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
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about me • more about PainScience.com
Shin pain is a common and often chronic running injury, yet poorly understood by most health care professionals.
Welcome to the most detailed exploration of shin splints (shin pain) available. This is not just a web page: it is an online book, about 23,000 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; most web pages are brief and crappy, barely scratching the surface of the topic.1
This tutorial is hundreds of times longer 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 splints, but 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 79 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,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.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.
Shin splints is an extremely common repetitive strain injury 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.”
pro Strong enough for a pro But made for patients. The main text is user-friendly, but oodles of footnotes provide extra info and citations.
I do criticize many common practices and beliefs. If you disagree, let me know—I can take it, and I’ve made many changes over the years based on quality feedback.
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!
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.
Shin pain is routinely misunderstood and mistreated
Shin splints involve several issues that doctors and therapists are particularly uninformed about, and often fail to consider or treat:
Many professionals do not 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?
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
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
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 the only thing professionals know is quarter-century old conventional wisdom. Such large gaps in professional knowledge make it tough for patients to find competent help for more severe and stubborn cases of shin pain.
How can you trust this information about shin splints?
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?
Compartment syndrome — high-pressure swelling, fluid that’s trapped in a limb — is one kind of tissue failure that mostly afflicts lower legs.9 It’s 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 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.
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.
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.
What causes shin splints?
There are two ways of thinking about the “cause” of shin pain:
the stress and risk factors that lead to it, and/or
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:
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)…
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This document and all of PainScience.com 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.
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— New section: Added a great, practical new tip for diagnosing and predicting medial tibial stress syndrome.
— Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention.
— Minor science update: Citation of Collins 2008, a review of icing evidence (or the lack of it), plus related editing.
— Update: Careful and thorough editing/update of NSAID recommendations, especially with regards to safety.
— New section: Made a new section dedicated to other causes, after adding a science update about a fascinating example of a rare cause of stubborn shin pain.
— Correction: Reduced confidence in the results of a major study of special footwear (Knapik, the subject of the last update). See Boot Blooper for more information.
— New item: Added a brief but very well-researched review of platelet-rich plasma injection.
— Minor update: Added a fun sidebar about a bizarre source of shin pain.
— New section: A new section mostly based on a particularly striking new treatment story from a reader.
— Science update: Added another bad-news citation, and type of evidence.
— Science update: I didn’t really ever expect a science update about tuning-fork diagnosis. But here it is! See the concluding footnote.
— Minor update: Upgraded risk and safety information about Voltaren Gel.
— Expanded: Added much more detailed self-help information for trigger points.
— Science update: Weak but interesting new evidence on natural running and injury prevention.
— Minor update: Addressed some common fears about the threat of getting out of shape while resting.
— Updated: 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?.
— Minor update: Added reference to Kong et al, about the effect of shoe wear.
— Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman.
— Major update: 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: Another substantial addition to the tutorial, the third in recent history.
— New section: Another beefy new section for this tutorial, the second addition lately.
— New section: Finally, long overdue, a new section on this topic (for all the running injury tutorials).
— New section: 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.
— Major upgrade: Major miscellaneous improvements to the section today.
— Minor update: Added nutraceuticals to the section.
— New section: Starting off with just a few items. More will be added in time, but there’s four good ones to start.
— New section: No notes. Just a new section.
— Huge upgrade: 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 PainScience.com, and went up for sale.
— New section: New section to explain and highlight evidence from Gaeta about the high prevalence of microscopic bone damage found in long-distance runners.
— New section: No notes. Just a new section.
— New section: No notes. Just a new section.
— Major upgrade: Several major revisions and corrections.
— Update: Added colorful anecdote from the Canadian wilderness to illustrate the seriousness of acute compartment syndrome.
— Major update: Clarified diagnostic information significantly by integrating important information gleaned from Edwards et al
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
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
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
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
Batt ME. Shin Splints — A Review of Terminology. Clin J Sport Med. 1995;5(1):53–57. “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
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
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
Compartment syndromes outside of the calf are rare, because it’s all about plumbing: it’s harder to pump tissue fluid out of the lowest (most distal) large tissue compartments in the body. Once in a while there's a compartment syndrome in the forearm, because it has the same plumbing problem to a lesser degree. Compartment syndromes elsewhere in the body probably only occur in unusual circumstances involving very specific or serious injury. BACK TO TEXT
There are 70 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.