Common causes of shin pain when running

​If you have spent any significant time with the running population, you will likely have heard of the term “Shin Splints”.  This generic term frequently used to describe shin pain can have several underlying causes which all result in an annoying disruption of time spent running!
This article will explore the main factors that can result in the over-arching label of Shin Splints and the different terminologies that may be discovered when investigating this condition. With some further understanding of the subtle difference in presentation and possible causes, appropriate early management of pain could be achieved.
Medial Tibial Stress Syndrome

​What is it?
The medical world will more commonly describe exercise induced pain in the lower leg as ‘Medial Tibial Stress Syndrome’ (MTSS). This is thought to occur either when the muscles in the lower leg contract, causing a traction tension on the shin bone (Tibia) and tissue surrounding it (periosteum), or as a result of repetitive loading stress on the bone from impact activities. Its probably true that both schools of thought have relevance when considering the likely causes to this condition.
 
 
What are the symptoms?

• Pain on running or high impact activities. In the earlier phases this may not stop activity. Pain may even disappear once warmed up or reappear following the activity. As severity increases, it may be possible to notice pain throughout the entire session.
• In more severe episodes pain may continue for approx. 48 hours following the event, presenting itself whilst walking or climbing stairs.
• The pain is often described as an intense ache which can be replicated by pressing along the lower third of the inside boarder of the Tibia.

What causes it?
MTSS is classified as an overuse injury. It is commonly suffered among the running population due to the repeated impact stress to the lower limb experienced during this activity. Factors that can influence its prevalence are multiple and can be both intrinsic and extrinsic in nature.
Intrinsic risks consider the biomechanics of the runner. Structural and postural inefficiencies such as low or high foot arches, the angle of the shin (tibial torsion or varum) or muscle imbalances can all have an impact on the stress on the muscle’s attachment to the bone.
Extrinsically the risks are posed regarding sudden significant increases in running intensity (duration or frequency).  Firm surfaces such as road running or hill running can cause additional stress.
How to treat it

• The application of ice aids recovery immediately following a run. This could be beneficial for up to 72 hours after the event.
• limiting the pain aggravating activity. This may mean a complete rest from running or a more moderately progressing programme, training short of painful symptoms.
• Substitute high impact activities with non-impact such as swimming or cycling while the inflammation settles.
• Introduce gentle stretching to the lower limb, in particular the calf.
• Myofascial release techniques may be beneficial to alleviate muscle hypertonicity.
• persistent or recurring symptoms should be examined by a physical therapist to establish potential intrinsic factors that need to be addressed. These may include the use of supportive insoles or the introduction of strengthening exercises to address postural or functional muscular imbalances.

How to prevent it

• Introduction to new activities such as running, or progression in training load, should be gradual allowing the body time to adapt to the stress.
• Appropriate conditioning programmes to compliment the running training should be considered.
• Appropriate stretching should be carried out, including a sufficient warm up and cool down.
• A variation of surfaces to include softer terrain would reduce the occurrence of such high impact.
• Ensuring appropriate footwear for both the type of terrain and to provide support and shock absorbency to the foot.
• Efficient running gait.

 
Stress fractures
What is it?
There are schools of thought that consider MTSS to be on a continuum, where the later stages present with a stress fracture to the Tibia. In essence a stress fracture is a repeated force creating stress on the bone at a rate greater than the bone can support. For a bone to adapt and become stronger it undergoes a degree of stress response. A healthy stress response causes microscopic degeneration of the bone which is sequentially reabsorbed creating a growth in the bone tissue. If this stress becomes more intense than the reabsorption rate, the microscopic degeneration increases and eventually a tiny crack in the bone can form. This is termed a stress fracture. If at this point the stress continues, the bone becomes at risk of a more significant fracture that is commonly recognised as a break.
Tibial stress fractures are  a common site. This bone is subjected to high impact weight bearing stress so is vulnerable when considering the activity of running. 

​What are the symptoms?

• Increasing pain on weight bearing activities, particularly high impact such as running.
• Initially pain may progress towards the end of the run but gradually become more noticeable earlier in the session.
• Pain is localised to a small area of the bone (1-2cm).
• Swelling may be evident
• The tibia may be painful to touch over the site of the fracture
• It may be the cause of an unexplainable pain at rest or at night.

 
 
How to treat it?

• R.I.C.E (Rest, ice, compress and elevate) protocol is most beneficial in the first 24-48 hours of an acute flare up.
• Prevent all impact activities such as running for the first 4-8 weeks. Specifically, whilst pain is present.
• Alternative non-impact activities such as swimming and cycling would be advocated.
• NSAIDs (anti-inflammatory drugs) may help manage pain and swelling.
• It is advisable to seek medical advice to address any intrinsic factors that have led to the injury.

How to prevent it

• Introduction to running or progression in training load should be gradual allowing the body time to adapt to the stress.
• Consider cross training to vary the training load.
• Runners with osteoporosis or low levels of Vitamin D may consider a very gradual increase in training intensity to ensure the bones have optimal time to adapt to the impact load without causing too much stress.
• Ensure a healthy balanced diet to encourage Vitamin D absorption for improved bone health.
• Ensuring the use of appropriate footwear, which provides adequate shock absorbency.

 
Anterior compartment Syndrome
Chronic exertional compartment syndrome is something we have explored in a previous article www.taylormaderehab.com/blog/everything-you-need-to-know-about-calf-injuries-for-runners
The lower leg is separated into 4 major compartments: the anterior, the superficial posterior, the deep posterior and the lateral compartment. The anterior compartment is in the front of the lower leg to the outside of the tibia. This syndrome can create symptoms that maybe mistaken for ‘shin splints’. 

​What are the symptoms?

• Described as aching, tight, cramping pain that worsens during exercise easing once the activity has stopped.
• There maybe evidence of swelling, heat or redness.
• The most significant difference between these injuries is the site of pain. Anterior compartment syndrome is experienced on the outside (lateral boarder) of the Tibia. MTSS is located on the inside (medial boarder).
• There may be numbness or tingling between the first and second toe or weakness in the lower leg.

How to treat it?

• Substitute running for non-impact activities initially to settle the symptoms down.
• NSAID may offer some benefit.
• Soft tissue massage and stretching to the muscles at the front of the shin.
• Occasionally the implementation of insoles or orthotics can help offer support to the lower limb.
• Running on softer surfaces and wearing appropriate footwear can promote shock absorbency.
• If symptoms persist, seek advice from a health care professional.

How to prevent it?

• Ensure a gradual introduction and progression to any running training.
• Consider cross training activities to vary training load.
• Maintain supportive footwear most suitable for your posture and gait.
• Carry out a complimentary conditioning programme to promote trunk stability and optimal postural alignment.
• Vary the running surface.
• Carry out a general stretching routine of the lower limb.

All the presentations of shin pain described here are because of abnormal stress on the lower limb during running, so its worth while ensuring that an optimal environment is provided. Ensuring efficient gait, appropriate supportive footwear and general conditioning and maintenance practices are met. If symptoms persist it is always wise to seek further advice from a health care professional.