Many high school runners at one time or another will experience pain in the shin region. Many times this condition is called shin splints. The term shin splints started about 30 years ago. At that time it was felt that the pain along the shin bone was due to one of the muscles pulling on the shin bone (tibia) and causing small little tears in the tibia. Although the terminology has changed, it is still the pull of the muscle that is often the cause of the pain.
The main muscle on the front (anterior aspect) of the tibia is the anterior tibial muscle. The muscle on the inner side of the shin is the posterior tibial muscle. Either one of these muscles will contribute to shin splint type pain.
Shin splints generally present as a fairly diffuse pain along either the front or inner side of the shin. There often is no swelling. Pain may be present at the beginning of the run and decrease as the run goes on or may be present throughout the whole workout. A better term to use is medial tibial stress syndrome (if the pain is on the inner aspect of the shin) or anterior tibial stress syndrome (if the pain is on the front of the shin).
If pain is intense and localized on the shin, you may have a stress fracture. More on this later. Although quite uncommon, it is possible to have a cyst or something similar in the tibia or muscle causing similar symptoms to shin splints, which is why I recommend at least an x-ray by the second visit.
I see a number of runners who think they have a stress fracture. A stress fracture is a small fracture in the bone that is usually caused by repetitive microtrauma, such as running. The problem is ascertaining the existence of a true stress fracture.
Some of you may have heard of bone scans. Bone scans use a radio active dye to detect bony turnover, which is present in a number of conditions in addition to a stress fracture. The problem I have found with bone scans is they are too sensitive. I have seen many runners with positive bone scans in areas that had no symptoms. If a bone scan is negative, then I can rule out a stress fracture. But a positive bone scan may not be definitive. You can and will often get different opinions.
I prefer to use the bone scan as an aid but not as a definitive diagnosis. Sometimes I will order an MRI, which may be a little more definitive in diagnosing a stress fracture. I sometimes may use a CAT scan, which if positive often means a stress fracture is present. However, if a stress fracture is truly present sometime in the future, usually within 2-3 months there will be some changes on a regular x-ray.
The bottom line with stress fractures and bone scans is that a positive bone scan may not always mean a stress fracture is present.
Medial or anterior stress syndrome is often caused by a combination of different factors. As such if you have shin pain consider looking at the following as possible causes:
- Faulty shoe gear. Worn out or improperly fitting shoes causing increased amounts of stress on the shin.
- Too much of an increase in training too soon.
- Unyielding surfaces, such as running many laps inside the school hallways. Although running on the street may increase strain on the shin, good running shoes do help control this.
- Muscular imbalance or weak anterior or posterior tibial muscle. This is usually not detectable and therefore I often recommend strengthening exercises for the involved muscle.
- Biomechanical problem. This is often the cause and includes anything from running form to a structural problem such as having one leg longer than the other.
- Mental. I have seen runners talk themselves into having shin splints. I can tell many stories about patients who had shin splints Sunday to Friday and then on race day had no pain.
Patients who overpronate or oversupinate tend to have a higher rate of shin splints. Pronation and supination can be confusing. Many patients think they are overpronators when in fact they oversupinate and vice versa. To truly explain pronation and supination is quite timely especially when you consider the fact that one part of the foot can pronate while another can be supinating. However, as a rule of thumb, if your foot rolls in a lot, you overpronate, while if your foot rolls out a lot you oversupinate.
Treatment includes identifying the cause and addressing it. Symptoms can be eased with ice massages before and after running. Advil or aspirin will help, but should not be considered a full treatment as prolonged use has many potential side effects.
Physical therapy, including whirlpool and ultrasound, should provide some relief. I use many different taping techniques. If you’re lucky you have a knowledgeable physical therapist in your school who knows these techniques. Proper shoes are needed. Strengthening and stretching the affected muscle is important. If symptoms
are prolonged, consider seeing a sports medicine specialist, preferably one who runs.
Sometimes the pain will disappear without treatment and then suddenly reoccur. I tend to be fairly aggressive in allowing patients to run. if there is no swelling and mild pinpoint pain, I have no problem letting someone run. As pain becomes more increased, my opinion will depend more on the patient than anything else. Every patient is different.
My philosophy is somewhat analogous to one of Bob Kennedy’s quotes, “running hurts.” The key is learning how to listen to your body and know when you’ve gone too far. The fact is, any doctor can tell you to rest and stop running and the pain will usually subside. The hard part is knowing when it is safe to run. But, there is no definite answer. So I’ll leave with this: remember running is supposed to be fun.
~ Dr. Ira Meyers