SHIN AND LOWER LEG PAIN (SHIN SPLINTS)

CONDITION

Shin splints is a term that describes pain along the inside of your lower leg or shinbone (tibia) (Figure 1 below). Shin splints occur with repeat impact activities that damage tissues faster than the body can repair them.

Figure 1

Shin splints usually get better with simple treatment (described in self-care below).
Be aware that more serious lower leg conditions, such as a stress fracture or blood clot, can cause similar symptoms.

Sports medicine doctors generally discourage use of the term shin splints because it is nonspecific and can encompass a broad range of problems. Nevertheless, it continues in wide use by patients who have long been familiar with it as a way to describe this common condition.

Causes

The exact cause of shin splints is debated. However, it is most likely a result of overload, irritation and injury to the tissues, muscles and tendons (fibrous bands of tissue that attach muscle to bone) in the lower leg. Activities and conditions that can lead to shin splints include:

impact activities such as jogging, running, dancing and marching in the military.
sudden increases in intensity (how hard you are working), frequency (how often you are doing an activity) and/or duration (how long you are doing an activity during each workout).
poor running form such as crossing your legs in front of your body, using too much upper body motion and crossing your arms over the center of your chest
training on hard surfaces such as concrete
running on uneven terrain, start-and-stop activities or sports (like basketball and soccer) and running downhill or uphill a lot
wearing poor-quality or worn-out shoes
having flat feet or high arches
being knock-kneed or bow-legged
having tight muscles in your lower legs, especially in your calves and the surrounding muscles
poor conditioning
obesity
smoking

Symptoms and Signs

You will have burning, aching and/or sharp pain over the inner, or medial, shinbone (tibia), usually spanning an area from the mid-leg to just above the ankle.
Sometimes, pain occurs over the front of your lower leg.
Pain usually occurs at the start of or early into impact activities (such as running) that result in symptoms.
You sometimes notice that discomfort improves as you warm up or continue to perform the activity.
Sometimes, pain will start near the end of an activity that results in symptoms.
Your pain will get better with rest or soon after stopping the activity that produced it.
As your injury gets worse, you may notice that pain:
- develops more easily
- becomes more intense
- continues throughout activities and for many hours after activities
- occurs with minimal weight-bearing activities like walking and climbing stairs.
Pain may increase with pushing off of your toes during running and sports.
You will have tenderness over the affected tissue when you push on them.
Tenderness is usually over a broad area on your inner shinbone, not over a small or pinpoint area as it would be with a stress fracture.
Swelling occurs occasionally but is usually not noticeable.
Shin splints never cause significant swelling, redness, warmth, sudden onset pain, muscle weakness, numbness, tingling or loss of sensation or result in your skin becoming more pale. Weakness in the muscles over the front of your lower leg can result in your forward foot slapping the ground when you run.
- If you have any of these signs or symptoms, your doctor needs to rule out more serious causes of lower leg pain that can cause permanent damage.
- Serious causes of lower leg pain can include stress fracture, compartment syndrome (high pressure within soft tissues of the leg) and blood vessel blockage.

WHEN TO CALL YOUR DOCTOR

Call your doctor right away (night or day) if:

After an injury or fall, you develop significant pain, swelling, weakness, the inability to push off of your toes or difficulty putting weight on your leg.
You develop pain in your leg that awakens you from sleep.
You have pain, redness, warmth and/or swelling in your leg or calf muscles.
You develop severe pain suddenly during an activity that may have caused it, especially if the pain gets worse with continued weight bearing, occurs with swelling and/or you hear a crack or pop with the injury.
You have any numbness, tingling or loss of sensation in your leg, ankle or foot that lasts more than a few minutes.
You have severe weakness in your leg and ankle muscles that lasts for more than a few minutes after activity.
You notice any paleness or change in your skin color in you leg, foot or ankle with activities that might have caused it.

Call your doctor during regular office hours if:

Your shin pain is getting worse.
Your shin pain persists throughout activities and/or lasts after activities with rest.
Your shin pain occurs with minimal impact activities such as walking.
You notice any brief numbness, tingling, loss of sensation or muscle weakness during or after exercise.
You are not sure what is causing your leg pain and it does not fit the above description of shin splints.
Your symptoms fit the above description of shin splints, but persist after two to three weeks of the self-care measures recommended below.

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SELF-CARE AT HOME

Stretching

Exercises that stretch the muscles on the back of your leg should be performed daily, held for 30 seconds and repeated three times each.
- Calf stretch: Take the position in Figure 2. Lean forward toward the wall while keeping your back leg straight to feel the stretch in your calf muscle.
- Deep calf and heel tendon stretch: Take the position in Figure 3. Lean forward toward the wall while keeping your back knee bent until you can feel the stretch over the back of your ankle.

Strengthening

Strengthening exercises should be performed once daily.
- Toe raises: Stand with your heels on a step or stair (Figure 4). Grasp the wall or stair railing and slowly lower your toes below the step until you feel a stretch over the front of your ankle. Then, slowly pull your toes back up as high as you can, using the muscles on the front of your lower leg and ankle. Do two to three sets, repeat each raise 10 to 20 times with each set and rest briefly between sets.
- Heel raises: Stand with the ball of your injured foot on a stair or step (Figure 5). Raise your heels by pushing up onto your toes using your calf and arch muscles. Hold a tip-toe position for one to two seconds and then lower your heels slowly below the step. Do two to three sets daily, repeat each raise 10 to 20 times and rest briefly between sets.

Pain Control

Apply an ice pack or a cold pack to your painful shin bone and surrounding muscles. Hold it in place with plastic wrap or an elastic wrap for 20 minutes three times daily, especially after weight-bearing activities.
- Place a thin washcloth between the cold pack and your skin to minimize the risk of frostbite.
- Ice massage can help. Freeze water in a paper cup, peel the top of the cup back so the ice is sticking out and then rub the ice over the painful area for a few minutes at a time. Let your shin get warm between massages. You can use ice message any time you have pain or after activities that will probably cause pain.
You may take ibuprofen (Advil® or Motrin®) if you can tolerate it. (See labels for dose and risks.)
An over-the-counter arch support placed in each shoe can sometimes reduce symptoms.
Avoid walking barefoot and wear good-quality athletic shoes with the added cushion or support they provide until your symptoms resolve.
Buy new running shoes if your old shoes are more than six months old, have more than 500 miles on them or if the sides of the soles look creased.
You may try using a shin sleeve (Figure 6) to prevent or reduce symptoms when you return to activities.

Figure 6

Recommended Activity

Avoid any activities that worsen your symptoms until all shin pain has resolved. These may include sports or exercises that involve running, cutting, marching and jumping.
Stay active doing no-impact or low-impact exercise activities such as swimming, rowing, bicycling, or using an elliptical trainer or glider until your symptoms are minimal or resolve.
When you have had no shin pain for a week, you may gradually return to impact activities such as running.
- Run or walk on soft surfaces such as tracks or trails.
- Use walk-run intervals to get back to your previous level of exercise.
- You may want to start intervals by walking for four minutes, jogging for one minute and repeating this three to four times.
- You can gradually decrease the amount of walking and increase the amount of jogging until you are jogging for your entire workout, then increase jogging time gradually.
- If your symptoms return, see your doctor.
Make sure you have good running form. Don’t cross your legs or arms in front of your body and keep upper body motion with strides to a minimum.

PREVENTION

Start new running, cutting and jumping activities slowly.
Train on soft surfaces such as a soft track or dirt trail.
Progress training volume appropriately. Never increase intensity, frequency or duration of activity more than 10 percent every 10 days to two weeks.
Avoid long runs that exceed 30 percent of your weekly mileage.
Do regular stretching and strengthening as described above.
Replace running shoes at least every six months or 500 miles, whichever comes first.
Consider using arch supports, especially if you have very flat, high-arched feet.

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FOR MORE INFORMATION

REFERENCES

Sease F, Bolin D: Lower leg syndromes. In Mellion M, Putukian M, Madden C: Sports Medicine Secrets, 3rd Edition, p381-5, Hanley & Belfus, Philadelphia, 2002.
Wilder R: Overuse injuries: tendinopathies, stress fractures, compartment syndromes, and shin splints. Clinics in Sports Medicine 23(1):55-81, 2004

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Authored by Christopher Madden, M.D.

Favorably reviewed by The American Medical Society for Sports Medicine

http://amssm.org

Disclaimer: This content is reviewed periodically and is subject to change as new healthcare information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.