Medial tibial stress syndrom

Shin splints is a general term used to describe exercise-induced pain in the front of the lower legs, or shins.

The shin pain can be felt during or after strenuous activity, particularly running, or sports with sudden stops and starts, such as basketball and tennis.

The pain is felt along the shin bone (tibia), which runs down the inner part of your shin. At first you will feel a dull, aching pain. If you ignore it and continue to exercise, it can become very painful and you may have to stop exercising altogether.

It's really important not to "run through the pain" because shin pain could be a sign of an injury to the bone and surrounding tissues in your leg. Continued force on your legs will make the injury and your pain worse.

If possible, stop doing the activity which causes the problem for at least two weeks. You can still exercise during this time, but choose activities that don't put too much force on your shins, such as cycling, swimming, cross-training or yoga.

Why shin splints happen

Shin splints have a number of different causes. You're at risk of getting shin splints if you:

• have been running for less than five years
• run on hard surfaces or slopes
• wear poorly fitting or worn-out trainers that don't cushion and support your feet properly
• are overweight, as this places extra stress on your legs
• have flat feet or your feet roll inwards, as this puts more pressure on your lower legs
• have weak ankles or a tight Achilles tendon (the band of tissue connecting the heel bone to the calf muscle)
• have tight calf muscles

Medial stress syndrome

The most common cause of shin splints is medial tibial stress syndrome (MTSS).

MTSS is the result of frequent and intense periods of exercise when your body isn't used to it. Long-distance running and sports involving a lot of stopping and starting, such as basketball and tennis, increase your risk of getting MTSS. Suddenly increasing the distance and/or pace you run are also common causes.

These activities place a considerable amount of pressure on your legs, particularly if they are carried out on hard ground, and can cause injury to the bone and surrounding tissues.

MTSS is thought to occur when the layer of connective tissue covering the surface of the shin bone (periosteum) becomes inflamed.

It can become inflamed if too much pressure is placed on your shins, or if your foot rolls excessively when it hits the ground. This is known as over-pronation and it puts abnormal forces through the tibia and the shin bone.

The pain is usually felt in both shins and it can take several days, or even weeks, for the pain to decrease once you stop the activity.

Self care

You should stop the activity causing your shin splints for at least two weeks. After this time, the pain in your shins should begin to decrease and you can gradually resume the activity (see below).

While you're resting your legs, you can continue to do low impact activities, such as cross-training, cycling or swimming. Pool running is also a good way of maintaining cardiovascular fitness.

Pain relief

Pain and swelling can be relieved by holding an ice pack against your shins (a bag of frozen peas wrapped in a tea towel works well). Do this for 10 minutes every two to three hours for the first two days.

You can also use over-the-counter painkillers, such as paracetamol and ibuprofen, to help relieve the pain and inflammation. Stretching your calf muscles and the front of your leg can also help.

Choosing the right shoes

It's important your running shoes give you the right amount of cushioning and support for your weight and foot type. If your foot rolls inwards, you may need to have orthotics (rigid shoe inserts) fitted.

Go to a specialist running shop if you are buying running shoes for the first time. A trained member of staff will be able to carry out a number of tests, including a gait analysis, and advise which shoes are best for you.

If you continue having problems with your shoes, a podiatrist can give a more expert opinion and look at your overall lower limb biomechanics. Podiatrists specialise in diagnosing and treating foot problems.

Find a podiatrist in your area.

When to visit your GP

See your GP if the pain does not improve. They will investigate other possible causes, such as:

• reduced blood supply to the lower leg, particularly if you smoke 
• tiny cracks in the shin bone (stress fractures), which usually, but not always, give pain in only one leg
• a leg muscle bulging out of place (muscle hernia)
• swelling of the leg muscle that compresses nearby nerves and blood vessels, known as compartment syndrome (see below) 
• a nerve problem in your lower back (radiculopathy)

The pain of compartment syndrome is usually felt in both legs and only comes on with exercise. It can be felt in the front, side or back of the leg and, sometimes, in all three. Unlike the pain of MTSS, the pain caused by compartment syndrome quickly subsides when exercise ceases.

Seek immediate medical assistance if:

• the pain is severe and follows a fall or accident
• your shins are hot and inflamed
• the swelling gets worse
• the pain persists during rest

Your GP may refer you for physiotherapy, or you may be able to refer yourself. You could also opt to see a physiotherapist privately. Read more about accessing physiotherapy.

The physiotherapist can assess your injury, show you some exercises and advise a suitable programme of rehabilitation.

Alternatively, your GP may refer you to a consultant orthopaedic surgeon with a foot and ankle interest, or a consultant in sport and exercise medicine. These doctors are trained in assessing and treating sport-related problems.

Getting back to your normal exercise programme

You can return to your usual activity after at least two weeks of rest, and only after the pain has gone. Increase your activity level gradually, building up the time you spend running or doing sports.

Run on a flat, soft surface, such as a recreation ground or playing field. Keep the distance and intensity of your run to 50% of what it was before the injury. Stop immediately if the pain returns.

Gradually, over a period of three to six weeks, you can increase the distance you run. After six weeks, you can gradually start to increase your pace.

Make sure you warm up properly before starting to exercise and, afterwards, take time to cool down. Learn how to warm up before exercising and how to stretch after exercising.

Preventing shin splints returning

You can avoid shin splints in the future by:

• wearing running shoes with the correct level of cushioning and support
• using orthotics (supportive insoles) if you over-pronate or have flat feet (running shop staff or a podiatrist will be able to advise you further about this)
• avoid training on hard surfaces whenever possible
• build up your activity level gradually
• improving your overall strength and flexibility