Shin Splints

Synonym: medial tibial syndrome

A complex syndrome characterised by exercise induced pain in the lower leg. Shin splints may be due to interosseous membrane tears, periosteal avulsions, tendinitis, periostitis, muscle sprains or fascial hernias.

• Medial shin splints are caused by traction of tibialis posterior muscle origin on the interosseous membrane and tibia. It may even show radiologically as periostitis.
• Medial shin splints is usually an overuse phenomenon.
• Other predisposing causes are:
  • Poorly fitting shoes.
  • Running on hard surfaces.
  • Running on cambered surfaces.
  • Hyperpronation when running.
  • Change of running pattern, for example from road running to running on a synthetic running track.

• Shin splints tend to occur in runners.
• People who are unfit who suddenly start exercising are at risk of developing a stress fracture of the tibia.
• Contributing factors include varus hindfoot, excessive forefoot pronation, genu valgum, excessive femoral anteversion and external tibial torsion.

• Pain and tenderness may be severe and are localised to the posteromedial border of the middle and distal third regions of the tibia.
• Pain initially tends to occur after running but later also occurs during running.
• When severe, climbing stairs can also be painful.
• Tenderness is usually more localised with stress fractures.

Pain over the anterior aspect of the proximal tibia is often caused by referred pain from the patellofemoral joint (anterior knee pain). Other causes of shin pain include:

• Stress fracture (localised bone tenderness and overlying oedema)
• Chronic compartment syndrome (lateral shin pain may be due to a compartment syndrome of the tibialis anterior - see below)
• Muscle strain
• Tumour
• Infection
• Paget's disease
• Tabes dorsalis

• X-rays: usually normal in periostitis; initial x-rays may be normal with stress fractures and so repeat x-rays are often indicated if clinical suspicion persists (bone scan is much more sensitive and preferred if available).
• Bone Scan:
  • Radionuclide bone scanning is more effective than x-rays at showing stress fractures and shin splints.¹
  • Periostitis appears as linear streaking over postero-medial aspect of the tibia.
  • With stress fractures, the scan shows a localised 'hot spot'.
• MRI has also been shown to be useful in discrimination between stress fracture and shin splints before x-rays show a detectable periosteal reaction in the tibia.²

• Rest is the key to treatment of stress fractures and periostitis.
• Management in the acute stage is rest, ice, mild elevation and a non-steroidal anti-inflammatory drug (NSAID).
• Advise to wear shock absorbing insoles in shoes and maintain fitness with non weight-bearing exercises such as swimming or cycling.
• Once symptoms subside the patient should start a steadily increasing exercise programme.
• A podiatrist can fit orthotics to prevent hyperpronation, if this is the causative factor.
• Stress fractures may take up to 12 weeks to heal completely.³
• Casting may be indicated.
• Fasciotomy of the posterior superior compartment may be indicated in severe cases.³

• Caused by a compartment syndrome due to swelling of the tibialis anterior muscle.
• The muscle swells with exercise producing relative muscle ischaemia due to the restriction of muscle expansion caused by the fascial compartment.
• Most often occurs due to long-distance running, hill running or an over- flexible shoe.
• Pain is lateral to the tibia. There may be numbness of the big toe.
• Treatment:
  • Immediate treatment is rest, ice and slight elevation.
  • Increase cushioning in shoes.
  • Avoid compression as this will aggravate the condition.
  • Fasciotomy may be required for severe cases or when conservative management is ineffective.³