Shin splints are common among runners, race walkers and individuals who participate in soccer, football, lacrosse and dance. Shin splints are a non specific diagnosis for lower leg pain. One common cause of shin splints is periostitis. Periostitis is an inflammation of the periosteum. The periosteum is a dense connective tissue covering the shin bone or tibia. Periostitis results from an overuse injury that usually develops gradually over a period of weeks to months. Periostitis can also occur after one excessive bout of exercise. The periosteum serves as an attachment site for the muscles originating on the tibia. Muscle overuse causes the periosteum to pull away from the tibia causing inflammation. Think of the tibia as a bow and the muscles as the bow string. As you pull on a bow string the bow bends. As the tibia bends it causes pulling of the muscle attachment off of the tibia.
Periostitis of the tibia has also been classified as medial tibial stress syndrome. Medial tibial stress syndrome is associated with an overuse of the anterior and posterior tibial muscles. Both of these lower leg muscles have attachments via tendons to the foot bones. The origin of these two muscles is where you will complain of pain. The locations of pain are the lower inside half of the tibia and, less commonly, the upper outside portion of the tibia.
You will usually notice the pain when you start exercising and it decreases or goes away as you continue to exercise. Your pain maybe worse after you stop exercising or it will bother you the next morning.
The pain from periostitis of the tibialis posterior muscle is located on the lower inside half of the tibia. Abnormal foot and lower leg alignment can cause excessive flattening of the foot that requires excessive work from the posterior tibial muscle to help stabilize the arch. This stress causes microtears and inflammation in the periosteum attached to the lower inside half of the tibia. Custom foot orthotics along with proper running shoes are quite successful in treating posterior tibial muscle periostitis due faulty foot mechanics.
Pain from periostitis of the anterior tibial muscle is located on the upper outside portion of the tibia. Anterior shin splints often occur in both legs. Anterior shin splints is caused from over-training or improper training, especially, if your running program includes a lot of excessive downhill running or a sport requiring rapid starts and stops.
You may also have an imbalance between the weaker anterior muscle group and the larger and stronger posterior group. Tightness of the calf muscles may further aggravate this condition. These stresses result in microtears and inflammation in the periosteum attached to the upper outside portion of the tibia. Successful treatment includes modified rest with changes in your training program. Physical therapy to address muscle weakness, tightness and imbalance is paramount. Foot orthotics will be indicated if abnormal foot mechanics are the cause of the muscle tightness or imbalance.
In some cases of periostitis there can be a progression to micro-fractures or stress fractures along the tibia. Generally there is not a sudden break of the bone but usually you will complain of a gradual increase in pain until it becomes quite severe.
There are a number other causes of lower leg pain that can mimic periostitis. They include: tendonitis, a partial muscle tear, growth plate inflammation, referred lower back pain, lower leg muscle imbalance, a leg length difference and compartment syndrome.
Compartment syndrome can occur in muscles originating from the tibia. Muscles are surrounded by fascia which allows for a separation between adjacent muscles. This fascia does not stretch. Pressure within the muscles can increase due to activity. The fascia does not allow the pressure to diminish. This can lead to muscle damage and pain.
If you have shin splints a proper diagnosis via a thorough history and physical exam is essential to rule out causes other than periostitis.
Treatment of Shin Splints
Conservative treatment for periosteal injuries usually consists of rest, ice, immobilization, compression and elevation, physical therapy, foot orthotics and footwear.
- Rest or major modified activity
You need to dramatically reduce the frequency, intensity and time of your activity/exercise. This means you need to reduce the duration of your activity/exercise between 50 to 90 percent and doubling or tripling the time between your workouts. You can pursue cross training or try a different type of exercise such as swimming.
You cannot make the mistake of taking a few weeks off from you normal routine and then going right back to the same schedule without a reduction in training. If your activity is not modified your pain will return and it may become worse.
This is extremely useful for reducing the inflammation following a workout. You can apply ice for 10 to 15 minutes over the painful area as this will both decrease pain and increase healing time.
In some instances, if the pain in your legs does not respond to foot orthoses and physical therapy modalities immobilization will be required. Immobilization is accomplished with a removable or walking cast/boot or a non-removable fiberglass cast. The length of time of immobilization can vary between two to six weeks.
Compression bandages using Coban™ or Elastoplast™ taping prior to or following an athletic event or workout may be extremely beneficial. You can try a shin splint wraps such as a neoprene sleeve. Compression can help reduce recovery time.
- Leg Elevation
Elevation of your lower extremities above your heart can help to reduce the flow of blood to the legs and will help to reduce the inflammatory process. This can help to reduce pain and healing time.
Non Steroidal anti-inflammatory drugs
Oral drugs such as Ibuprofen or Naprosyn are very useful for reducing pain and inflammation during the acute stages. However, one the down side anti-inflammatory drugs do have the potential to cause stomach irritation, ulcers or kidney problems. Therefore, you should limit the use of these medications to the acute phase of the injury.
- Deep tissue massage
Deep tissue massage is useful technique for treating shin splints. You may be advised to seek deep tissue massage from a qualified physical or massage therapist. Deep tissue massage will be able to break down and smooth out knots in muscles or tight areas within the muscle. This will help reduce pain and prevent recurrence.
- Custom foot orthotics
The stabilization of any abnormal foot and lower leg alignment is crucial. If this goes unaddressed, you will continue to experience a recurrence of periostitis. Custom foot orthotics will address help address the underlying cause of posterior or anterior shin splints.
Your choice of footwear is also important since different running shoes and cleats/turf shoes have different degrees of support and motion control. After about 450 miles running shoes typically lose 30 to 40 percent of the shock absorbing capabilities. The tread may look fine but the capacity to prevent injury is reduced. Uneven wear patterns from one shoe compared to the other may also be an indication of abnormal motion in one leg. (Please refer to “How to check to see if your running shoe needs to be replaced”)