Shin Splints

Shin splints are very common. They are the cause of 13% of all running injuries, with an incidence of 3.9 per 1000 hours of training.

Shin splints is a generic term that encompasses a number of causes of pain on the front of the shin/lower leg. This pain commonly caused by a sudden increase in running mileage or speed/hill work, lack of rest days, a change of foot wear, faulty biomechanics, tight calf muscles or even running to catch the bus in the wrong shoes!

If the pain becomes severe and constant there may be underlying stress fractures or compartment syndrome of the lower leg. Both of these complaints need further investigations to diagnose. MRI or bone scan are the investigations of choice.

1. Anterior tibialis overuse syndrome:

The symptoms tend to be dull aching and tenderness in the muscles of the lateral shin that may occur during or after exercise.

The treatment will often include rest, ice, soft tissue manipulation, massage, stretches, strengthening of the calf muscles and anterior tibials and gradual return to running. Kinesio tape can help with a pain free return to training.

Acupuncture to the muscles surrounding the shin bone can give excellent pain relief in just 2 or 3 sessions in the acute phase.

It is often useful to look further up the kinetic chain at the knee, hip, core, thorax and sometimes even the upper limb if the symptoms persist. Suboptimal movement patterns and muscle weakness elsewhere can play an important part in lower limb biomechanics.

A podiatry assessment can be helpful if the problem is due to faulty foot mechanics and it may be necessary to wear orthotics either temporarily or permanently to resolve the problem.

If symptoms are unresolving and become severe a differential diagnosis of compartment syndrome should be suspected and MRI is required.

2. Tibial stress reaction.

This is a low grade stress fracture where the bone may look normal on an x-ray but will be identified on bone or MRI scan. This is caused by an inability of the bone to adapt and repair in response to an increase in biomechanical stress caused by running. This is either a fatigue reaction in normal bone or due to an underlying insufficient bone mineral density or osteoporosis. If the latter is suspected it may be necessary to perform a DEXA scan to assess bone mineral density. Common causes of reduced bone mineral density in athletes are amenorrhoea (lack of periods) Vitamin D and Vitamin K insufficiency and poor diet (low calcium intake) or menopausal hormone changes.

The symptoms include localised bone pain on the anterior or medial border of the tibia often reproduced with hoping and progressively worsens with running. Can persist during walking activities and sometimes in bed at night.

Management: Stop running for 4-6 weeks (if low risk of poor fracture healing), followed by a gradual return to normal mileage over the next 4-6 weeks. Simple analgesics such as paracetamol or co-codamol. Continue to cross train (Swim, Bike, Row, Elliptical, Aqua jog). Address factors such as suboptimal biomechanics, specific strength and conditioning, calcium and vitamin insufficiencies.

3. Tibial stress fracture:

This is characterised by similar symptoms as a stress reaction although the pain may be more intense and antalgic gait adopted. A fracture and periosteal reaction will be identified on an x-ray, may still proceed to MRI or bone scan. Crutches or a brace may be necessary for the first 1-2 weeks, then a gradual return to low impact cross training starting with swimming and aqua jogging. It is important to refrain from running for 6-8 weeks before starting a gradual return to previous mileage for 4-6 weeks. Other treatment  modalities are consistent with a stress reaction described above.

If non-union occurs it is essential to seek the opinion of a sports medicine specialist or orthopaedic surgeon.

And finally……Prevention is better than cure!

1. Incorporate changes and increases in your training gradually.

2. Always allow adequate rest and recovery.

3. Get your GP to check vit D levels twice yearly Oct/Nov and Mar/Apr.

4. Supplement your daily vit D and calcium intake.

5. Make sure your daily calorie intake is adequate for your energy output, aim for a BMI >19kg/m2.

6. Female athletes who don’t have regular periods should ask their Gp for a DEXA scan. Male or female athletes who have had more than 1 stress fracture should also request a DEXA and explore other risk factors for osteoporosis with their Gp or Sports Med Doctor.

7. Incorporate a specific strength and conditioning programme into your training to address any functional weakness, suboptimal biomechanics, flexibility and core stability.

If you would like to see a Consultant in Sports and Exercise medicine for a diagnosis and management advice I highly recommend Dr John Rogers MRCGP FFSEM(UK), appointments can be made by emailing sportandexercisemedicine@gmail.com or phoning The Alexandra Hospital, Cheadle on 01614957000.

John is a renowned consultant in sports and exercise medicine who works with British Athletics. He has a keen interest in endurance athletes from 800m up to the marathon and is particularly interested in tendinopathies, stress fractures and associated medical problems.

References:

Rogers, J. Stress Fractures in Runners. BMC Newsletter.

Bennell KL et al.(1996) The incidence and distribution of stress fractures in competitive track and field athletes. A 12 month prospective study. AJSM 24:211-7

Kaeding CC et al.(2005) Management and return to play of stress fractures. CJSM 15:442-7

Pegrum J et al. (2012)Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ 344:e2511

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