SaveYourself.ca •Sensible advice for aches, pains & injuries
 

Stubborn shin splints?

Shin pain is a common and often chronic running injury, yet poorly understood by most health care professionals.

Save Yourself from Shin Splints!

Causes and treatment options for shin splints explained and discussed in great detail, especially shin pain caused by myofascial trigger points, compartment syndrome, medial tibial stress syndrome, and stress fracture

22,000 words, updated May 15th, 2014 — What’s new?
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

Welcome to the most detailed exploration of shin pain available. This is not just a web page: it is an online book, about 18,000 words dedicated to the most scientifically current exploration of shin splints. The average orthopedics text devotes only a paragraph or a page to shin pain, and tutorials published in medical journals are usually no more than a few pages. Information available online is also scanty, and of generally poor quality.1

This tutorial is many times that long and thoroughly explores every common type of shin pain: the kinds of tissue failure involved, surprising scientific controversies and mysteries, plus the most neglected and underestimated factors in shin pain, crucial to understanding many difficult cases.

What works for shin pain? What doesn’t? Why? I can’t promise that the information in this tutorial will lead to a cure for your shin pain. However, I can guarantee that you will get a much deeper understanding of the subject.

I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about shin splints for a few years. Unlike several painful problems I write about, I’ve never actually had this one — my interest is purely geeky & professional. ~ Paul Ingraham
About footnotes. There are 71 footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.
Try one!

What are shin splints?

Shin splints is an extremely common problem in runners and running athletes and can be impressively complicated and stubborn.

Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.

from a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Daniel Lieberman, evolutionary biologist of “Born to Run” fame

And as many as 35% of those injuries are shin splints.23

Almost always called “shin splints,” but that’s a curiously old-fashioned term — like “lumbago” or “consumption.” Why does only shin pain get called “splints”?4 Because shin splints means shin pain — sort of5 — it’s a bit silly to offer it up as a diagnosis to someone complaining of shin pain:

“Doctor, I have shin pain.”

“Ah, you have shin splints!”

“I just said that.”

The term “shin splints” has multiple personality disorder: it might refer to nearly any of several problems that cause shin pain, depending on what you read or who you talk to. This extremely detailed tutorial aims to help readers, both professionals and patients, with all the different shin pain problems that get stuck with the label “shin splints.” It might have been easier to create a tutorial for each of those different conditions, but it is shin splints that people get diagnosed with and shin splints that people think they have — so this is a shin splints tutorial!

Which shin splints is the “real” shin splints: compartment syndrome, medial tibial stress syndrome, or stress fracture?

They are all “real” shin splints. People often mistakenly believe that the real shin splints is limited to just one of these. For instance, medial tibial stress syndrome — irritation and degeneration of the shin bone, and/or the soft tissue around it — is probably what most professionals think shin splints is these days. And it probably is the most common type of shin pain.

“Shin splints” is a curiously old-fashioned term — like “lumbago” or “consumption.”

However, it is definitely not the only kind! Until I studied this subject intensively, I believed that real shin splints was “compartment syndrome,” and other kinds of shin pain were just … well, just other kinds of shin pain. But I soon learned that there are actually at least three major, known and common kinds of shin pain, as well as some little known and rarer types, any of which may get labelled as the “real” shin splints, depending on who you are listening to. Effectively, shin splints really does mean any kind of shin pain.

The confusion about the naming of shin pain probably can be traced to the truly deep and cosmic mysteries that surround shin pain. Many cases defy easy classification. Either they seem to possess the symptoms of several different problems, or they actually are more than one problem.6 Many scientific studies of shin pain have created more questions than they answered. Diagnosis and treatment can be difficult, and some cases of shin splints are almost freakishly severe. There is almost no limit to how intense and stubborn shin splints can get.

The tibialis anterior muscle of the shin usually contains significant myofascial trigger points (muscle knots) — an under-diagnosed and under-treated factor in many cases of shin pain.

The tibialis anterior muscle of the shin usually contains significant myofascial trigger points (muscle knots) — an under-diagnosed and under-treated factor in many cases of shin pain.

Shin pain is routinely misunderstood and mistreated

SaveYourself.ca is devoted to education about pain problems that are often misunderstood and ineffectively treated, and for which there are particularly good-bang-for-buck opportunities for more effective treatment. Shin splints involve several issues that doctors and therapists are particularly uninformed about, and often fail to consider or treat:

  1. Few professionals understand how dangerous acute compartment syndromes are, and often fail to recognize them and give appropriate warnings to patients. This is a symptom of widespread ignorance about the causes of shin pain, and generally poor training among certain kinds of health professionals. If your physical therapist isn’t aware that some shin pain can actually be lethal, how well are they likely to understand a complex chronic case?
  2. Painful muscular dysfunction is a significant factor in many cases of shin pain, but this is almost always missed or underestimated — health care has a huge blind spot for muscle, and often ignores the role of muscle in injuries.7
  3. Tissue fatigue is another critical shin splints concept, and yet the majority of professionals have rarely or never thought of it in this way, thinking instead only of the mechanics of tissue failure instead of the chemistry (homeostasis).8 Many clinicians probably aren’t even aware that there is a major scientific controversy about this — as major as a controversy about shin pain can be, anyway.

There are no “shinologists” — for most professionals, shin pain is just one of a list of hundreds of common pain problems they deal with, and they are more or less completely unaware of the finer points of the subject, particularly recent scientific research. In many cases they only thing professionals know is quarter-century old conventional wisdom. Such significant gaps in professional knowledge make it nearly impossible for patients to find competent help for more severe and stubborn cases of shin pain.

How can you trust this information about shin splints?

I question everything and I have fun doing it. I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of shin pain. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 80 footnotes here), and I always link to the original sources.

Danger! Please do not try to run through shin splints! Acute compartment syndrome can be extremely dangerous!

Until you feel confident that you know which type of shin pain you have, you should assume the worst and avoid aggravating the condition. Why?

One kind of tissue failure in the lower leg — compartment syndrome — is extremely dangerous when acute. Compartment syndrome involves a vicious cycle which is not necessarily self-limiting (as many other injuries are). Once it starts, it may spiral out of control and literally kill the affected muscles, causing permanent deformity and disability at the very least, and even risk lethal infection. Triple yikes! This is absolutely serious, and quite unlike most other athletic injuries.

Although the pain is usually severe enough to stop people from running, some athletes may be foolhardy enough to try to keep going — if this is you, please stop! Rapidly worsening shin or calf pain absolutely must be treated like a medical emergency, and not just a cramp on your style. You are in danger of destroying your athletic career!

Compartment syndrome was Ken Hildebrand’s worst injury after being trapped for four days under an ATV. “My leg swelled up about four times the size of normal,” Hildebrand said.

Ken Hildebrand of Alberta, Canada, knows just how serious compartment syndrome can be. On January 8, 2008, Mr. Hildebrand was pinned under an all-terrain vehicle in the Rocky Mountains. He survived for 96 hours by eating rotting animal carcasses, drinking melted snow, fending off coyotes with a whistle, and thinking of his grandchildren.

But compartment syndrome was his worst problem!

My leg swelled up about four times the size of normal. And in order for blood to get through they have to slice the muscle so that it can drain and then they slowly let it repair itself. The leg is good now, I'm going to be able to keep the leg, but the foot is still iffy.

Ken Hildebrand on “As It Happens,” CBC Radio One, January 23, 2008

In Mr. Hildreband’s case, compartment syndrome was the consequence of trauma, and he suffered a particularly severe case of compartment syndrome, with extreme swelling. However, equally dangerous consequences are possible in runners who try to “run through the pain.” So don’t!

Reassuring concluding note: chronic compartment syndromes, by contrast, are relatively safe — frustrating and uncomfortable, but much less dangerous. Shin or calf pain that has been around for a while and isn’t rapidly worsening is pretty unlikely to be a serious problem.

Acute compartment syndrome is no joke

To treat acute compartment syndrome, the muscle compartment is sliced open to relieve the pressure. Tissue bulges like a hot sausage spilling out of its casing. The result is a massive surgical wound that takes months to heal and leaves substantial scarring.

Acute compartment syndrome is no joke

To treat acute compartment syndrome, the muscle compartment is sliced open to relieve the pressure. Tissue bulges like a hot sausage spilling out of its casing. The result is a massive surgical wound that takes months to heal and leaves substantial scarring.

Part 2

Etiology

What causes shin splints?

There are two ways of thinking about the “cause” of shin pain:

  1. the stress and risk factors that lead to it, and/or
  2. the nature of the tissue injury — which tissues are actually damaged and how.

For instance, you can say that shin splints are caused by excessive running on hard surfaces with an excessive ankle pronation — you might be wrong, but you could make that guess! — which then results in a lesion like a stress fracture in your tibia (shin bone). In this view, the lesion to the tibia is simply the actual mechanism by which overuse or overloading of the tissue finally causes pain, but the “root” cause is overloading.

Or it might be simpler to just say that your shin splints are caused by the stress fracture itself. Perhaps it’s overly simplistic, but it’s a valid point of view for a condition where the root causes and risk factors involve a considerable amount of mystery.

You can go either way here. Thanks to the labelling confusion, it’s really a matter of personal preference how to talk about it.

The main risk factor for shin splints: tissue overload

Only one major risk factor for shin pain is known with any confidence:

  1. excessive physical stress

Shin splints is routinely defined as an overload, overuse, or exercise-induced problem, and this is quite correct — it’s not the whole story, but it’s correct as far as it goes. Not every case of shin splints involves tissue overloading, but most probably do. It is the one thing that is probably involved in nearly every case and kind of shin pain.

This seems straightforward, but don’t be fooled: there are additional mysteries in why shin splints happen to some people and not others, and in which tissues it is actually affecting and how, and tissue fatigue has clinical implications that are often underestimated (and which make up a good part of this tutorial). Despite their willingness to define shin splints as a tissue fatigue problem, few professionals are willing to study it or treat it as a tissue fatigue problem. If overuse is the primary problem, then rest is probably the highest priority in recovery — but rest tends to be marginalized and underestimated as a treatment option, in favour of a wide array of “fancier” theories and therapies. Such as …

Introducing several other possible risk factors

There is considerable scientific controversy and confusion about the other risk factors and stresses that might cause or contribute to shin splints. They particularly include a wide variety of biomechanical problems — all kinds of anatomical, gait and postural issues, basically all concerned with one kind of “crookedness” or another — factors that are supposedly significant according to one expert or another, but which may or may not actually be. Such as (these are just a few examples)…

END OF FREE INTRODUCTION

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  • Free second tutorial! When you buy this tutorial, you will also get Save Yourself from Trigger Points and Myofascial Pain Syndrome! — a $1995 value. Myofascial trigger points (muscle knots) are an underestimated factor in many cases of shin pain. Basic treatment options for trigger points are provided here, but the full trigger points is available for readers who wish to know more.
 
TABLE OF CONTENTS PREVIEW
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Part 2.3

Appendices

Acknowledgements

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Reader Comments


One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.


What’s new in this tutorial?

This article was first published January 10, 2003. Minor changes were made over several years. More significant improvements were begun in August of 2007, when this change log was started, and it went through intensive development into an advanced tutorial in the spring of 2009.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 34 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Minor update (May 15 '14, section #3)Added a fun sidebar about a bizarre source of shin pain. See section #3, Diagnosis: How do you know which kind of shin splints you’ve got?

New section (Apr 2 '14, section #2.6)A new section mostly based on a particularly striking new treatment story from a reader. See section #2.6, A couple trigger point stories.

Science update (Dec 23 '13, section #2.8)Added another bad-news citation, and type of evidence. See section #2.8, The great pronation fizzle.

Science update (Dec 11 '13, section #3.3)I didn’t really ever expect a science update about tuning-fork diagnosis. But here it is! See the concluding footnote. See section #3.3, From high-tech to low-tech: the tuning fork test!

Minor update (Mar 29 '13, section #4.1)Upgraded risk and safety information about Voltaren Gel. See section #4.1, You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.

Expanded (Nov 29 '12, section #3.4)Added much more detailed self-help information for trigger points. See section #3.4, Confirming the role of muscle knots in shin pain by treating them.

Science update (Nov 20 '12, section #4.9)Weak but interesting new evidence on natural running and injury prevention. See section #4.9, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Minor update (Dec 13 '11, section #4.2)Addressed some common fears about the threat of getting out of shape while resting. See section #4.2, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Updated (Oct 16 '11, section #4.8)Added new references to fascia science, regarding the alleged relevance of fascial contractility to compartment syndrome. This is also supported by a substantial new free article, Does Fascia Matter? See section #4.8, Stripping: a popular massage techique for the shins.

Minor update (Sep 28 '11, section #4.10)Added reference to Kong et al, about the effect of shoe wear. See section #4.10, Running softly and the impact of impact: the not-so-significant connection between stress fractures and how jarring your running gait is.

Update (Aug 22 '11, section #4.10)Now officially endorsing Oesh shoes. See section #4.10, Running softly and the impact of impact: the not-so-significant connection between stress fractures and how jarring your running gait is.

Minor update (Jul 29 '11, section #1)Added a reference about the poor overall quality of online information about common injuries. See Starman. See section #1, Introduction.

Major update (Jun 21 '11)Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

New section (Jun 17 '11, section #4.10)Another substantial addition to the tutorial, the third in recent history. See section #4.10, Running softly and the impact of impact: the not-so-significant connection between stress fractures and how jarring your running gait is.

New section (May 3 '11, section #4.8)Another beefy new section for this tutorial, the second addition lately. See section #4.8, Stripping: a popular massage techique for the shins.

New section (Mar 20 '11, section #4.9)Finally, long overdue, a new section on this topic (for all the running injury tutorials). See section #4.9, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Important new info (Feb 8 '11)Where’s the fire? Recently I published a major new article about repetitive strain injuries (like shin pain), in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. This significant fact of biology is not yet given proper attention in this tutorial, and it should be. I learned the science of this myself only just recently, and it is going to take me a while to revise all of the tutorials and articles that are affected by it. Meanwhile the new RSI article is available, free to all, and I have also mentioned and linked to it where necessary throughout all tutorials. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

Minor upgrade (Dec 2 '10, section #2.4)Upgrade to the description of popliteal artery entrapment syndrome (PAES), which is often confused with compartment syndromes. See section #2.4, A more detailed looked at the six common types of shin pain.

Minor upgrade (Dec 2 '10)Repaired an alarmingly large batch of typographic errors. Amazing what slips through!

New cover (Aug 6 '10)At last! This e-book finally has a “cover.” SHOW

Minor update (Apr 7 '10, section #4.4)Added results of a study of in elite dancers. See section #4.4, Surgery for shin pain.

New section (Oct 1 '09, section #4.1)An important new section on anti-inflammatory medications, notably including discussion of Voltaren® Gel, a worthwhile treatment option for shin splints only recently got into my radar. You can read about Voltaren in a free article as well as here in the tutorial, but the tutorial covers the topic specifically as it relates to each of the different kinds of shin splints. See section #4.1, You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.

Major bibliography update (Jul 2 '09)Major bibliography update. The SaveYourself.ca bibliography has long been the largest of its kind. It contains an incredible amount of surprisingly readable information about musculoskeletal health science, and it is now possible for visitors to search and sort the bibliography with powerful new features. For instance, every source about shin pain referenced in this tutorial can now easily be displayed in a single search, with a variety of options.

Major upgrade (May 31 '09, section #4.11)Major miscellaneous improvements to the section today. See section #4.11, Stretching is probably mostly ineffective for all kinds of shin splints.

Minor update (May 18 '09, section #4.13)Added nutraceuticals to the section. See section #4.13, Brief debunkery of several other therapies that you should be skeptical of.

New section (May 17 '09, section #4.13)Starting off with just a few items. More will be added in time, but there’s four good ones to start. See section #4.13, Brief debunkery of several other therapies that you should be skeptical of.

New section (May 17 '09, section #3)No notes. Just a new section. See section #3, Diagnosis: How do you know which kind of shin splints you’ve got?

Huge upgrade (May 7 '09)About a dozen new sections, many more footnotes, and widespread editing for clarity and thoroughness. Today this tutorial is now officially “extremely detailed,” like the other advanced tutorials on SaveYourself.ca, and went up for sale.

New section (Apr 5 '09, section #3.2)New section to explain and highlight evidence from Gaeta about the high prevalence of microscopic bone damage found in long-distance runners. See section #3.2, MRI and CT scanning may be helpful.

New section (Apr 5 '09, section #2.7)No notes. Just a new section. See section #2.7, Bone tired: medial tibial stress syndrome is probably about bone fatigue, not inflamed soft tissue.

New section (Mar 16 '09, section #4.12)No notes. Just a new section. See section #4.12, Strengthening is probably also a completely ineffective therapy.

Major upgrade (Aug 15 '08)Several major revisions and corrections.

Update (Jan 27 '08, section #1.5)Added colorful anecdote from the Canadian wilderness to illustrate the seriousness of acute compartment syndrome. See section #1.5, Danger! Please do not try to run through shin splints! Acute compartment syndrome can be extremely dangerous!

Major update (Aug 6 '07, section #3.1)Clarified diagnostic information significantly by integrating important information gleaned from Edwards et al See section #3.1, A diagnostic algorithm (you know it’s good if it’s an “algorithm”).

Notes

  1. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
  2. Estimates run as high as 35% in some studies (see Yates), which found shin pain in more than a third of naval recruits at the end of basic training. This is the highest figure ever reported, but other studies have also reported quite high numbers. Shin pain clearly ranges anywhere from “pretty darned common” to “rather shockingly frequent.” BACK TO TEXT
  3. As are all knee injuries from the knee down. Ferber et al estimated in 2009 that about 80% of all running injuries occur in the knee and lower leg. 50% of those are in the knee, while “injuries to the foot, ankle, and lower leg—such as plantar fasciitis, Achilles tendinitis, and medial tibial stress syndrome (also known as shin splints)—account for almost 40% of the remaining injuries.” BACK TO TEXT
  4. Back splints, anyone? Shoulder splints? Head splints? I’ve been wondering about this little bit of language oddity for years now, but I still can’t dig up anything about the origins of “splints” and why it’s apparently exclusive to shin pain. BACK TO TEXT
  5. Batt. Shin Splints — A Review of Terminology. Clinical Journal of Sports Medicine. 1995. “Currently the term [shin splints] is used widely and variably, with little consensus of definition. Broadly, it denotes the occurrence of exertional lower leg pain …” BACK TO TEXT
  6. Edwards et al. A practical approach for the differential diagnosis of chronic leg pain in the athlete. American Journal of Sports Medicine. 2005. The authors of this paper describe several common lower leg pain problems (several of which are covered by this tutorial, and including at least three types of shin splints) and then comment that “symptoms associated with these conditions often overlap, making a definitive diagnosis difficult.” BACK TO TEXT
  7. The importance of muscle dysfunction is a recurring theme throughout this website. It’s not relevant to every injury, but it is involved to some degree in most kinds of injuries, either as a root cause or a significant complicating factor. I’ll explore this in much greater detail below. BACK TO TEXT
  8. Generally speaking, medical philosophy about overuse injuries is significantly bogged down by a simplistic over-emphasis on “mechanical” risk factors such as various kinds of crookedness. Shin pain is certainly blamed on a variety of common anatomical scapegoats (like excessive foot pronation), none of which have ever really been established scientifically. Much more about all this below! BACK TO TEXT

There are 63 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.


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