middle to lower thirds of the anterior or lateral part of the tibia, which is the larger of two bones comprising the lower leg.

Shin splints are the most prevalent lower leg injury^[3] and affect a broad range of individuals. It affects mostly runners and accounts for approximately 13% to 17% of all running-related injuries.^[4][5] High school age runners see shin splints injury rates of approximately 13%.^[6] Aerobic dancers have also been known to have shin splints, with injury rates as high as 22%.^[7] Military personnel undergoing basic training experience shin splints injury rates between 4–8%.^[8][9]

Signs and symptoms

Shin splint pain is described as a recurring dull ache along the inner part of the lower two-thirds of the tibia.^[10] In contrast, stress fracture pain is localized to the fracture site.^[11]

Biomechanically, over-pronation is a common factor in shin splints and action should be taken to improve the biomechanics of the gait.^[9] Pronation occurs when the medial arch moves downward and towards the body's midline to create a more stable point of contact with the ground.^[12] In other words, the ankle rolls inwards so that more of the arch has contact with the ground. This abnormal movement causes muscles to fatigue more quickly and to be unable to absorb any shock from the foot hitting the ground.^[3]

Causes

While the exact cause is unknown, shin splints can be attributed to the overloading of the lower leg due to biomechanical irregularities resulting in an increase in stress exerted on the tibia. A sudden increase in intensity or frequency in activity level fatigues muscles too quickly to properly help shock absorption, forcing the tibia to absorb most of the impact. This stress is associated with the onset of shin splints.^[13] Muscle imbalance, including weak core muscles, inflexibility and tightness of lower leg muscles, including the gastrocnemius, soleus, and plantar muscles (commonly the flexor digitorum longus) can increase the possibility of shin splints.^[14] The pain associated with shin splints is caused from a disruption of Sharpey's fibres that connect the medial soleus fascia through the periosteum of the tibia where it inserts into the bone.^[13] With repetitive stress, the impact forces eccentrically fatigue the soleus and create repeated tibial bending or bowing, contributing to shin splints. The impact is made worse by running uphill, downhill, on uneven terrain, or on hard surfaces. Improper footwear, including worn-out shoes, can also contribute to shin splints.^[15][16]

It is possible that a vitamin D deficiency contributes to shin splits. A study found that patients suffering from shin splints were 9.5 times more likely to have a vitamin D deficiency than an age- and sex-matched control group, that did not have shin splints.^[17]

Diagnosis

Shin splints can be diagnosed by a physician or physiotherapist after taking a thorough history and performing a complete physical examination. The physical examination uses gentle pressure in attempts to replicate the type of pain experienced in order to determine whether there is tenderness over diffuse section of the shank.^[18][19] The pain has been described as a dull ache to an intense pain that increases during exercise, and some individuals experience swelling in the pain area.^[20] People who have previously had shin splints are more likely to have it again.^[18]

Vascular and neurological examinations produce normal results in patients with shin splints. Radiographies and three-phase bone scans are recommended to differentiate between shin splints and other causes of chronic leg pain. Bone scintigraphy and MRI scans can be used to differentiate between stress fractures and shin splints.^[18]

It is important to differentiate between different lower leg pain injuries, including shin splints, stress fractures, compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome.^[19] These conditions often have many overlapping symptoms which makes a final diagnosis difficult, and correct diagnosis is needed to determine the most appropriate treatment.

Treatment

Treatments include rest, ice and gradually returning to activity.^[14] Rest and ice work to allow the tibia to recover from sudden, high levels of stress and reduce inflammation and pain levels. It is important to significantly reduce any pain or swelling before returning to activity. Strengthening exercises should be performed after pain has subsided, on calves, quadriceps and gluteals.^[14] Cross training is recommended in order to maintain aerobic fitness e.g. cycling, swimming, boxing etc.^[21] Individuals should gradually return to activity, beginning with a short and low intensity level. Over multiple weeks, they can slowly work up to normal activity level. It is important to decrease activity level if any pain returns. Individuals should consider running on other surfaces besides asphalt, such as grass, to decrease the amount of force the lower leg must absorb.^[3] Orthoses and insoles help to offset biomechanical irregularities, like pronation, and help to support the arch of the foot.^[22] Other conservative interventions include footwear refitting, orthotics, manual therapy, balance training (e.g. using a balance board), cortisone injections, and calcium and vitamin D supplementation.^[14]

Less common forms of treatment for more severe cases of shin splints include extracorporeal shockwave therapy (ESWT) and surgery.^[23] Surgery is only performed in extreme cases where more conservative options have been tried for at least a year.^[24] However, surgery does not guarantee 100% recovery.

Epidemiology

Risk factors for developing shin splints include:

• Excessive pronation at subtalar joint^[3]
• Excessively tight calf muscles (which can cause excessive pronation)^[25]
• Engaging the medial shin muscle in excessive amounts of eccentric muscle activity^[3]
• Undertaking high-impact exercises on hard, noncompliant surfaces (ex: running on asphalt or concrete)^[3]
• Biological Sex: Woman^[26]
• Smoking and low fitness level^[27]
• Vitamin D deficiency^[17]

While medial tibial stress syndrome is the most common form of shin splints, compartment syndrome and stress fractures are also common forms of shin splints. Females are 1.5 to 3.5 times more likely to progress to stress fractures from shin splints.^[3][6][28] This is due in part to females having a higher incidence of diminished bone density and osteoporosis.

References

Further reading

• {{cite journal|doi=10.1136/ard.2005.043281|pmid=16699055|pmc=1798176|year=2006|last1=Alonso-Bartolome|first1=P.|title=Medial tibial stress syndrome due to methotrexate osteopathy|journal=Annals of the Rheumatic Diseases|volume=65|issue=6|pages=832–3|last2=Martinez-Taboada|first2=V. M.|last3=Canga|first3=A.|last4=Blanco|first4=R.}}
• {{Cite journal | doi=10.1001/jama.236.2.163|title = Susceptibility of women athletes to injury. Myths vs reality| journal=JAMA: The Journal of the American Medical Association| volume=236| issue=2| pages=163–165|year = 1976|last1 = Haycock|first1 = C. E.}}
• {{cite journal|doi=10.2165/00007256-200939070-00002|pmid=19530750|title=Medial Tibial Stress Syndrome|journal=Sports Medicine|volume=39|issue=7|pages=523–546|year=2009|last1=Moen|first1=Maarten H.|last2=Tol|first2=Johannes L.|last3=Weir|first3=Adam|last4=Steunebrink|first4=Miriam|last5=De Winter|first5=Theodorus C.}}
• {{cite journal|doi=10.1186/1758-2555-1-11|pmid=19519909|pmc=2700791|year=2009|last1=Raissi|first1=G. R.|title=The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes|journal=Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology : Smartt|volume=1|issue=1|pages=11|last2=Cherati|first2=A. D.|last3=Mansoori|first3=K. D.|last4=Razi|first4=M. D.}}
• {{cite journal|doi=10.1177/0363546509343804|pmid=19776340|title=Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Medial Tibial Stress Syndrome|journal=The American Journal of Sports Medicine|volume=38|issue=1|pages=125–132|year=2010|last1=Rompe|first1=Jan D.|last2=Cacchio|first2=Angelo|last3=Furia|first3=John P.|last4=Maffulli|first4=Nicola}}
• {{cite journal|doi=10.1249/00005768-199506000-00002|title=Effect of foot posture on the incidence of medial tibial stress syndrome|journal=Medicine & Science in Sports & Exercise|volume=27|issue=6|pages=800–804|year=1995|last1=Sommer|first1=Hillel M.|last2=Vallentyne|first2=Stephen W.}}
• {{Cite journal |pmid = 18347118|year = 2008|last1 = Tweed|first1 = J. L.|title = Etiologic factors in the development of medial tibial stress syndrome: A review of the literature|journal = Journal of the American Podiatric Medical Association|volume = 98|issue = 2|pages = 107–11|last2 = Avil|first2 = S. J.|last3 = Campbell|first3 = J. A.|last4 = Barnes|first4 = M. R.|doi = 10.7547/0980436}}

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