Possible Diagnosis: Shin Splints
Understanding Shin Splints and Related Injuries
True “shin splints”, or Medial Tibial Stress Syndrome (MTSS), is one of the most common overuse injuries experienced by athletes, especially runners. However, several other injuries can cause similar symptoms and are often mistaken for shin splints. It’s crucial to differentiate between these conditions, as the treatment and recovery plans can vary significantly.
Below is a comprehensive guide covering shin splints and related conditions, as well as a comparison table to help differentiate them.
How to Differentiate Between These Injuries
Identifying Shin Splints vs. Other Conditions
Pain Location
Shin Splints: Pain is usually diffuse and felt along the inner edge of the shin.
Stress Fracture: Pain is localized and sharper.
Compartment Syndrome: Pain comes with a sensation of tightness or pressure.
PTTD: Pain is more toward the inside of the ankle and foot.
Periostitis: Pain is diffuse but felt along the entire length of the shin.
Pain After and During Activity
Shin Splints: Pain worsens during activity and may persist afterward but improves with rest.
Stress Fracture: Pain becomes constant, even at rest, especially in later stages.
Compartment Syndrome: Pain worsens with activity but subsides quickly with rest.
PTTD: Pain is present with weight-bearing activities and is often accompanied by foot collapse (flatfoot).
Periostitis: Pain improves with rest but may still be tender when touched.
Response to Rest
Shin Splints: Pain improves with rest.
Stress Fracture: Rest is essential, and the pain will not fully resolve until the fracture heals.
Compartment Syndrome: Symptoms go away with rest but return during activity.
PTTD: Pain decreases with rest but can persist if not addressed.
| Condition | Pain Location | Pain Timing | Key Symptom | Main Causes | Treatment |
|---|---|---|---|---|---|
| Shin Splints (MTSS) | Inner edge of shin | Worsens during activity | Dull, aching pain | Overuse, flat feet, inadequate footwear | Rest, ice, gradual return to activity |
| Tibial Stress Fracture | Localized on shin (usually middle to lower third) | Worsens during and after activity, may persist at rest | Sharp, localized pain | Repetitive impact, poor biomechanics | Rest, offloading, gradual return |
| Compartment Syndrome | Front or side of lower leg | During activity, subsides with rest | Tightness, pressure, possible numbness | Exercise-induced pressure buildup | Rest, stretching, possible surgery |
| Posterior Tibial Tendon Dysfunction (PTTD) | Inner ankle and lower leg | Worsens with weight-bearing activity | Flatfoot deformity, arch collapse | Overpronation, repetitive strain | Rest, orthotics, strengthening exercises |
| Periostitis | Diffuse along shinbone | Worsens with activity, tender after | Swelling or tenderness along shin | Repetitive impact, running on hard surfaces | Rest, ice, gradual return |
Medial Tibial Stress Syndrome (MTSS) – "Shin Splints"
Description
MTSS, commonly referred to as shin splints, is caused by repetitive microtrauma to the tibia due to overuse, poor biomechanics, or improper training techniques.
Symptoms
Dull, aching pain along the inner edge of the shinbone (tibia).
Pain worsens during or after physical activity, particularly running or jumping.
Tenderness along the lower two-thirds of the inner shinbone.
Pain may be widespread along the tibia, unlike stress fractures, which tend to be localized.
Presentation in Track and Field Athletes
Events: Middle- and long-distance runners, sprinters, jumpers (long jump, triple jump, high jump), and hurdlers.
Common Activities and Causes:
Overuse from High Running Volume: Runners in endurance events (800m to 10,000m) often increase their weekly mileage too quickly, especially during pre-season or intense training blocks, which overloads the tibialis posterior and surrounding structures.
Heel Striking: Sprinters and middle-distance runners who have a heavy heel-strike pattern or poor running mechanics may increase the load on the tibia. This over-reliance on heel striking, especially at higher speeds, can exacerbate stress on the shin.
Running on Hard Surfaces: Repetitive running on hard surfaces (e.g., asphalt, concrete, or an overly compact track) can significantly increase the impact forces transferred to the shin, contributing to microtrauma.
Inadequate Footwear: Using worn-out or non-supportive running shoes can fail to absorb shock properly, transferring more force to the tibia, particularly in athletes with high arches or flat feet.
Flat Feet (Overpronation): Athletes who overpronate (where the foot rolls inward excessively) during their running stride, particularly distance runners, place more stress on the posterior tibial muscle, leading to shin splints.
Improper Jumping Mechanics: In jumpers (long jump, high jump, triple jump), repetitive impacts from take-offs and landings can stress the shin, particularly when poor foot placement or take-off angles are used. Landing heavily on the forefoot without proper shock absorption can increase strain on the tibia.
Treatment
Rest and Ice: Rest from high-impact activities and apply ice for 15-20 minutes, 2-3 times a day.
Calf Stretching and Strengthening: Stretch the calves and strengthen the foot and ankle muscles to support proper mechanics.
Footwear adjustment: Use supportive shoes with proper cushioning, or consider custom orthotics if necessary.
Low-Impact Activities: Engage in cross-training exercises like swimming or cycling to maintain fitness while reducing impact on the shins.
Gradual Return to Activity: Slowly reintroduce running and jumping, starting with low-intensity sessions on soft surfaces.
Rehabilitation Phases for Medial Tibial Stress Syndrome (MTSS)
Phase 1 (0-2 weeks):
Goal: Reduce pain and inflammation, allow healing.
Rest and Ice: Avoid high-impact activities and ice the affected area several times a day.
Compression and elevation: Use compression sleeves to reduce swelling and elevate the legs when resting.
Gentle calf stretching: Lightly stretch the calves to reduce tension on the shin.
When to Progress: Move to the next phase when pain subsides during daily walking and basic movements.
Phase 2 (2-6 weeks):
Goal: Strengthen the muscles around the shin and gradually return to activity.
Toe raises and heel drops: Strengthen the muscles of the lower leg with exercises like toe raises and calf raises.
Foot and ankle strengthening: Use resistance bands to strengthen the foot and ankle muscles to improve shock absorption.
Cross-training: Engage in low-impact activities like swimming or cycling to maintain fitness while reducing stress on the shins.
When to Progress: Progress to running when you can performs strength exercises (like calf raises) without pain, and once pain during light running subsides.
Phase 3 (6-12 weeks):
Goal: Return to running and sport-specific activities.
Gradual running program: Start with short intervals of running mixed with walking, slowly building up the duration of running sessions.
Plyometric exercises: Slowly reintroduce light plyometrics, such as jump rope and bounding.
When to Progress: Gradually return to full intensity when you can run or jump without pain or compensatory movement.
Prevention Tips
Strengthening Exercises: Incorporate calf and lower leg strengthening exercises like calf raises and toe taps into your routine.
Progressive Training: Avoid sudden increases in mileage or intensity. Follow a gradual running progression.
Proper Footwear: Ensure that you have supportive shoes that match your foot type (e.g., flat feet, high arches).
Exercise Videos
General Strength Exercises for Shin Splint Recovery
Toe Taps for Strengthening
Research Links
Research on shin splints rehabilitation and prevention: Read here
Tibial Stress Fracture
Description
A tibial stress fracture is a small crack in the tibia caused by repetitive loading without adequate recovery, often resulting from overtraining or biomechanical inefficiencies.
Symptoms
Localized pain in a specific area of the tibia, usually along the middle to lower third of the shin.
Pain is sharp and worsens with activity but may persist even at rest in advanced stages.
Swelling and tenderness over the fracture site.
Pain is worse with weight-bearing activities and running.
Presentation in Track and Field Athletes
Events: Middle- and long-distance runners, sprinters, jumpers (especially long jumpers), and hurdlers.
Common Activities and Causes:
Sudden Increase in Training Volume or Intensity: Athletes who rapidly increase their running mileage or intensity (such as interval training or hill workouts) are at high risk. For example, a distance runner doubling their weekly mileage during a pre-season training camp may be prone to stress fractures.
Overstriding in Sprinters and Hurdlers: Sprinters and hurdlers who take excessively long strides often have a harsh heel-strike or over-extend their legs, resulting in an inefficient stride that places undue stress on the tibia. This is common in athletes focusing on maximum velocity or top-end speed without proper sprint mechanics.
Downhill Running or Sprinting: Downhill running or performing sprints on inclines (e.g., hill workouts) can increase tibial stress, as the anterior tibialis muscle works harder to decelerate the foot on downhill surfaces. The tibia is placed under greater loading stress due to the braking forces.
Improper Landing Techniques in Jumpers: Long jumpers and triple jumpers, who frequently land with poor mechanics (e.g., excessive forefoot landing or improper body alignment on impact), experience greater localized stress in the tibia, increasing fracture risk.
Inadequate Recovery: Athletes who do not allow sufficient recovery between high-intensity training sessions, especially during competitions or track meets, may develop stress fractures due to the accumulated load on the tibia.
Treatment
Complete Rest: Stop all impact activities. Use crutches or a walking boot to offload the affected leg, especially in more severe cases.
Bone Health: Ensure adequate intake of calcium and vitamin D to support bone healing.
Cross-training: Non-weight-bearing activities like swimming or cycling can maintain cardiovascular fitness without stressing the bone.
Gradual Return to Running: Only after full healing (6-8 weeks or longer), begin a gradual return-to-running program, starting with walking and progressing slowly.
Recovery Phases and When to Progress
Phase 1: Complete Rest and Offloading
When to Progress: Bone healing confirmed via imaging (X-ray or MRI) and no pain with weight-bearing activities.
Phase 2: Partial Weight-Bearing and Light Strengthening
When to Progress: Pain-free during light weight-bearing and cross-training activities.
Phase 3: Full Weight-Bearing and Low-Impact Loading
When to Progress: Pain-free during low-impact running drills.
Phase 4: Gradual Return to Running
When to Progress: No pain during steady running or jumping, with progression monitored.
Compartment Syndrome (Chronic Exertional)
Description
Chronic Exertional Compartment Syndrome (CECS) occurs when excessive pressure builds within the muscle compartments of the lower leg, typically triggered by exercise, limiting blood flow and compressing nerves.
There’s also acute compartment syndrome which is a medical emergency, usually resulting from a traumatic injury (e.g., a direct blow).
Symptoms
Tightness, swelling, or cramping in the shin area, often described as a “pressure” sensation.
Pain that worsens during activity but subsides with rest.
Numbness, tingling, or weakness in the foot due to nerve compression.
Muscle weakness or foot drop in severe cases.
Presentation in Track and Field Athletes
Events: Sprinters, middle-distance runners, hurdlers, and jumpers.
Common Activities and Causes:
Repetitive Sprinting or High-Intensity Interval Training (HIIT): Sprinters and middle-distance runners who regularly engage in repeated high-speed runs may experience excessive muscle swelling in the lower leg, causing increased pressure within the anterior compartment (where the tibialis anterior muscle resides). Athletes with limited calf flexibility are particularly vulnerable to CECS.
Running on Hard Surfaces: Running on hard tracks or concrete can exacerbate the symptoms of compartment syndrome by causing constant high-impact forces on the lower leg.
Rapid Acceleration and Deceleration: Athletes who repeatedly accelerate (sprinting or jumping) and decelerate (stopping abruptly) put additional strain on their lower leg compartments, limiting the muscles’ ability to recover between intense efforts. This is common in track events where starts and stops are frequent (e.g., sprinting in relay events or 400m hurdles).
Tight-Fitting Equipment: Wearing excessively tight compression socks or improperly fitted shoes can increase the pressure in the lower leg compartments during sprinting or jumping, limiting blood flow and contributing to symptoms.
Treatment
Rest and Modify Activity: Temporarily stop running or impact activities and try cross-training options that don’t exacerbate the symptoms.
Stretching and Massage: Gentle stretching of the lower leg and massaging the area can help relieve tension.
Surgery (Fasciotomy): In severe cases where symptoms persist, a fasciotomy (surgical release of the compartment) may be necessary to relieve the pressure.
Recovery Phases and When to Progress
Phase 1: Rest and Symptom Control
When to Progress: Move to the next phase when pain subsides during walking or light jogging.
Phase 2: Stretching and Soft Tissue Mobilization
When to Progress: Progress when pain-free during stretching and low-intensity exercise.
Phase 3: Strengthening and Biomechanics
When to Progress: Move to running when strength and biomechanics (calf and tibial muscle control) improve without symptoms.
Phase 4: Return to Running and Sport
When to Progress: Return to full competition when the athlete completes sprints or event-specific activities (jumping, hurdles) without compartment pressure symptoms.
Posterior Tibial Tendon Dysfunction (PTTD)
Description
PTTD occurs when the posterior tibial tendon, which runs along the inside of the ankle and supports the arch of the foot, becomes inflamed or damaged. Over time, the weakened tendon can no longer support the foot’s arch, leading to flatfoot.
Overpronation: People with flat feet or who overpronate during running are more prone to this injury.
Repetitive strain: Overuse from activities like running or high-impact sports can damage the tendon.
Symptoms
Pain along the inside of the ankle and lower leg, often radiating up to the shin.
Pain worsens with weight-bearing activities, particularly running or standing for long periods.
Flatfoot deformity: The arch of the foot may collapse over time, leading to overpronation (the foot rolls inward excessively).
Presentation in Track and Field Athletes
Events: Sprinters, jumpers, and distance runners, especially those prone to overpronation or with poor arch support.
Common Activities and Causes:
Overpronation During Running: Distance runners with flat feet or excessive foot pronation are particularly vulnerable to PTTD. Overpronation places excessive stress on the posterior tibial tendon, especially during long-distance runs or extended training sessions. This becomes worse with poor foot mechanics over time.
Repetitive Jumping or Sprinting: Jumpers (long jump, triple jump, high jump) and sprinters who repeatedly land or push off from unstable foot positions may stress the posterior tibial tendon. This is especially common if they land with excessive inward foot rolling (overpronation).
Poor Footwear or Lack of Orthotics: Athletes with pre-existing flat feet or high arches who do not wear supportive footwear may suffer from tendon strain. A lack of orthotic support can accelerate the condition, particularly in high-impact track and field events.
Treatment
Rest and Immobilization: Limit activities that place stress on the foot and ankle. A walking boot may be necessary in severe cases.
Foot Orthotics: Custom orthotics can provide arch support and relieve strain on the posterior tibial tendon.
Strengthening Exercises: Perform exercises to strengthen the posterior tibial tendon and support the arch, such as toe raises and foot doming.
Gradual Return to Activity: Slowly reintroduce running and other high-impact activities with proper footwear and support.
Recovery Phases and When to Progress
Phase 1: Rest and Offloading
When to Progress: Progress when pain subsides during walking and weight-bearing.
Phase 2: Strengthening and Arch Support
When to Progress: Move to weight-bearing exercises and jogging when pain-free.
Phase 3: Return to Weight-Bearing Activity
When to Progress: Progress when walking and light running are pain-free with proper arch support.
Phase 4: Return to Full Sport
When to Progress: Return to full sprinting and jumping when pain-free and no arch collapse is present during full-speed drills.
Periostitis (Inflammation of the Periosteum)
Description
Periostitis is inflammation of the periosteum, a thin layer of tissue that surrounds the bone. This condition often affects the tibia in athletes due to repetitive stress or trauma to the shinbone. Unlike stress fractures, periostitis typically involves diffuse pain along the shin rather than a localized area. The condition can result from chronic irritation caused by repetitive impact activities, leading to inflammation in the periosteum.
Repetitive impact: Common in athletes who engage in high-frequency running or jumping activities, especially on hard surfaces.
Overuse injuries: A sudden increase in training volume or intensity can trigger inflammation of the periosteum.
Symptoms
Diffuse pain: Pain is felt along the shinbone, typically the lower third of the tibia.
Increased pain with activity: Pain worsens during running or jumping and may persist afterward.
Tenderness along the tibia: The area may remain tender to the touch even after stopping activity.
Swelling or inflammation: There can be visible swelling along the shinbone due to the inflammation.
Presentation in Track and Field Athletes
Events: Middle- and long-distance runners, sprinters, hurdlers, and jumpers (long jump, triple jump).
Common Activities and Causes
Running on Hard Surfaces: Repeated impact from running on hard surfaces like tracks or roads increases the stress on the tibia, contributing to periostitis. This is especially common in middle- and long-distance runners who perform high-mileage workouts on concrete or track.
Overtraining and Sudden Increase in Volume: Athletes who rapidly increase their running volume or frequency, such as during pre-season training, are at high risk of developing periostitis. Distance runners and sprinters who abruptly intensify their workouts without adequate recovery time may overstress the periosteum.
Improper Foot Strike: Sprinters and distance runners who heel strike excessively can generate abnormal forces up the tibia, leading to irritation of the periosteum. Heel striking increases the braking forces on the tibia with each step, especially during high-speed running or sprinting.
Jumping Events (Repetitive Impact): Athletes in jumping events (e.g., long jump, triple jump) often experience periostitis due to the repetitive impact forces when landing and taking off. The increased strain on the lower leg during explosive movements can inflame the periosteum, especially in those with poor landing mechanics.
Inadequate Footwear: Poorly cushioned or worn-out shoes that don’t absorb shock adequately can cause periostitis by increasing the repetitive stress on the tibia. This is particularly a problem in athletes running on hard surfaces or with poor foot mechanics (e.g., overpronation).
Treatment
Rest: Limit or stop activities that aggravate the shin pain. Rest is critical to reducing inflammation in the periosteum and preventing further injury.
Ice and Anti-Inflammatories: Apply ice to the painful area for 15-20 minutes several times a day to reduce swelling. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief, though long-term use should be avoided due to potential impact on healing.
Footwear Adjustment: Ensure that running shoes provide adequate cushioning and arch support. Custom orthotics may be necessary for athletes with flat feet or high arches to improve foot mechanics and reduce strain on the tibia.
Cross-Training: Engage in non-impact activities such as swimming or cycling to maintain fitness while reducing the load on the shins.
Recovery Phases and When to Progress
Phase 1: Rest and Load Reduction
Focus: Allow inflammation to subside and prevent further irritation of the periosteum.
Interventions: Cease running or jumping and use ice regularly to reduce inflammation. Cross-training (e.g., swimming, cycling) can be introduced to maintain cardiovascular fitness without stressing the shin.
When to Progress: Progress when the athlete experiences pain-free walking and reduced tenderness along the tibia during rest and daily activities. Typically, this phase lasts 1-2 weeks depending on the severity.
Phase 2: Mobility and Flexibility Restoration
Focus: Restore range of motion in the ankle and improve muscle flexibility to reduce tibial loading.
Interventions: Calf and anterior tibialis stretches 2-3 times daily to alleviate tension. Ankle mobility exercises (e.g., ankle circles) are essential to restoring proper mechanics.
When to Progress: Move to the next phase when the athlete can stretch and perform ankle mobility exercises without pain, and shin tenderness has significantly reduced. This phase typically lasts 1-2 weeks.
Phase 3: Strengthening and Biomechanical Correction
Focus: Strengthen the muscles that support the lower leg and correct biomechanical issues.
Interventions: Introduce strengthening exercises, such as eccentric calf raises, to build lower leg resilience. Address any biomechanical issues such as overpronation with orthotics or changes in footwear. Include foot intrinsic muscle exercises (e.g., toe raises) to improve shock absorption during running.
When to Progress: Progress when the athlete can complete strength exercises without discomfort and perform short, pain-free walks on soft surfaces. This phase typically lasts 2-3 weeks, depending on individual progress.
Phase 4: Gradual Return to Sport
Focus: Reintroduce impact activities gradually while monitoring for any return of symptoms.
Interventions: Begin with short, low-intensity running sessions on softer surfaces, such as grass or a cushioned track. Progress by following the “10% rule” (increase volume by no more than 10% per week) while monitoring for any shin discomfort.
When to Progress to Full Activity: Return to full track and field activities when the athlete can run or jump pain-free, with no shin tenderness, and has full strength and mobility. This phase can take 4-6 weeks depending on severity and recovery response.
Conclusion
Each injury has specific mechanisms within track and field that contribute to its development. These range from biomechanical faults like overpronation or heel striking to training errors like overuse or running on hard surfaces. Recovery phases should be clearly outlined, with progression based on pain reduction, strength restoration, and the ability to perform sport-specific tasks without symptoms.