Shin Splints Treatment, The Complete Guide

So far I’ve discussed risk factors as “causes” of shin pain — the things that might cause tissue to fail. But which tissues fail? And how do they fail? When tissue actually fails, that’s what actually causes the pain. But one of the interesting things about shin splints is how so many similar symptoms can be caused by such different kinds of tissue failure. Of course, other body parts have a variety of ways they can hurt — shoulders have many ways to cause trouble, for instance — but in the shins there is an unusual combination of similar symptoms (ow, my shins!) with quite different tissue failure.

These are the types of tissue failure in shin splints, the immediate (proximate)25 causes of shin pain. Each will be discussed in more detail below — this is just an introduction to them. First, “the big four”:

1. myofascial trigger points (muscle “knots”)
2. medial tibial stress syndrome (and variations)
3. stress fracture (only one!)
4. compartment syndrome

And there’s also some less common and/or less shin-like issues:

5. assorted tendinitises of the lower leg
6. popliteal artery entrapment syndrome (“It’s a trap!”)
7. some nerve entrapments (“It’s another kind of trap!”), esp radiculopathy/sciatica (irritation of nerve roots in the lower back)
8. bone cysts (probably not your problem, unless you are 10 years old, see more below)

Any of these conditions can coexist, and I suppose it’s even possible that some extremely unlucky patient might have them all. The first item is not just capable of coexisting with the others, it’s inevitable: trigger points are present to some degree in almost all kinds of shin pain. For instance, if you had a case of compartment syndrome, it would be weird if you didn’t also develop some trigger points.

All of these are quite different, and will require separate discussion and different care, but fortunately there is also some overlap which is going to make this a bit easier — for instance, a well-designed resting strategy is an important treatment option (and almost universally botched) for nearly all of them. Although there may be several different types of tissue failure, lots of stress on the tissue is probably the only major risk factor that they all share.

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I will explore the nature of shin pain in considerable detail. I’ve already listed the main causes of shin pain above, but I haven’t explained them yet. In this section I will say a little more about each of them, and then I will get into even more detail in the sections after that.

So here’s the next layer of detail, starting again with “the big four”:

1. Myofascial trigger points (MTPs), a.k.a. muscle knots, are basically just “abnormal sore spots.” How they actually work is a mystery, the science is sketchy, and trigger point therapy is badly overhyped… but no one disputes that people get sore spots. They seem to crop up around other pain problems. They may be the actual source of some pain, and/or just a complication. They also have a tendency to mimic other kinds of pain problems: for instance, it might feel like a stress fracture, but it could actually be a trigger point. Their clinical significance is generally underestimated, even by massage therapists. I believe they are a factor in most shin splints cases. Trigger points are a huge, messy topic.
2. Medial tibial stress syndrome is an irritation of the connective tissue around the bottom half or third of the shin bone, the tibia. Its exact nature is the subject of a surprising amount of scientific controversy — is it a bone or soft-tissue injury, or a bit of both? No one knows for sure. Regardless of which tissues are involved, they are quite difficult to calm down once they are irritated in the first place, as with most other overuse injuries.
3. Stress fractures are the most familiar type of shin splints, and so easy to understand that little needs to be said to clarify their nature: the bone has begun to crack under excessive load. They usually consist of a hairline fracture of the tibia or fibula, usually in the upper half of the shin.
4. Compartment syndrome is caused by a “design flaw” in the human shins: the wrapping around the muscles on the front of the shin (think of a sausage wrapping) is a bit small for the stresses/traumas that its contents must occasionally endure. There’s no room for swelling! Pressure inside the compartment can rise sharply and interferes with normal circulation and movement of tissue fluids, which irritates the muscles even more, starting a potentially dangerous vicious cycle. Since it is common for runners to suffer irritation of the shin muscles, they often get this kind of shin splints. Another muscle compartment in the back of the calf may also routinely suffer the same problem, and can also cause shin pain.26

All of these major types of shin pain have something in common: they are all related to tissue fatigue. Most other causes of shin pain are more pathological in nature, rather than being caused by repetitive strain, and will be discussed more later in the context of diagnosis.

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I’ve introduced compartment syndromes in the conventional way: sometimes, when irritated, muscles in the lower leg don’t have room to swell, causing them to choke off their own blood supply when overused.

But nothing is simple in musculoskeletal medicine. There are problems with common assumptions made about compartment syndrome. Namely, that there’s pressure involved! In 2014, Franklyn-Miller et al argued persuasively in the British Journal of Sports Medicine that pressure does not seem likely to be the actual problem.27 Um, wut? Isn’t pressure the defining characteristic of this condition?!

To date, no conclusive evidence exists to demonstrate cellular hypoxic damage or decreased capillary perfusion.… no evidence of a direct association between this rise in compartment pressure and the pain and reduced muscle function

In fact, it’s not even clear that we can measure pressure in the muscle compartment. There are some problems with a classic paper on the topic,28 and “there is clear evidence that intracompartmental pressure measurement should no longer be considered a valid diagnostic tool for compartment syndrome.”

Ruh roh! So, if not pressure, then what?

A muscle overuse syndrome. Maybe caused by poor running form (exaggerated heel strike). Franklyn-Miller et al:

Muscle overuse syndromes are not new. They are well described in the literature, significantly in musicians and office workers (occupational overuse syndrome) and there is a clear synergy with the predisposing factors in repetitive exercise: increasing frequency and the intensity or load of work and practice; and, altered limb biomechanics alongside limited rehabilitative intervention. We believe that in patients with exertional leg pain related to the myofascial compartments we are simply observing a phenomenon seen commonly in other patient groups; that of muscle overload. As the aetiology in these patients is biomechanical we have described their condition as a ‘biomechanical overload syndrome’ (BOS).

If they are right, then compartment syndrome isn’t one of the main causes of shin splints — instead, what looks like compartment syndrome is probably just a blend of the other causes: some combination of tissue stress injury to bone, muscle, and connective tissue.

The idea of a muscle overload syndrome has a lot of overlap with “trigger points” in particular. Trigger points are a specific, speculative way of talking about what happens when muscles are chronically irritated (by overuse, and maybe also by underuse). And so Franklyn-Miller et al’s paper provides some support for a major focus of this tutorial, and some of its treatment recommendations.

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This might be the most valuable chapter of the tutorial, the best bang for your buck: the most evidence-based and clinically useful perspective on shin pain that your doctor probably won’t even bring up. I suspect it’s relevant to many cases, and leads directly to therapeutic options that can be surprisingly cheap and effective, with minimal fuss and risk. Pretty good stuff!

That said, it’s hardly The Answer: it’s just an easy, safe option to pursue. It’s not too good to be true, it’s just ordinary good — a reasonable theory about a tough problem, not a miracle cure.

The reason that the idea of trigger points is so important to shin splints: no matter what kind of shin pain you have, trigger points are probably involved to some degree. And they may also be the most treatable aspect of shin pain.

Muscle knots, formally known as myofascial trigger points (TrPs), are a factor in many of the world’s aches and pains. The case for this is made in detail in the trigger points tutorial. For much more information — all the information you could possibly want, really — see the PainSci trigger points guide, The Complete Guide to Trigger Points & Myofascial Pain. Just a few key points of trigger point science are emphasized here.

Most simply, a trigger point is an acutely sensitive spot with no obvious explanation — no injury, no disease, no venomous snake clinging to your leg. It’s just sore. These spots come and go in most people like pimples, and some people seem to be far more prone to them than others, probably because the dazzling complexity of biochemistry involves countless obscure variables and vulnerabilities. But they do seem to crop up more in and around overloaded and injured tissue and other pain problems. They are both a cause of trouble and complication of other troubles.

But we don’t actually know what a trigger point is.

The only widely known hypothesis remains unvalidated: a trigger point is a tiny spasm, a small patch of contracting muscle tissue that is exhausted and metabolically “toxic” or “sick.”29 Such a nasty patch of dsyfunctional muscle tissue can cause symptoms ranging from mild stiffness to severe pain and a variety of odd side effects. Even though the existence and importance of trigger points is well known to medical specialists and researchers, most doctors and therapists know almost nothing about them, so misdiagnosis and ineffective treatment are epidemic. And so is aggressive, overconfident over-treatment from professionals who think they knw far more about trigger points than anyone actually can know.

This hypothesis, and the whole topic of trigger point therapy, is controversial.30 There’s lot of hype and B.S. about trigger points, and way too many professionals now believe in them like religion, exaggerating their importance and cashing in on it. Although skepticism is warranted, my position is that the kerfuffle over the nature of trigger points is a legitimate, ongoing scientific controversy — not a closed topic. I believe that humble, conservative trigger point therapy is justified, but it must be presented as “experimental.”31

Trigger points and shin splints

Your shin is meaty. There’s a prominent bony ridge, of course, but there’s also quite a large muscle covering the lateral surface — the tibialis anterior muscle. It lifts the foot, and is a powerful arch supporting muscle as well — its tendon wraps under the arch like a stirrup.

The tibialis anterior muscle commonly develops a major trigger point. According to the conventional wisdom, it’s essentially a localized spasm, a small patch of contracted tissue that becomes metabolically swampy and painful. Regardless of the physiology of it, the tibialis anterior sensitive spot always forms in about the same location, in the top third of the muscle. This spot is “perfect spot #3.”

This trigger point probably precipitates compartment syndromes — it is probably often the first thing to go wrong in the compartment, and then aggravates pretty much everything that goes wrong in the compartment after that.32

What is more certain is that tibialis anterior trigger points complicate shin splints that are primarily caused by something else, and that they can be the entire cause of shin pain. Many people with shin pain may have only trigger point pain. And people with one of the injuries listed above will probably also have an acute trigger point that tends to make the situation worse. It is not unusual for such trigger points to result in chronic misdiagnosis.

Why is the tibialis anterior so dang “triggery”?

Trigger points are probably common in the tibialis anterior muscle because it is routinely subject to strong stresses, especially eccentric contraction.33 For instance, the tibialis anterior muscle will often suffer severe delayed-onset muscle soreness (DOMS) after hiking down a mountain, or running down a long hill.

When you are going down a hill, the toes have a long way to “fall.” The tibialis anterior contracts to resist and control the lower of the forefoot, preventing your it from slapping down hard. Similarly, when you are running on a hard surface and heel strike is sharp, the tibialis anterior must work extremely hard to prevent foot slapping. All of this probably predisposes the muscle to exhaustion and dysfunction.

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Terri Rebmann, a long-distance runner in St. Louis, was stopped by shin pain in 2007. When she first contacted me, she had seen “3 sport medicine physicians, 4 physical therapists, and a chiropractor” including an impressively credentialed physical therapist who specialized in “anterior tibialis pain in female athletes.” She was almost ready to give up and was considering exploratory surgery. Unfortunately, the possibility of a trigger point had never been suggested to her — not even by the tibialis anterior expert. She consulted me because she thought, “It’s worth asking one more person before I give up exercise forever.” Predictably (or I wouldn’t be sharing this), it turned out that a tibialis anterior trigger point seemed to be at least one important part of her problem:

I have started practicing trigger point release/therapy. I can’t say that trigger point therapy has completely cured my problem, but it’s helped tremendously! I am now running every other day, 6 miles or so per run. When I do have pain, it’s tolerable and the trigger point therapy/self massage helps. The pain is always gone by the end of the day.

Terri Rebmann, PhD, RN, CIC, distance runner, St. Louis

“White pain,” and then relief

This kind of story is amazingly common. I only use them on PainScience.com sparingly, because anecdotes are such a problem.34 That said, here’s another one that’s particularly spectacular. I’ve adapted it for brevity and anonymity with approval. Her story follows several weeks of shin splints during training for a half marathon, unresponsive to several attempts at self-treatment. And then things got more complicated …

I developed pitting edema35 in both of my lower calves. The shin splints were no better or worse, but this odd pitting edema just wouldn’t resolve. I tried wearing compression sleeves at rest, I tried wearing them while running, I tried wearing them immediately after running. I tried elevation, heat, ice, venous wrapping — nothing. No change. Nada.

Two nights ago, out of desperation, I got a ten minute massage on my calves (an option at the salon I go to). The Vietnamese gentleman that did the massage speaks zero English, so asking him questions is like playing a bad game of charades. My attempt to ask him to explain what he was doing exactly was an epic fail.

He looked at my calves, mumbled a bit, and then grasped my shins and stuck his thumb firmly into a spot about 3-4 inches above my inner ankles. I almost came unglued with the pain! It was what I would call as a nurse “white pain” — a highly unscientific term that patients really identify with. A lot of pain!

My Vietnamese shin whisperer did not let go, he just held on tight to that horrible spot on my shins as I tried not to squirm and cry out. When he finally did let go, he did some light foot massage and something odd using his thumbs again behind my knees (which did not hurt at all), but that was it. I went home, went to bed and that was the end of that … until I woke up the next morning.

The swelling was 100% gone. The shin splints were 100% gone. I ran six miles that next night without any pain, and zero return of the swelling. Its been three days, and I’m still miraculously pain and swelling free.

Just from pushing on a sore spot.

Stopped on a hill

I’ll conclude with a third anecdote of my own.

One day my right shin started to hurt quite suddenly walking down a steep hill in downtown Vancouver. I had been running the day before, and my shins were aching and tired: I could feel them struggling to keep my toes from slapping down with every step, and then it got intensely painful. In the space of a minute, it became nearly impossible to continue down the hill. I stopped twice and tried to “shake it out,” wiggling and stretching my knees and ankles, but it roared back with every step down the slope.

Clearly the pain wasn’t going away on its own. Honestly, I wasn’t sure how I was going to get home.

Or maybe I did know. I sat down on the curb and rubbed my tibialis anterior with moderate intensity for a couple minutes. I quickly found and focused on an area of exquisite “good pain” in the upper tibialis anterior muscle, the classic trigger point spot (I have already mentioned it a couple times, and I’ll describe it precisely later in the book). My suffering quickly eased, and I resumed walking down the hill with only a slight limp. Five minutes later, it was like it had never happened.

This was not “shin splints,” per se — yet. It was just a rapid and extremely brief flare-up of shin pain. But what if it hadn’t gone away? What if I hadn’t known what to do with my shins that afternoon? It might have gone away on its own, but I doubt it. There’s a strong possibility that it would have been the first day of a much longer, painful journey — days at least, probably weeks, and maybe months. It’s a bit chilling to think of all the suffering that I may have averted. But I knew where and how to press, apparently — not that it’s terribly technical — and the problem was nipped in the bud.

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None of these stories validate common ideas about trigger points, but they are suggestive, and I suggest that no one should neglect trigger points as a potential factor in shin pain. By no means can you count on a miraculous result — there are too many variables, and there is too much biology we don’t understand — but you have little to lose from learning a bit about it and experimenting cautiously. There’s more below about how to do that.

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Just as the pounding runners inflict on their shin bones can cause a stress fracture, it causes more subtle failure of the tissue first. Microscopic cracks and cavities form. The microscopic bone structure thins — this is called osteopenia, a milder version of osteoporosis. A “bone fatigue” injury.

In 2006, researchers found that 100% of the painful shins studied in long-distance runners had such abnormalities. 100%!36

CT scans of tibiae

On the left, a cross-section of a healthy tibia — notice how the bone texture is even. On the right, a damaged tibia in a hurtin’ long-distance runner, with uneven texture marked by dots.

That’s a strong piece of evidence. On the one hand, it certainly tells us that running is hazardous to your tibias. On the other hand, it’s surprisingly possible to have the bone fatigue and no symptoms: the same research also showed that a few runners without pain also had bone abnormalities — about 15% of them were running around with scannable flaws in their tibias, but no actual symptoms.

Imaging technologies often show problems in people who have no pain, and with some conditions this is an extremely important thing for patients to understand.37 In the case of shin pain, however, this study found only a few cases of painless abnormalities, and it’s reasonable to assume that such patients are simply in the early stages of shin-wrecking and will probably start to hurt before long. Such abnormalities are almost undoubtedly a warning sign of an impending tibial stress fracture.

Another important point to take from this evidence is the idea that shin splints doesn’t just/always involve “inflammation” of the connective tissue wrapping around the tibia — an old idea about shin pain — but can instead be “a bone stress reaction that has become painful” (that’s a quote from the authors of the study). Bone can ache with fatigue.

This might seem like a hair-splitting difference, but here are three practical implications off the top of my head:

• Superficial inflammation would might be more responsive to icing and topical anti-inflammatory medications. A bone stress reaction would likely be less responsive.
• If the superficial tissues are inflamed, then the tone of lower leg musculature would probably be a significant factor — because you don’t want tight muscles yanking on irritated attachments to the bone — but not so much if the main problem is bone fatigue.
• While a superficial inflammation of the periosteum would probably be sensitive to impact as well, it would probably be much less sensitive to it than bone fatigue. So this evidence suggests that reducing impact specifically might be important in recovery from shin splints. Much more about that below in the impact section.

But the difference between deeper bone and shallower periosteal fatigue isn’t huge, and they likely co-exist in many cases.

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A 2018 study flagged “peak braking force” as a novel new risk factor for medial tibial stress syndrome.38 It’s an interesting and noteworthy data point, though not terribly consequential — it boils down to being an extra reason to “soften” running style, a strategy that is discussed in considerable detail below: see Hitting the road: shoes, surfaces, impact, and the spring in your step.

Peak braking force (PBF) is a measure of how hard your feet push backward horizontally on impact. PBF spikes on the downhill, because forward movement is powered by both momentum and gravity (and resisted by friction). This is in contrast to vertical impact forces, which is the much more conventional thing to worry about. Thanks to gravity, measurements of vertical forces in running are much larger than the horizontal forces.

But the horizontal forces are definitely still there.

The trial was done in my backyard — in Burnaby, a suburb of Vancouver. Napier et al measured a half dozen running gait metrics in sixty-five healthy female recreational runners and then tracked them through a half-marathon training program. It was some fancy measuring, like motion-capture tech for the movies. The runners were festooned with reflectors and recorded while running on a treadmill.

About a third of the runners got hurt, and shin splints was the most common injury (followed by ITBS), but there was no statistical correlation with most of things they measured — most surprisingly “average vertical loading rate,” which was the prime suspect. The authors were looking for that specifically.

Instead, PBF was prominent in the injured! Extremely prominent.

Runners with the highest PBF scores were eight times more likely to be counted among the injured than runners with the lowest PBF scores. Eight times! It’s a correlation, not proven causation, but I don’t think that is “just” a correlation. That’s a big enough number that it’s very likely they are related in some way, and that way could certainly be causal.

Or not! Remember, causality is crazy hard to prove. A prospective trial like this is the bare minimum, but there are still definitely other possible common denominators, deeper roots that could be the cause of both high PBF scores and shin splints (see below).

So this is an interesting result that certainly looks like PBF could cause shin splints.

But it’s also a bit of an outlier in the literature, reporting a novel risk factor for the first time, based on data from a smallish study of women only, and measuring gait only on a treadmill, and there are other ways to explain the result. So there is definitely no guarantee that this result is going to be replicated by anyone else — and, a few years later, no one has even tried yet.

The authors reasonably concluded that braking force might be a good thing to try to reduce, and that probably can be done by running slower, “softer,” and with shorter steps (higher cadence) — stuff I have already been recommending in this tutorial for many years now.

If PBF doesn’t actually cause shin splints, then why are they linked?

Risk factors like this are correlations that might be explained by causation, but definitely not necessarily. Both risk factor and the injuries they are linked to can often be explained by something else… and so many risk factors are not causes, just fallible “indicators.”

So, if higher peak braking forces don’t cause shin splints, but they are genuinely correlated, then what do they have in common? What could cause both of them?

Physiology!

No one knows this, so I am just speculating, but here’s a hypothetical example. What if the real explanation for this 8× odds-ratio was a subtle tendency to fatigue faster? Which could easily be subtle, and have many possible causes, everything from illness to just a bit of mild but chronic sleep deprivation.

Fatiguing a bit faster than other runners could easily explain a change in running style that causes PBF to spike.

And many causes of fatigue could also easily explain a higher vulnerability to injury, independently of PBF.

Factors like this are systematically neglected in sports medicine. People specifically assume that sports injuries are simpler than they are, based mostly on an unjustified confidence that these injuries are basically “mechanical.” This illusion of knowledge keeps us from looking deeper. We fail to imagine other, messier, physiological, non-mechanical explanations for the data.

And that is a major reason why I am so reluctant to embrace structuralist explanations for shin splints (and much else).

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The significance of pronation is straightforward in principle: if your ankle is collapsing inwards a little when you run, it probably results in abnormally strong stress on the shin anatomy. This could be relevant to any kind of shin splints.

“Pronation” is the biomechanical bogeyman of runners, the anatomical monster under their beds. There isn’t a serious runner alive who hasn’t heard the term, and a fairly amazing number of them have been diagnosed as pronators and bought expensive orthotics and shoes to try to compensate for it. Historically, pronation has been blamed for basically every running injury, and quite a bit more (aches and pains in the hips and low back). Certainly the relationship between shin splints and pronation is one of the all-time favourite subjects for scientific experiments, and many such studies have found a correlation between overpronation and shin splints.

For instance, reviewed in 2009 by a research team at the University of Calgary, Reed Ferber, Alan Hreljac, and Karen Kendall.39 They looked at many dozens of studies, and tried to get a sense of whether or not the accumulated evidence is adequate to “blame” pronation for running injuries. And what did they conclude about pronation?

“No definitive answer can be put forth regarding potential running-related injury mechanisms and excessive foot pronation.” Ho hum. So, in over 250 studies of long-distance running injuries, there was “no definitive answer” about pronation.

Research that shows a “link”

More recently, as noted earlier, a couple big scientific reviews of risk factors for shin splints specifically did identify pronation in runners with shin splints, as measured by navicular bone height (“navicular drop”40).

And here’s one more I haven’t brought up yet: in 2014 — Neal et al were a little fussier, picked just 21 studies to study, and came to a more definitive sounding conclusion: they report “strong” evidence of a “small” risk.41 So, maybe something, but probably much ado about almost nothing.

What they identified there was a “link” between pronation and MTSS, not a causal relationship. Such findings have been (overwhelmingly) observations of simple correlation: runners with MTSS are more likely to have low-riding navicular bones.

What is normal anyway?

For what it’s worth, “normal” pronation range is approximately 6˚, give or take another couple degrees.42 Anything over 10˚ would be considered “over pronation” by nearly any clinician, and the further you go the more likely it is to be a real cause of trouble. However, as we have seen, the real clinical significance of over pronation is simply not known, and not likely to be great.

The pronation that we see in people could easily be normal, trivial anatomical variation and a big red herring. Podiatrist Ian Griffiths, one of my most expert sources on this topic, writing in 2012 (and I know his opinion on this hasn’t changed much):

[Overpronation] contributes nothing to our understanding — it is not definable, not reliable or valid, not diagnostic, its relationship to injury is not fully understood, and it does not dictate what the most appropriate management plan may be. It should not be replaced, it should be removed.

Ian Griffiths, Overpronation: Accurate or Out of Date Terminology?

Despite the numbers given above, a normal range of foot pronation has not been well established, and much of the research about pronation is based on assumptions about what “normal” is. Kind of puts an interesting perspective on all those times you’ve been told that you’re a pronator, doesn’t it? Compared to what? Chimps? Maybe a wide range of pronation is just how human beings work.

Causality and flat feet

The link between pronation and shin splints is weak, and there’s an excellent chance it’s not a causal link. People may not get shin splints because they over-pronate, but because they have something in common that makes them both likelier to get injured and likelier to have flat feet. And what could that be?

There’s at least one obvious candidate: one of the common and subtle connective tissue disorders. These conditions are routinely never diagnosed, so it’s highly plausible that they are a silent factor for many runners.

They are notorious for making people hypermobile in oddly specific ways, so they can also easily explain fallen arches. That explains A!

They are also notorious for making people prone to injury, so they could easily cause the injury. And that explains B.

So the flat feet and the injury could both be symptoms of that real cause — which is very subtle and basically never even considered.

Again, sports medicine and research needs more imagination about neglected X-factors, and more savvy about the relevance of general medicine to “simple” injuries. Although the pronation link suggests causality, it does not prove it by a long shot. It is the medical equivalent of circumstantial evidence in a courtroom — unconvincing, quite possibly not what it appears. It’s rare for experimenters to go to all the scientific trouble of even trying to prove cause. Ferber et al point out this weakness: only one study out of many dozens they reviewed “partially supported the speculation regarding a cause-and-effect” and “contradictory results were found in a study in which runners who had never sustained an overuse injury exhibited greater pronation.” That’s what you get when research isn’t built to sniff out cause-and-effect.

Pronation conclusions

The take-home message here is simple: with no clear research signal of a meaningful risk, it’s extremely unlikely that there is a strong link between pronation and shin splints. There might be a link, but it’s probably not a strong link, and it definitely isn’t necessarily a causal link.

Bear in mind that pronation has always been one of the most favoured of all possible risk factors for shin pain. We’re not talking about a particularly obscure or subtle theory here: this is something that the great majority of researchers and clinicians have “believed” in for decades now. For a long time, many cautious thinkers would have said that pronation was probably a factor in shin pain. And yet, when the evidence is reviewed, it’s just an unimpressive mess of contradictions.

Should you prop up your arches anyway?

I tackle this question below in a small section about orthotics. The bottom line (which won’t surprise you): it’s not crazy to try, but it’s not a good enough option to actually recommend.

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One of the most carefully conducted studies of risk factors for shin pain to date concluded that women were twice as likely to get shin pain as men (the study is by Yates et al, and we’ll be looking at it in detail in this section). It’s easy to look at a statement like that and think, “Wow, twice the risk, there really must be something to that! Women must have fragile shins!” But don’t do it. It’s a trap.

It’s a bit shocking how many doctors and therapists still tend to fall into that trap, treating women as if they are fragile and vulnerable, and so of course they get more shin splints — they just aren’t really built for running hard. Of course this obnoxious sexism is much less common than it used to be, but I guarantee it’s still out there.

Not only is that attitude obnoxious, the issue is much too complex to have such a dismissive, oversimplified view of it. Let’s look at this evidence a little more carefully …

The study was published in April 2004 by Ben Yates and Shaun White, of the Podiatry Department at the University College Northampton. To get their data, they studied naval recruits doing basic training. Soldiers (well, sailors in this case) doing basic training are always a good source of data about athletic injuries. One hundred and twenty-four recruits (84 men and 40 women) were studied as they went through basic training, to find out how many of them got shin splints, and to try to identify risk factors.

So how many got shin pain? And why?

As mentioned at the beginning of the tutorial, this study reported more shin splints than any other study, ever. An amazingly large number of recruits — thirty-five percent of them! — developed medial tibial stress syndrome.43 That’s significantly more than previous studies had shown. However, these particular recruits were also doing training that was pretty intense, more so than in past studies — apparently naval boot camp is more brutal than army boot camp! — so that might have a lot to do with the difference.

Shin splints is common!

35% of military recruits were diagnosed with shin splints. Most of them got it within the first four weeks of basic training.

Still, thirty-five percent … wow. That’s really a lot of shin splints.

The researchers were also looking at what the victims had in common, and they found two fairly strong factors shared by those with shin pain:

1. too much foot pronating, and
2. too much being a woman.

That’s right, once again researchers find evidence that suggests that women get hurt more easily: according to the authors, “female recruits had twice the risk of developing MTSS than males.” Over half the women developed symptoms of MTSS, compared to only 28% of the men. The authors write:

It has been shown that injury rates are higher when women train alongside men and are expected to achieve the same exit fitness levels … many female recruits reported that MTSS was precipitated when they had to “keep up” with male recruits while marching or doubling (jogging in step).

So, if women were allowed to exercise at their own pace, their injury rates might be identical — in which case they wouldn’t be “vulnerable” to shin splints in particular so much as they are vulnerable to overexertion. If for any reason men had to overexert to “keep up”, they would probably also have a much higher rate of shin pain. So, does this mean that women are actually more vulnerable to shin splints in particular? Probably not. It probably means only that women get more shin splints when they train with men.44 This is a pretty strong argument for women to run with women!45

And it’s probably not because they’re “wimpier.” It’s probably because women are, on average, shorter than men. (Not shorter than me — I am only 5’3", shorter than 99% of North America men, and at least half the women. My wife enjoys the fact that she is approximately one tenth of an inch taller than I am.) The significance of height is fairly obvious:

This may have resulted in overstrenuous gait changes with abnormally long stride lengths, thus increasing the risk of developing MTSS. This theory is supported by Jones et al, who found that the shortest 25% of women had a greater risk of injury than the taller 75%.46

What’s left of the idea of “feminine vulnerability” to shin splints now? Not much, of course. It’s not enough for the evidence to “kinda, sorta, maybe” support the idea. If the evidence isn’t quite strong, who needs it?

This is hardly a complete analysis, but my main point is made: that it’s a bit silly to “believe” that women are more afflicted with shin pain. It’s mostly just a great example of how confusing and complicated such issues can be, and how much disagreement there is even between experts.47 There’s no solid ground anywhere — except the ground your shins are pounding.

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Fascia is a polarizing topic, and many professional readers are going to have one of two reactions to the title of this chapter:

1. Excellent, he’s going discuss fascia! What took so long?
2. Oh hell no, he’s going to talk about bloody fascia? I’ll show myself out…

Sorry fascia lovers, but you’re not going to like this, but I encourage you to try to stick around for it anyway. Don’t treat this like a religious belief.

Those with reaction #2 will be appeased!

And for readers scratching their heads because they’ve never even heard the word “fascia”? Everything will be explained clearly…

The alleged general importance of fascia

The big controversial idea is that fascia — tough connective tissue wrappings around all muscles and organs — can get “distorted,” tight and restrictive, and it needs to be “released” by pulling on it artfully. Several prominent branded treatment methods are based on this idea, mostly since the 90s. Fascia is widely regarded as an exciting scientific frontier, with well-attended fascia conferences featuring gurus in the world of massage and manual therapy. Books have been written, empires built, and egos inflated. The word fascia is spoken with reverence and awe by a majority of the world’s massage therapists.

Fascia is a big deal. But it shouldn’t be. It’s one of the biggest red herrings in the history of musculoskeletal medicine. It’s much ado about nothing, a weird tempest in a teapot.

Although some fascia science may be inherently interesting as biology, no property of fascia has yet been shown to be clinically useful, no fascial pathology seems to be a factor in any common painful problem that we can do anything about, and no method of fascial manipulation is known to “fix” anything that’s allegedly wrong with fascia … or even change it. It’s very, very tough stuff.

I have challenged fascia fans to cite clinically relevant fascia science, with no result for years now. There are well-known studies of fascia’s toughness, its contractility, its involvement in soreness, its thickness in back pain, and much more. None of it actually confirms any clinical relevance of fascia, and some of it actually undermines it.

Even the “father of fascia,” Tom Myers, thinks that “now that ‘fascia’ has become a buzzword and is being used for everything and anything, I am pulling back from it in top-speed reverse… it doesn’t do half the things even some of my friends say it does.”

I’ve written extensively about this topic over many years. It’s much too big a topic to cover entirely here. For more information, see Does Fascia Matter? A detailed critical analysis of the clinical relevance of fascia science and fascia properties

Now, what about fascia and shin splints?

Some people believe that chronic compartment syndromes are a classic example of a “fascial distortion” — of a pathology caused by troubled fascia. Too tight! Alternatively, at the very least, even if the fascia is innocent and the problem is the swelling in a fascial compartment, it can still be treated by “releasing” the fascia — stretching or softening it, so that there’s more room.

Sounds great, but it’s probably all nonsense. There are several problems with this view, and some directly contrary evidence. Dahl et al’s 2011 experiment was quite persuasive.48 Basically they were looking for the fascial stiffness, tightness, or “distortion” in people with compartment syndrome, and found… the opposite.

They took tissue samples from the fascial compartment of the anterior tibialis muscle in several patients with compartment syndrome, several more who had both compartment syndrome and diabetes, and then some more from healthy individuals (for comparison, a control group). Although there was a lot of variability between individuals, on average there were no important differences, and in fact stiffness was 70% greater in the healthy patients — exactly the opposite of what one would expect to see if compartment syndrome was caused by stiff, thick fascia. The authors concluded:

structural and mechanical properties are unlikely to explain chronic compartment syndrome. To prevent chronic exertional compartment syndrome, it is necessary to address aspects other than the muscle fascia.

So fascial therapy for compartment syndrome is a treatment for a condition that hasn’t actually been identified. But even if it is…

Fascia is too tough to “release” anyway

Fascia is basically “gristle,” and while there are many variants and not all fascia is tough, the macroscopic fascial wrappings of muscle compartments definitely are. Trying to physically deform it49 would be like trying to stretch an oiled tarp through a blanket. Even without the blanket, even with good leverage, you couldn’t do it, because one of the most fascinating things about fascia is just how tough it is. Crazy tough!

This was shown in a now infamous study frequently cited to debunk fascia excitement.50 Chaudhry and colleagues showed that fascia is much too tough to “release” by stretching it. And that is consistent with well-established properties of fascia, namely that it’s extremely tough stuff. You cannot change the structure of fascia, because it is tougher than Kevlar. If the stuff were thicker, people would be bulletproof.

This is accepted even by prominent fascia gurus like Dr. Robert Schleip, who concluded in 2003 that plastic fascial change in response to moderate loading is “impossible to conceive.”51

Perhaps fascia can be “melted”? Some subtle effect? Now that’s just wishful thinking, or downright magical, with several absurd implications. If fascia could yield significantly or lastingly to any kind of touch, it wouldn’t be any good at its (tough) job of holding things together.

Bottom line: it makes no sense to blame fascia for compartment syndrome, or to try to change fascia as a treatment for compartment syndrome — except with a scalpel in an emergency, and more about that later.

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In 2005, Dr. Peter H. Edwards, Jr. published a paper in American Journal of Sports Medicine, offering a diagnostic algorithm to help simplify the process of identifying what sort of shin splints you have.52 He’s a doctor, so it’s not quite simple: as presented in the paper, the algorithm is impressively technical, complete with complex flow charts — you know something is good when it’s an algorithm and it comes with flow charts! All we need now is a laser pointer. (Shark-mounted, of course.)

Fortunately, although complex, Dr. Edwards algorithm is also excellent, and it can be boiled down to plain English quite easily … and that’s my job. Hopefully patients and professionals alike will appreciate the translation. So, here’s how it goes …

Patients can be neatly divided into two groups:

1. those who have pain when they rest, and
2. those who do not have pain when they rest.

Which are you? Having decided that, the remainder of diagnosing is fairly easy.

If your pain goes away when you rest, you probably have either:

1. compartment syndrome, or
2. impingement of a nerve or your popliteal artery.

If you have a very sensitive and specific spot in your lower leg, and you have tingling sensations, it’s almost certainly the nerve. If it’s hard to locate a specific tender spot, then it’s much more likely to be either a compartment syndrome or a popliteal artery impingement. Since compartment syndrome is much more common, and popliteal artery impingement often affects the calf significantly, I’m sure 99% of the people reading an article about shin splints can safely assume that they have compartment syndrome, not popliteal artery impingement. But you should at least know about the artery possibility.53

If you have pain even when you rest, then you probably have either:

1. medial tibial stress syndrome (MTSS), or
2. a stress fracture.

Both of these conditions tend to carry right on aching for quite a while after you stop exercising, and may even throb painfully when just sitting around at the office or at home. Telling the difference between MTSS and a stress fracture is relatively easy, fortunately: stress fractures are almost always in the upper two thirds of the shin, and MTSS almost always makes the bottom third hurt. These are not hard and fast rules, but good general guidelines. The difference can only be clinched by an X-ray (which can usually detect a stress fracture), or by CT or MRI scanning, which can detect bone damage even before it becomes painful — which is the topic of the next section.

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In Newman 2012, Australian researchers Phil Newman, Roger Adams, and Gordon Waddington discovered something quite clever: they could predict which healthy soldiers in training were going to get shin splints, with surprising accuracy, and they could do it with a simple pair of tests that anyone can perform.54 Tenderness and boggy swelling around the lower shin bone are basically a dead giveaway that MTSS is what you’ve got, or that it’s just a matter of time until you do. These are “pathognomonic” signs — strong, defining signs.

They did their tests on 384 soldiers, and the checked up on them over 16 months. Soldiers who were positive on both tests were eight times more likely to develop MTSS than if they were negative. Hardly any of the double-negatives got MTSS (a “negative likelihood ratio” of <0.001, which is super duper low). Each test was also predictive independently, but one of them much more so: although swelling was more rare, it was nearly as predictive as the two test combo. And they’re so easy there’s no reason not to do both.

Another key finding: three times as many women got shin splints. This has the odd, counter-intuitive implication that the tests are actually more reliable for men.

So what are these magical tests? Both are applied by hand to the lower third of the shin …

1. Press firmly and slowly with a fingertip along the inner edge of the shin bone. If it leaves a dent for more than a couple seconds, that’s “pitting edema,” and a positive test. This boggy tissue indicates that the area has been slightly swollen for some time. It’s such an easy test, check a few different spots to make sure you haven’t missed anything.
2. Squeeze the shin bone firmly. Your fingertips should be reaching into the muscular tissue behind the shin on the inside edge. The amount of pressure should be about the same as you would used to squeeze out a washcloth. If the squeeze is tender, it’s a positive test.

These signs are mainly about predicting, but they are also useful for diagnosing, because they are strongly associated with MTSS. These signs can help clinch a diagnosis of MTSS as opposed to the other causes of shin splints.

They also tell us something about the nature of MTSS: it smolders for a long time, up to several months and possibly much longer, before finally bursting into flame. On the bright side, this also implies that the legs can tolerate quite a bit of tissue trouble before becoming painful. And it’s also an excellent way to monitor progress in rehab, and risk in future years. Just keep checking!

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In any case where there are some diagnostic doubts — a common scenario with shin pain! — a scan may be quite useful in determining just how much of a factor bone fatigue is.

Medical technology can determine just how damaged your tibia is (or isn’t), long before it’s obvious. Bone scans, CT scans, and MRI scans can all reveal bone fatigue — the microscopic cracks and thinning which precede stress fracture, which I introduced above.

Bone scanning was previously considered the “gold standard” for detecting subtle abnormalities in bone. Bone scanning, however, is a fairly invasive and drastic procedure, in which a radioactive tracer substance is injected. Over several hours it gets into the bones, by which point you are practically glowing in the dark! A detailed picture of the bone can then be taken with a camera that detects gamma radiation.

Fortunately, bone scanning is now considered overkill for this kind of diagnosis. Studies like the one described above (Gaeta), and also Batt, have shown that MRI and CT scanning is just about as effective as bone scanning … and a lot cheaper and safer.

Indeed, they can show signs of problems developing in the tibia long before a stress fracture occurs, and even before you feel any pain. Not many runners are likely to seek out a CT scan before they are actually hurting, of course, but it’s interesting to know that you can detect problems before there’s pain.

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Here’s a simple and interesting test that you might be able to do yourself. It’s an easy test, but there is a catch: you have to have a tuning fork! Admittedly, not a lot of people have one of those just lying around the house these days. The tuning fork industry is not what it used to be, I bet. There’s an app for that.

Nevertheless, it’s such a good, quirky idea that it’s worth writing about. Briefly.

“Tuning Fork” by shaylor, CC BY-SA 2.0

To perform the test, simply hit a tuning fork and hold the butt against the middle of your shin bone or on your ankle bone. If the vibrations aggravate your shin pain, you almost certainly have a stress fracture! If it has no effect, you probably do not have a fracture.

Interesting, no? Alas, science says it probably isn’t very reliable.55 Shocker!

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It’s easy to get fooled: nearly everyone has a prominent myofascial trigger point (muscle knot) in the upper half of the tibialis anterior muscle. Just dig around with your thumbs in the upper half of the meaty part of your shin, and there’s a 98% chance you will find a deep, toothachy sensitivity. But … what does it mean? Is it the cause of chronic shin pain?

Treat it and see what happens.

Trigger points and general tissue sensitivity are common throughout the lower limb. Similarly, most people can easily find at least a few very sensitive spots in the calf, especially along the exposed edges of the leg bones, and at least some of those will be latent trigger points. It’s a “triggery” area.

The problem is that none of these trigger points are necessarily an important part of shin pain. It is quite possible for a person with no serious shin pain problem to have these problems. You can find out whether or not the trigger points you have are actually driving or complicating your shin pain by trying to get rid of them.

If you can find and treat a few key muscular trigger points in the lower limb, and your shin pain problem eases significantly, that’s pretty good evidence. Not perfect — the change in symptoms could be a coincidence, for instance — but good enough. And since it’s cheap and easy to experiment with self-treatment of trigger points, it’s a bit of a no-brainer to just go ahead and give this a shot. It’s remarkable how many cases of “stubborn” shin pain quickly vanish, or improve dramatically, with just a little treatment.

What exactly constitutes treatment for trigger points? A pill? Prayer? One of those things that Doctor McCoy would wave over people on Star Trek? Just stimulation, actually — changing the tissue state and neurological “equation” with a little rubbing. I’ll spell out the basics in another section below.

What if you fail?

Failing to treat shin pain this way does not mean that trigger points aren’t an important part of your shin pain — it might just mean that they are tricky to treat. Awkwardly, the worst cases of trigger-point-powered shin pain are actually the most likely to resist treatment. So we need some other ideas about how to evaluate this. Here’s a checklist. Check all that apply — the more you check, the more likely it is that trigger points are a significant factor in your shin pain.

• You have compartment syndrome, as confirmed by the diagnostic criteria above. Compartment syndrome is nearly always complicated by trigger points, much more so than MTSS or a stress fracture.
• When you press on sensitive spots in the tibialis anterior muscle, it doesn’t just hurt, but actually produces pain that feels a lot like your shin pain. Remember, that area will be sore on almost everyone — but if it’s the right kind of sore, if it feels like your shin pain, that’s good evidence that the trigger point is actually causing your pain. If you find the same thing with a spot elsewhere in the lower leg, that may be an indicator as well, but place less emphasis on this.56
• If you have foot pain, there’s a strong possibility that trigger points are involved, because tibialis anterior trigger points are notorious for causing foot pain as well as shin pain. Many people with shin pain also have some foot pain, but it may be significantly overshadowed by the shin pain, and gets overlooked as a diagnostic factor. Of course foot pain could be caused by many things, but it’s a good clue.
• If your shin pain isn’t particularly aggravated by impact, this could indicate that trigger points are more of a factor. Trigger points can cause pain on impact as well, but less so than MTSS and stress fractures, which are by their nature obviously very sensitive to being smacked around.
• If your lower limb feels particularly weak, stiff and heavy, this probably indicates greater importance of trigger points. Trigger points tend to cause these symptoms.
• If hot showers and baths seem to ease your shin pain, this is a strong indicator that trigger points are involved. Other kinds of shin pain will not generally be helped much by hot soaking, but trigger points will.

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Compartment syndrome can be extremely difficult to treat, especially once it passes a certain point. Severe cases like this will stop a runner from running or even walking without pain, and simply do not go away. If left untreated, a severe case of compartment syndrome can lead to starvation and death of the tissues, which you really do not want to happen.

Apart from this dire scenario, however, shin splints are much less ominous.

A hairline fracture, of course, can simply break the rest of the way. But usually, if rested properly, they will heal steadily.

Medial tibial stress syndrome and chronic compartment syndromes can be extremely persistent and painful, but will usually heal with enough rest. For an unlucky few, they can become extremely exasperating chronic problems requiring thorough experimentation with a variety of rehabilitation strategies and therapies. In the future, this article will be revised to provide extensive information for exactly these patients. Meanwhile, the self-treatment information below is adequate for mild and moderate cases.

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There are a variety of reasons why a case of shin splints might be unusually stubborn:

“Sneaky” stresses. It’s remarkable how often patients continue to engage in activities that they believe are safe, but continue to challenge tissues and retard healing. This topic will be addressed again below when we discuss proper resting strategy. Meanwhile, anyone with a difficult case should ask themselves: am I truly giving my shin the break it might need to heal?

Difficult trigger points. As discussed above, myofascial trigger points may be the entire cause of shin splints, or simply a complicating factor. In either case, they may be resistant to treatment: trigger points range from easy to treat all the way to nearly impossible, and no one knows why or how to predict how a given trigger point will respond to treatment.57

Abnormal anatomy. The most likely explanation for a stubborn case that usually won’t get diagnosed or even discussed by therapists and most doctors is that there may be something odd about your anatomy. We are not all created equal, and anatomical abnormalities can be at the root of many different kinds of problems. However, shin splints in particular is vulnerable to this problem. Did you know that there is actually a lot of uncertainty about what lower leg anatomy is even supposed to be like? Probably not — but there is!58 Even “normal” cases of shin splints and lower leg pain are often, by nature, caused by abnormal anatomy.59 But there may also be unique variations — abnormal anatomy that only you have 😃 — that is making your shin splints especially serious. There could be an invisible cause for your problem. For more information about this idea, see You Might Just Be Weird: The clinical significance of normal — and not so normal — anatomical variations.

Pain system dysfunction. Pain neurology and psychology is overwhelmingly complex and mysterious, and there are numerous subtle and poorly understood ways in which our interpretation of pain can become dysfunctional. See Pain is Weird for a primer on this subject.

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In addition to multiple causes of shin pain that are all accepted as different causes of “shin splints,” there are other things that can cause shin pain that are usually not considered to be sub-types of “shin splints.” But they could be mistaken for shin splints. What are some of these other possibilities? Just how many ways are there for shins to hurt? Fortunately, not too many more.

This is the first and last mention that most of these conditions will get in this book, but they do all deserve at least an introduction:

• Neuropathy causing shin pain usually involves the common or superficial peroneal nerves (almost the same thing). Like the notorious “funny bone” nerve (ulnar), they are somewhat exposed on the side of the leg just below the knee, and injury prone. Trouble with the sural nerve, on the back of the calf, is another much less likely cause of confusion; although it primarily affects the outer half of the back of the calf, symptoms may also almost wrap around to the front, causing some lower shin pain. Note that nerve entrapments can occasionally do a good imitation of a painful trigger point (deeper, aching pain), but usually they produce more classically nervy symptoms (electric and tingling).
• Tendinitis (yes, with an “i”60) of the Achilles, peroneal, or tibialis posterior tendons. None of these is especially likely to be mistaken for a shin problem, especially Achilles tendinitis, which is obviously on the back of the leg; still, with complications misdiagnosis is possible. Moving around to the side, the peroneal muscles and tendons might feel a little more like a shin problem, or a part of it, since you could certainly have a bit of both going on. However, most peroneal tendinitis is very ankle-y (outside). Tibialis posterior tendinitis is also ankle-y, but the inside, which is very unlikely to be confused with shin splints. However, even though the muscle itself is part of the calf, it is very deep, and discomfort in the muscle — which often goes with tendinitis — might be experienced as a deep shin pain.
• Popliteal artery entrapment syndrome (PAES) cuts circulation to the lower leg by pinching the popliteal artery where it passes through the back of the knee. It gets confused with compartment syndromes. It isn’t common but it’s not rare either,61 the most common of several ways that leg circulation can be impaired. It’s caused by an anatomical abnormality and/or scar tissue that forms in response to an overuse injury — so it can be provoked by running. The lack of blood starves the leg, resulting in a pale, cold calf and intense pain after athletic activity when demand for oxygen is greatest. Since the pain affects primarily the back of the leg, this problem is only occasionally diagnosed as a “shin splints” problem — it doesn’t seem very shin-y, and it doesn’t even really seem to make sense to call it a shin pain problem. It’s probably more common for genuine shin splints to be misdiagnosed as PAES than the other way around.

• Radiculopathy/sciatica is another kind of neuropathy — irritation of nerve roots exiting the lower spine.62 Nerve roots connect to skin and muscle in distinctive patterns, which aren’t very precise — lots of overlap and fuzziness,63 so the symptoms can be a bit unpredictable and unclear, and patients cannot reliably tell what’s radicular from location alone.64 But! The shin is roughly at the epicentre of typical radicular pain patterns. The most commonly affected nerve root (the fifth and lowest of the lumbar roots), causes symptoms (on average!) right in the “shinniest” part of the shin, and the effects of neighbours’ spread out from there, further to the inside (L4) and the outside (S1) of the leg.

  Radicular pain could also easily be worse during activities, sustaining the illusion of an “overuse” injury. And to really blow your mind, it’s even conceivable that mild chronic radiculopathy is actually responsible for the vulnerability of the tissues of the lower leg to developing an overuse injury in the shin — a root cause.

  Fortunately for diagnostic sanity, there are usually clear clues that you’re actually dealing with a back problem, not a shin problem. Not always! But usually. Radicular pain is more unpredictable and widespread than you’d expect from a leg injury. It also tends to be a “shooting” or electrical pain, plus some tingling, numbness, and weakness are also typical. The nerve roots most likely to be causing trouble can cause weakness and pain throughout the leg and lateral foot, and reduced or absent patellar and Achilles reflexes. If your patellar and Achilless reflexes are fine, it almost eliminates radiculopathy. Radicular pain is likely to be worse while sitting (and with changes in back position in general), another major distinguishing feature. And finally, you’re very likely to have some actual back pain — surprise! — and the back pain and the shin pain are likely to wax and wane in concert.

• Bone cysts are tumour-like growths. If you aren’t a kid with shin pain, and you don’t have one, you don’t need to worry about this at all. But, if you are, or you do …

  Unicameral (simple) bone cysts (UBC) are a common problem and completely unexplained — just one of those (damn) things. They mostly happen in kids (5-15), and mostly in the longest bones, usually the top of the femur or humerus … and, only once in a blue moon, a tibia. And they usually don’t hurt! And so it’s super rare for UBCs to imitate shin splints, because few of them occur in the shin, and only some of those are a problem. But they do happen! Sometimes even in both legs at the same time.65 They’re easy to remove surgically, and they can be identified with MRI … but who does an MRI for a stubborn case of shin splints? It’s a tricky diagnostic problem, for sure.66

• What about actual bone cancer? Not just a cyst? It can happen, of course, but it’s rare, and usually easy to distinguish from shin splints as it progresses — because it hurts much more, much more continuously, and more independently of exertion and strain.

• Proximal tibiofibular joint pain mostly causes lateral knee pain, and so it is more likely to be misdiagnosed as runners’ knee (the notorious iliotibial band syndrome) than shin splints. Although the injured PTFJ is not quite a knee joint and does cause pain below the knee, it is not nearly low enough for most people to think “ow, my shin” and actual misdiagnosis as shin splints is probably quite rare.

  However, I have encountered both of these diagnostic mistakes in my career. For example, one patient took his classic tib-fib pain to an orthopaedic surgeon who thoroughly and expertly assessed only his actual knee joint. When the patient said, “But doctor, the pain is below the knee! What about that?” The surgeon shrugged and said, “Oh, well, I can’t help you with anything below the knee. Might be shin splints?”

  In the eyes of a knee specialist, “below the knee” equals “shin splints” I guess. 😜

  All that said, there could be some people out there who have always thought their shin pain was rather high and lateral… and that could be tibiofibular pain. You can read more about it here: The Tibiofibular Joint and Knee Pain.

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A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.

This is a standard section in most of my books, covering several key points about placebo that are important context for any thorough discussion of evidence-based treatment options. I do not substantiate any of these points here — all the references are in a more detailed article about placebo.

• Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can collectively create the appearance of an effective treatment. Placebo is complicated!
• Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve pain than most symptoms, because pain is strongly modulated by perception. But that only goes so far.
• Placebo is not a magical mind-over-pain superpower and its effects tend to be minor and/or brief. It can’t affect injury and organic pathology; it can only tinker with our experience of them.
• Placebo can also backfire. When a placebo effect wears off — as it usually does — people often fear that they must be really screwed, and then placebo turns to nocebo, placebo’s evil twin: feeling worse because of belief.
• Placebo potency is driven by whatever impresses the patient with the seriousness and legitimacy of treatment: risks, costs, size, intensity, technology and even odd minutiae like the colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is all about putting on a show.
• One of the best ways to impress people is with novel and intense sensations, because the patient can feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are sensation-enhanced placebos (“interactive therapy theatre”).
• Placebo has been hijacked and re-branded for its public relations value to alternative medicine. If your treatment isn’t evidence-based, no worries: you can still sell the power of placebo! “The power of placebo” is widely, weirdly used as a justification for therapy that can’t beat a placebo.
• Placebo does not work when you know it’s a placebo, contrary to what many people have heard (based on a couple bad scientific papers). The popular idea of “placebo without deception” is just bullshit, based on an experiment that created a strong expectation effect by inflating the participants’ expectations of placebo. So it was just an odd way of getting to the same phenomenon.
• Many snake oils supposedly work on animals, and if animals are immune to placebo then the treatment must be legit. But animals (and their biased human observers and caregivers) are definitely not immune to placebo. In fact, with animals there is even more opportunity for an illusion of a treatment effect.

We have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo.”

Book Review, Unlearn Your Pain [Schubiner], by Scott Alexander

Is it okay to pay for a placebo?

Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment, raised in most discussions about a treatment that failed to beat a placebo in a fair test (invariably overlooking the fact that neither the treatment nor the placebo actually work very well).

I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely you are to get even a minor benefit.

And paying for things is never completely harmless.

Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placebos to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. I’m gambling on getting a genuine benefit, with a bit of placebo as a consolation prize. So, for me, the plausibility has to be there.

Comic by Loren Fishman, HumoresqueCartoons.com.

What I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.

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Most drugs work on only about a third of the population, they do no damage to another third, and the final third can have negative consequences.

Craig Venter, extremely famous and spooky smart geneticist (public lecture, Vancouver, May 3, 2011)

Vitamin “I” — ibuprofen, the main ingredient in drugs like Advil and Motrin — is an almost universal treatment choice for shin pain (and, of course, every other repetitive strain injury). The drugs ease inflammation and fever, and the injury seems to be inflamed, so it’s a perfect match! Or people just take them because it’s a pain-killer and they have pain to kill. For one reason or another, nearly every patient and professional assumes that NSAIDs are at least somewhat helpful, though few are foolish enough to think it’s any kind of a cure.

In fact, the NSAIDS are probably one of the weakest treatment options — because of course repetitive strain injuries are not actually very “inflamed,” per se.

Scientific evidence on this topic has always been scarce and discouraging,67 and even the anecdotal evidence for ibuprofen is weak. I’m sure there are some testimonials for ibuprofen — there are testimonials for anything. But consider: even though ibuprofen is probably the first or second line of defense for virtually every case, the world is clearly still full of serious, chronic shin pain … that ibuprofen could not stop.

NSAIDs may have more relevance to some kinds of shin splints than others, though — more than just pain control. Reducing inflammation cannot cure damaged tissue — it can only reduce the intensity (pain) of inflammation. But sometimes inflammation is most or all of the problem, so taking the edge off it might be better than just a little symptom control. Compartment syndrome is probably the best example …

Compartment syndrome — Compartment syndrome is defined by swelling. If that swelling is part of an inflammatory response — which it often would be initially — then eliminating the inflammation early on has the theoretical potential to actually solve the problem, by controlling the swelling. However, as the problem becomes chronic, the “chemical profile” of the compartment probably looks less and less inflamed, and more and more like it’s just suffocating — a more serious situation that NSAIDs can’t touch. Probably NSAIDs aren’t miraculously curing many cases of chronic compartment syndrome, but it might be surprisingly helpful in the early stages.

Medial tibial stress syndrome and stress fracture are painful but relatively stable conditions. If you can control the pain with NSAIDs, that would be pure win: eliminating the symptom would cure the problem as far as the owner of the shin is concerned. But NSAIDs aren’t likely to work that well, the shin would remain in danger regardless, and there are reasons to avoid NSAIDs even if they work (coming up below).

Trigger points — Muscle pain does not seem to be inflammatory by nature. Muscle knots (trigger points) are more like poisoned muscle than injured muscle. Although there’s some anecdotal evidence that taking an anti-inflammatory medication might reduce muscle pain a little, mostly it doesn’t seem to work very well.

So NSAIDs might be useful, depending on which kind of shin splints you have. But they may miss the mark in principle, and they also have limits where they are relevant. Their primary limitation is simply that there is only so much inflammation that they can control, even when that’s worthwhile.

And then there’s the bad news.

NSAID chemistry may be mostly irrelevant to the chemistry of shin pain, but it gets worse: they may actually interfere with recovery from the connective tissue degeneration that actually is the problem, because NSAIDs retard soft-tissue healing. Just what every RSI victim needs! (Fortunately, they don’t actually damage connective tissue, like steroid injections. Probably.) There’s no direct evidence that NSAID use will impede recovery from any type of shin pain… but it’s possible.

And it gets even worse! NSAIDs are also well-known as “gut burners” for their disagreeable and common effects on the gastrointestinal tract, which is a deal-breaker for many patients. And they can, paradoxically, actually cause headaches.68 Oh, and one more thing: they increase the risk of strokes and heart attacks, even in healthy people, at any dose. (Diclofenac [Wikipedia], a popular oral NSAID almost everywhere on Earth but North America, has even worse cardiovascular side effects than the others.69 Oral diclofenac specifically should probably be banned.) Lovely!

A drug is a poison with potentially beneficial side effects.

Dale Favier, Massage Therapist, poet

I know some readers are thinking right now, “Yeah, well, okay … but I’m still going to take my Vitamin I.” With dosing caution — small doses, short-term use — I have no serious objection. If there’s any reason to take them, it’s that they might relieve some pain by unknown mechanisms (the inflammation question is not exactly simple).

Or — and this seems almost crazy, I know — you could just actually heed the science, ignore the conventional “wisdom,” and never bother popping another NSAID unless you’ve got some uncomfortable classic inflammation to take an edge off. Imagine two NSAID scenarios …

• The (not-unlikely) worst-case scenario: slowed healing, aggravated pain, GI tract upset, increased chance of a stroke or heart attack, waste of valuable seconds popping pills.
• Best-case scenario: temporary modest pain relief, no side effects.

Speaking of dosing caution: why soak your whole system with NSAIDs just to reduce inflammation in one small area?

Voltaren Gel — not exactly a magic bullet, but probably safe, reasonable & worth a shot.

Voltaren is basically another NSAID (diclofenac) in a tube, and a relative newcomer to the range of options. Because you smear it on and it’s absorbed through the skin, you don’t have to carpet bomb your entire digestive tract and circulatory system with the stuff to get it to the problem. This significantly reduces your overall exposure to the risk of the side effects mentioned above70 — but you still get an adequate dose into the tissue with the issue.

Another reason that Voltaren is interesting and well worth bringing up here: it would never have been approved for sale if it didn’t have some genuinely persuasive evidence attached to it. The stuff actually seems to do something for arthritis pain — pain that probably has much more in common biologically with RSIs. So we’ve got something like a shred of a reason for optimism here and greatly reduced risk. Yahtzee!

• Worst-case: It could be just as much of a chemical clean miss as any other medication, in which case you’re basically just smearing expensive Vaseline on yourself.
• Best-case: It could actually provide some real pain relief, with a very low risk of side effects.

To wrap this up, here’s comedian Louis CK satirizing a doctor talking about the painkiller dilemma: “Oh, it’ll do some intestinal damage after a while. But you’ve just got to weigh that against how much you like your ankle not hurting!” This is a short excerpt from his 2008 stand-up show, Chewed Up, which is well worth buying.

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Rest is the most important and misunderstood and neglected treatment option for all of the big four types of shin splints. It is particularly essential to rest adequately before proceeding with any other vigorous rehab exercises, especially strengthening.

Almost everyone tries “taking it easy for a while,” and that will certainly help or even outright solve the majority of minor cases. And yet for many serious and chronic cases, the patients I talk to have rarely done much more than that. It is routine for me to encounter athletes who insist that they have “tried resting” who have not actually done a good job of it, both because athletes tend to be lousy at taking it easy — and I am speaking as an athlete with that problem — but also because no one has ever explained to them what a good resting strategy actually consists of.

I do not mean to portray rest as a miracle cure for shin pain. However, it is cheap and safe and can be much more effective than most people realize. It is well worth trying thoroughly and properly before resorting to any other costly or riskier treatment option, especially surgery.

Stress fractures are more or less completely resolved by adequate rest — obviously. If you rest thoroughly enough and long enough, almost all stress fractures will heal. If it doesn’t seem to, it’s probably because it coexists with a case of MTSS or a compartment syndrome, which may be less responsive to rest. Nevertheless, even serious MTSS too may ease dramatically with adequate rest.

Trigger points are unpredictable in their response to rest. To the extent that muscle dysfunction is a factor in your case, rest may help — it’s worth a try. But so many factors determine how stubborn a trigger point is that it is hard to know what it will do. Whereas the other kinds of shin pain are more or less directly the result of overuse, trigger points may be present for other reasons, and so they may not disappear when the overuse is removed from the equation.

Most readers of this tutorial are already well into chronic pain. However, for future reference, if you start to develop shin pain while running or during any sport, reduce your activity intensity immediately. If it persists, stop altogether for 3-10 days, possibly more for the most ominously painful cases. There is good evidence that a major risk factor in developing overuse injuries is trying to push through the pain.71

What constitutes a “good resting strategy”? Here are some key concepts that often get missed …

The envelope of function is a graphical expression of your tolerance for tissue stress. Too much stress, too fast, and tissue will fail — that much is obvious. What almost everyone misses is that overuse injuries collapse the envelope of function. Once you have exhausted tissue’s capacity to absorb punishment, your tolerance for additional stress collapses. Suddenly, things that used to be no problem at all are capable of causing pain, or (insidiously) just keeping your tolerance low. This is how “taking it easy” fails: you take a break from running, sure, but not from walking or a dozen other “easy” activities that are nevertheless stressful enough to perpetuate the injury. The basic lesson here is that you can’t just rest from the activity that hurt you in the first place — for a while, you have to rest from anything that might be aggravating the tissue.

In the case of shins, this means you also need to avoid walking — even if it’s not obviously painful.

If that sounds like a tall order, it is. That’s the point: proper resting is a pretty substantial commitment. It’s also well worth trying. I have seen many recoveries from overuse injuries that seemed to come from applying primarily this one principle. And it’s hard to imagine an injury where the need is more obvious than in the case of most kinds of shin pain, which are so obviously caused by overexertion.

The fear of resting. Especially among runners and athletes prone to shin splints, there is a very common, nervous objection to the suggestion to rest thoroughly: the fear that you will “go to pot” or get critically out of shape. It’s true, you can lose your athletic edge pretty quickly. Optimal, competitive fitness takes hard, constant maintenance. But you lost your shot at maintaining optimal fitness the moment your shin started hurting, and you aren’t going to get it back until it stops.

You certainly won’t “go to pot” in a month. Or two. Or even six. All the more so because there are plenty of ways of continuing to pursue fitness while protecting your shin(s). But you certainly will go to pot if you never heal. First things first. It takes what it takes. And the only thing worse than having to rest for a while is failing to heal entirely. In general, you have to be healed before you can maintain or develop fitness, let alone optimize it.

If you’re specifically worried about gaining weight, there are many experts saying loud and clear that calorie intake is by far more relevant to fatness than exercise. Do your best to eat less when you’re not exercising (and of course that’s not necessarily easy).72)

For more about good resting strategy, see The Art of Rest.

Here’s a diagram I’ve borrowed from my tutorial on PFPS. It plots three examples of stressful activities on a graph: falling on your kneecap, a marathon & a hike. Each of them is outside the “envelope of function” — either too intense, or too sustained, for the tissue to tolerate. The “envelope” is the space on the graph where you can tolerate the combined intensity & duration of stress. After injury, that space shrinks!

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If you have compartment syndrome, don’t just rest: rest with your feet up.

Elevating the affected leg is a crucial component of self-treatment for compartment syndromes. Getting the lower leg above the heart greatly facilitates venous blood flow, lymphatic function, and reduction of the swelling in the compartment that is fundamental to the problem.

So put your feet up!

Anyone with compartment syndrome should be integrating elevation into their treatment plan. Every minute that you spend with your affected leg elevated reduces the pressure in the compartment and gives the tissue more opportunity to return to homeostasis. It is well worth experimenting with long periods of elevation, 30 minutes and beyond, to see if “more is better.” It may be, it might not be, but it’s certainly worth trying.

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Countless articles online (I tried to count them and failed) say exactly the same thing: you may have to consider surgery for your shin splints, if conservative therapy doesn’t work. That’s basically true, but it leaves one wanting more — and, when I write a tutorial, I try to offer a little more. What’s involved in surgery, and what evidence is there that it will help?

As always, when I write about surgery, I am out of my depth — I am no surgeon. This section is a survey of the basics, referencing and interpreting the work of the real experts. It’s more than you can easily find on your own trolling the internet, but it’s hardly a complete, in-depth analysis of the subject either. Naturally, you should always consult an orthopedic surgeon — if not three of them — before making any decisions about surgery.

Surgery is indeed a useful option for chronic cases of MTSS and compartment syndrome. It’s also usually the only serious option for the two not-quite-so-common causes of shin pain: artery and nerve entrapments. It has no relevance at all to stress fractures or to cases dominated by trigger points.

For MTSS, there are only two somewhat recent scientific papers that give us any guidance, but fortunately that guidance is fairly clear: a study of about 75 patients done in 2003,73 and an even smaller Swedish study with similar results.74 See the footnotes for the full abstracts.

Medial tibial stress syndrome. Surgery for MTSS is a fasciotomy, in which irritated connective tissue is cut or scraped from the bone and allowed to regrow in a healthier state. Although Yates et al report that “outcomes of surgical treatment of this condition have varied” in the past, nevertheless they found an excellent, good or fair result was achieved in all but 9% of the legs they operated on. They concluded: “Surgery can significantly reduce the pain associated with medial tibial stress syndrome.”

The 2007 Swedish study was only half the size, and results weren’t quite as good, but still enough to raise eyebrows: 65% of their patients improved.

Despite some promising results, I think the real message here is twofold:

• We still know very little about how to operate on this condition and whether or not it works. Like so many of the injuries I write about, we are basically still in the dark ages — we really do not have the evidence yet.
• It’s not risk free. Surgery is never risk free. In both studies, some patients had negative outcomes — they got worse, not better.

So surgery could be a viable option for MTSS, but it is an option that should not be considered until all other options have been exhausted.

Compartment syndromes. For patients with a confirmed diagnosis of chronic compartment syndrome, surgery is likely to be the only realistic choice. However, fortunately, it is also a straightforward and effective one. In 2008, Derek Farr and Harlan Selesnick wrote in American Journal of Orthopedics that “Most [compartment syndrome] patients do not respond well to nonoperative intervention. Fasciotomy provides satisfactory relief of symptoms and helps patients return to their sports.”75

Note that I also think it is worth experimenting with the relatively cheap and easy option of trigger point therapy for a compartment syndrome, especially for the tibialis anterior muscle. I have almost no direct experience with success stories of this nature — compartment syndrome is rare enough that I have had relatively little experience with different treatment methods and outcomes. But it’s plausible and reasonable, and the low stakes certainly make it worth a try before resorting to surgery. More about this below in the trigger point treatment sections.

Stress fracture. Tibial stress fractures are not generally regarded as operable, because they can usually be treated without it. However, for the rare cases where a stress fracture is not healing, surgery is an option, and a 2009 study of elite dancers in the American Journal of Sports Medicine found that surgery worked quite well.76 Between 1992 and 2006, seventeen hundred dancers were evaluated at a dance medicine clinic; only 24 of them had stress fractures (not many), and conservative therapy had failed in only 7 cases. Those dancers were operated on: their fractures were stabilized with “drilling and bone grafting or intramedullary nailing” — good old carpentry-style surgery! They did well — shins that had previously refused to knit finally knitted. Recovery was slow but steady in all cases, and they were all dancing normally again by about the six-month mark.

Popliteal artery entrapment. Surgery for popliteal entrapment syndrome is effective. A 2009 study in Journal of Vascular Surgery found that 43 patients, “under general anesthesia, all had excision of the soleal band, with relief from symptoms.”77 The trick is simply being diagnosed correctly in the first place.

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If ice can help a repetitive strain injury in any way beyond brief numbing, no one has ever actually proven it or shown how it might work78 — an ordinary, common home remedy that science has almost totally ignored. We can only speculate.

Icing shin splints may be helpful for MTSS and compartment syndrome particularly. The purpose of icing is to reduce inflammation, which is likely to be present to at least some degree in both of those conditions. Even if there is minimal inflammation — remember, there’s some scientific debate about how much “inflammation” per se is really involved (in MTSS in particular) — icing is so cheap and easy and safe that it’s probably worth experimenting with.

For MTSS, focus your icing along the inside edge of the tibia. For anterior compartment syndrome, focus on the meaty front of the shin. Apply raw ice in strokes for about three minutes or until you’re numb, whichever comes first. See Icing for Injuries, Tendinitis, and Inflammation for more information about icing technique. The only safety concern is to avoid over-icing in one session, which can “burn” the skin.

I think that “power icing” — many sessions of icing — has some chance of working in cases where ordinary amounts of icing might fail. You should particularly consider this strategy if you find icing in smaller doses has an obvious benefit — if so, it’s well worth trying a larger quantity of icing. There is no scientific evidence to support this theory, but I have a few reasons to believe it might work, and there is little harm in experimenting with it. To ice intensively, simply do a large number of icing sessions per day for three days: that’s at least 15 sessions, three days in a row. If this has no effect, the experiment is complete and you can safely assume that power icing is not going to work for you. On the other hand, you may find that it helps enormously!

Stress fractures are unlikely to be helped much by icing. The bone is going to heal in its own sweet time, with or without ice. Ice is unlikely to do anything for a stress fracture except temporarily relieve pain.

Cases dominated by trigger points are unlikely to respond well to icing. Trigger points, as a general rule, do not like to be chilled. There are exceptions, due to the complex array of physiological variables, mostly unknown, which affect the acuity of trigger points. By contrast, they do tend to like heating. This will be discussed with other trigger point treatment options.

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Impaired circulation and therefore oxygen deprivation is the major cause and the greatest danger of compartment syndrome. Dipping your legs alternately in hot and then cold water is a very effective way of stimulating circulation in the compartment without irritating the tissues. See Contrast Hydrotherapy for more information about the basic technique.

The worse your case of compartment syndrome, the more cautious you need to be, however. The heating phase of contrast hydrotherapy may cause some swelling in the compartment. Switching to cold should immediately “balance” that effect, which reduces the risk considerably — in fact, the whole idea of contrasting a leg with compartment syndrome is to “pump” the compartment with this alternation in states, so you actually want a certain amount of heat and swelling followed by cooling. However, use the heat cautiously, especially at first: do not use excessively hot water, and keep the heating phase somewhat short, perhaps only 30 seconds. Here’s a recommended procedure for compartment syndrome:

1. 30 seconds, hot water, ~95˚F
2. 45 seconds, icy cold water
3. 45 second, hot water, ~100˚F
4. 60 seconds, icy cold water
5. 60 second, hot water, ~105˚F
6. 60 seconds, icy cold water
7. 60 seconds application of raw ice to make sure it’s really chilled
8. 3 minutes, rest with leg elevated to “drain” compartment

By “contrast” (ha ha), for most other conditions — including MTSS — contrasting can be more aggressive with the heating phase, and there’s no need to finish with ice and elevation. It’s just the unique characteristics of compartment syndrome that require the more cautious approach.

MTSS and trigger points can probably benefit from contrasting as well. Stress fracture is less likely to be helped.

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I have made the case that trigger points — poorly understood sensitive spots in muscle — are a factor in most cases of shin pain, and a major or dominant factor in at least some cases, causing, mimicking or complicating the problem. Over the years, I have seen several “stubborn” cases of shin pain vanish with just one or two sessions of trigger point therapy for the tibialis anterior muscle. This is the best-case scenario, and certainly not every case goes so well. However, even when trigger point therapy didn’t completely solve the problem, it often reduced the symptoms so significantly that it was a heck of a lot better than nothing.

Suppose you have only a moderate intensity of chronic shin pain, and you more or less manage to continue running or playing or whatever it is that you like to do — it’s uncomfortable, but you manage. You’re reading this tutorial not so much because you have a severe case, but because it’s so annoyingly persistent. Lots of shin pain patients are in this position! Then along comes some trigger point therapy, and your symptoms are reduced, say, 60% — not exactly a cure, but still quite helpful! In fact, at only 40% of its previous intensity — which was almost liveable to begin with — now suddenly it’s just not that big of a deal anymore. Sure, you still have a little pain, but you can easily live with it. It’s not a cure, but it’s still a success story.

Read fifty other articles about shin pain, and you might not find a single one that says anything more than “try a little massage.” Go see anyone but a massage therapist, and chances are good that they won’t seriously recommend massage for this condition either. And yet I suspect that massage is probably one of the most promising treatments.

Massage has the potential to improve a case of shin pain almost regardless of which kind it is. But I have no direct scientific support for that claim whatsoever,79 and I’m biased on this topic, so I’ll try to keep my enthusiasm in check. So you can’t do massage for shin pain because it’s evidence-based: you can only do it because it’s worth trying, because it makes some sense and isn’t obnoxiously expensive or risky to try. Sometimes that’s about as good as it gets in health care.

Obviously, the best-case scenario is trigger point therapy applied by a skillful, experienced therapist. (For help identifying the right therapist, see How Do Your Find Good Quality Massage Therapy?) But self-treatment using your own thumbs or self-massage tools is not only a perfectly good option in the case of shin pain, it’s actually preferable: you can easily reach your own leg,80 and it’s a lot easier and cheaper than trying to find good professional help.

Another thing that makes trigger point therapy for shin pain so particularly straightforward is that there is just one key trigger point that is going to be by far the most important in the majority of cases, and it’s easy to reach and find and press on, and easy to heat, and easy to stimulate with gentle movement. This critical trigger point is in the top third of the meaty part of the shin, in the tibialis anterior muscle.

This spot is one of the “perfect spots” in the body for massage — perfect spot No. 3. A complete guide to this trigger point is published as a separate article:

Basic trigger point therapy consists of four things:

1. Rubbing. Simply reach down and rub the upper third of your shin muscle! For more detail, see the full Spot No. 3 article.
2. Heating. As a general rule, trigger points love heat. The lower leg is easy to dunk in hot water or wrap a heating pad around. This might seem like a trivial advantage, but there are areas of the body where it is quite difficult to comfortably and easily heat trigger points.
3. Mobilizing. Mobilizing is simply gentle rhythmic contraction and elongation of muscle tissue. In the case of the lower leg, mobilizing could not possibly be simpler: just draw circles with your toes! This will alternately contract and elongate every muscle in your lower legs. This basically just encourages normal muscular function. However, this exercise is much more tiring to the lower leg muscles than most people expect. It’s easy to exhaust the tissues and aggravate trigger points. An appropriate number of mobilizations in a bad case of shin pain is sets of only about 20 toe circles (ten each way), a few times per day. Assess your own tolerance for the exercise: the goal is to stimulate without irritating. Adjust your intensity and repetitions accordingly.
4. Avoid aggravating factors. Trigger point therapy isn’t just about actively “repairing” trigger points, but about avoiding anything that will irritates them. Avoid anything that tends to makes trigger points worse, particularly as muscle exhaustion and chills.

Combine and experiment with these techniques for 2–3 days. If basic trigger point therapy for the tibialis anterior has little or no effect, there are two possibilities:

1. Trigger points aren’t your problem, and you should move on to other treatment options.
2. Trigger points are your problem, but they are difficult to treat and not responding quickly. A little more experimentation is justified, but not a lot more.

It’s not easy to know which is the case! If you have good reasons to believe that trigger points really are the problem — for instance, if you checked off every item in the checklist for trigger points above — then you should probably continue to experiment with self-treatment. You could simply try more persistence: keep doing the basic therapy above for a while longer. And/or seek professional assistance. And/or study trigger points in more detail with the PainSci trigger points guide: The Complete Guide to Trigger Points & Myofascial Pain.

What about the calf muscles?

There is a strong possibility that there are also clinically relevant trigger points in the calf. Since medial tibial stress syndrome involves painful irritation where calf muscles are yanking painfully on the edge of the tibia, it’s not much of an intellectual leap to realize that those calf muscles might also benefit from some massage.

Trigger points in the calf are a little trickier to reach (though still manageable), but also much less specifically predictable than Perfect Spot No. 3. Although there are a couple of key spots in the calf where trigger points tend to hang out, it’s better not to get hung up on trying to find those spots: instead, simply feel free to explore for any sensitive spot. A sensitive spot may or may not actually be a trigger point, but it’s just fine to treat it “as if” it were — just rub it respectfully — and see what happens.

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Stripping is worth its own chapter because it is a particularly common approach to massage for shin splints. Indeed, it’s an almost inevitable technique, if you take your shins to a massage therapist. But it’s also a confusing mix of potential benefits with counter-productive ambiguity and — often — intensity.

Stripping in this context refers to long, deep strokes along the length of the lanky tibialis anterior muscle. It almost always seems to be associated with strong pressures and challenging intensity for the patient, but it doesn’t have to be that way: like any other massage pressure, it can be carefully modulated to suit patient tolerance, and it should be. A problem with stripping is that, in practice, it’s usually applied with a no-pain-no-gain sensibility — typical of trendy “fascial release” styles of massage — that has the patient gasping.

This is so much the case that gentler strokes simply wouldn’t be called stripping. A gentler, softer stroke with the palm along the length of the same muscle would just be called massage (effleurage or “deep stroking” to be precise). To make it stripping, add more pressure and do it with an elbow, knuckles or a tool!

The name is curious: it seems to be an almost poetic description of the technique, hopelessly vague. Is it “stripping” away tension and stiffness? Is it massaging in a strip shape? Is it stripping trigger points out of muscle? Is it stripping layers of connective tissues away from each other, breaking sticky adhesions between them? Do we call it stripping because it sounds and seems like ripping or scraping? Some therapists certainly act like it! The name seems to be more about the feel of the word than anything more clinically precise.

Stripping and “fascial release”

So is stripping anything more than a strong massage? Many massage therapists think so, and probably the majority who choose to “strip” shin splints, based on the currently fashionable idea that they might be able to loosen the connective tissue “sausage wrapping” around the anterior muscle compartment (fascia). Fascia can contract a little, and the pressure it exerts on the compartment it surrounds could conceivably be a factor in compartment syndrome — but the contraction is almost certainly too weak for that.81 And from that shred of dubious clinical significance, it’s another long reach to assume that it’s possible to change the behaviour of the fascia — to convince it with therapy to stop squeezing.82

If fascia isn’t actually actively squeezing the compartment, then it is simply too small for the contents, and fascial therapy would only be relevant if it could actually change the size of the compartment — that is, permanently loosen the fascial wrapping enough to effectively treat compartment syndrome — but this is pretentious wishful thinking. Fascia is extraordinarily tough stuff, and creating even a minor, temporary change in its flexibility is simply impossible.83

As covered in detail above in the fascia chapter, therapists often express science-y sounding excitement about biological properties of fascia. Unfortunately, although fascia may be scientifically interesting, there is no reason to believe that it can be sculpted like clay to a degree that would be useful here.

And, of course, stripping compartment syndrome could easily also be a problem …

Dangers of stripping

It should go without saying at this point that stripping is going to be ineffective or even dangerous for some cases — but I’m saying it anyway, because stripping is so likely to be offered by massage therapists, and so likely to be intense. The enthusiasm for stripping is such that it could well be offered even when the underlying problem is a stress fracture or, god forbid, compartment syndrome.

Stripping is particularly inappropriate for compartment syndrome, because the compartment is under pressure, and stripping significantly increases that pressure. Tissues inside a swollen compartment are also much more likely to be boggy and literally fragile, harmed by chronic hypoxia, and more susceptible to adverse reactions. Is a bunch of microtrauma, and maybe even some macrotrauma, going to help compartment syndrome? Probably just the opposite. The only way to perform stripping more safely on a swollen muscle compartment is more gently and very slowly, giving the compartment a chance to “drain,” if it can.

A surprisingly good analogy: it’s just like rolling up an air mattress. The valve cannot release air as quickly as you can roll. Rush it and the valve hisses as the remaining air is squeezed tightly into the end of the mattress.

Stripping for trigger points.

What about stripping for cases of shin splints that seem to be all about trigger points? Or at least complicated by them?

Trigger points are a mysterious phenomenon, perhaps even a neurological illusion — not what they seem to be — and so it’s never clear what will make them go away and what won’t, and it varies widely from case to case, even day to day. In my experience, sometimes some good strong “stripping” — not too extreme, but strong — seems to get terrific results. Other times, not at all. And when you are thinking in terms of stripping, it is certainly easy to over-do it.

Self-massage tools for stripping-style massage

You can self-strip easily. Rolling pins are almost perfect, actually. And a tool like the The Tiger Tail Rolling Muscle Massager is truly perfect: a slightly yielding and grippy foam rubber surface, actually designed for this and similar jobs. If you want to strip your shins, that will work well.

The Tiger Tail Rolling Muscle Massager

Perfect for “stripping” your own shins.

The only clear common denominator in the meaning of stripping is simply “really strong and focused strokes,” and yet it is emphasized way out of proportion to how many patients actually need that style. If I had my druthers, “stripping” as a concept would be retired and we would simply perform whatever safe massage intensity is appropriate and appealing for a given case. So don’t strip. Just rub!

Most of the time, people would be better off with something less aggressive than “stripping.”

Foam rolling

Using a foam roller on your legs isn’t really “stripping,” but it’s pretty close. It’s a blunt instrument, but it can be used fairly powerfully.

Foam rollers are often regarded as if their use is a massage therapy technique in its own right, something we would still want to do even if we had a massage therapist on retainer. But the simple truth is that it’s just a handy self-massage tool: it applies pressure, period. Whatever massage is good for is what foam rolling is good for. However massage is limited is how foam rollers are limited. There has never been the slightest shred of evidence that foam rolling does anything physiologically different from the effects of massage.

Rollers are mechanically convenient for certain kinds of self-massage chores, and not for others. The main reason to use a foam roller rather than some other tool is just pure convenience: they just “fit” better on certain body parts.

Like the lower leg! It’s easy to apply and control pressure to any of the musculature of the lower leg. That’s it.

I’ve already mentioned tools like the Tiger Tail and rolling pins, which are obviously just smaller, harder rollers. But foam rollers are ubiquitous; you could well already have one. And the softness and wide diameter of foam rollers could be a great way to start especially — an easy first massage step.

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If there’s any reason for a shin splints victim to go barefoot, wear minimalist shoes, or high-tech shoes, or tinker with running posture and technique in any way, it’s probably to reduce impact. Impact is potentially relevant to all causes of shin splints, but most obviously (duh) stress fractures. And perhaps since the publication of Franklyn-Miller et al in 2014,84 impact also has more to do with compartment syndrome than has been appreciated in the past. If they are right that compartment syndrome is a misleading term and it’s actually “biomechanical overload syndrome,” then reducing impact would be a major way of treating it.

But the problem with impact is not as obvious as you might think. There’s lots about impact that is counter-intuitive. For instance, “high impact” exercises — like jumping down from a height — are actually less jarring to the shin than running is, mainly because of effective shock absorption in the joints.86 I would still advise caution with any high-impact exercise, but it’s quite interesting that things that look like they would probably be quite hard on shins aren’t actually so bad.

And hard-surface running on roads and sidewalks isn’t an obvious a villain as it seems like either. It is not necessarily terrible for runners in general; I fully explore that debate in a dedicated article, Is Running on Pavement Risky? But the risk of impact aggravating your shin splints is an avoidable risk, and stress fractures are right at the top of lists of running injuries that are most likely to be bothered by jarring gait.

I’ll deal thoroughly with barefoot/minimalist running in the next section; it’s such a huge fad, and so conceptually relevant, that it needs special attention. But there are many other important ideas to consider first …

Impact and injury: do they go together?

Maybe. Probably a bit. It’s surprisingly hard to tell.

The impact of walking/running is measured in many ways. Loading rate is the main technical way of measuring how jarring a runners’ steps are: how fast load is applied to tissues. Peak acceleration at various anatomical landmarks is another. There’s a lot of research about impact, some of it concerning different surfaces, just a few of those specifically about the relationship between impact and injury. As of the end of 2016, there were only about 18 decent experiments, with too many differences between them to clearly interpret. A review of these by van der Worp et al concluded just a single thing with confidence: a history of stress fractures is associated with higher impact forces in running gait.87

Furthermore, there is a broad association between higher loading rates and runners with all kinds of injuries (no specific one).90 And that’s backed up by a good quality trial from just a little later in 2016: Davis et al found that “all impact-related variables were higher” in 250 women runners who got injured in a year after extensive gait analysis.91 Also, the best evidence so far on barefoot running makes it pretty clear that running without padding is problematic.92

And one final interesting data point: horizontal forces matter too. In fact, a 2018 study showed no correlation between vertical loading rate and MTSS, but injured runners were dramatically likelier to have a high “peak braking force,” a measure ow how hard your foot pushes backwards on impact. This study was discussed in detail above in the chapter “Does peak braking force determine when you break?”

So the common-sense idea that impact is injurious does appear to have some scientific support. Thus it probably makes sense to try to reduce it.

Just keep in mind that it’s amazingly complicated and unclear. Zadpoor et al found that ground reaction forces (how hard you hit the ground) actually have no correlation with stress fractures, and loading rates (how fast you hit the ground) are only slightly correlated.93 That’s surprising for what seems like the most impact-related running injury. When van der Worp et al concluded that loading rate is associated with stress fractures, it’s probably not the whole story.

Maybe it’s because the stresses that fracture are not simple. The forces in normal running are mostly below the threshold at which we would expect them to cause stress fractures directly, but Milgrom et al demonstrated94 that there are much stronger forces involved in activities that involve greater shear strain,95 probably enough to cause fractures more directly/quickly. Thus it is runners who include a lot of stairs and jumps that are potentially at greater risk for stress fractures than just running, regardless of surfaces. This is just a good example of the thick layers of “it depends” obscuring the truth.

Shocking absorption! How we take a lickin’ and keep on tickin’

Humans have a couple main biological shock absorption tricks:

• Muscle tuning is the dynamic dampening of impact vibrations with precisely timed muscle contractions — a very cool system.96 And quite exotic (and likely not embraced by all experts).
• Springing is the more obvious one: we adjust the springiness of our entire body by being bendier. Harder surface? More bending! Softer surface? Less bending!97 It’s obvious in an extreme example, like bouncing on a trampoline, where you can keep your knees straight; but jump down just one metre onto concrete, and you’ll have to bend your knees quite a lot. We do the same thing much more subtly when we walk and run. We’re amazing at making much finer, faster adjustments to surface rigidity when running.98

Bodies can and do work to minimize the effect of jarring steps on any one anatomical structure. Every precisely timed vibration-dampening contraction takes energy and yanks on our anatomical rigging; every bit of extra springing takes joints a little further into flexion, with a little more muscle power to control the movement.

The amount of bending and bracing may be directly relevant to shin splints. And if it is, then so is the surface hardness. And therefore so too is the springiness of what we put between our feet and the ground.

For example: consider the tibialis anterior

On a hard surface, the transition from heel-strike to flat foot (double-support phase) demands exceptional muscular performance from the long-suffering tibialis anterior muscle — more than it can provide in many people, in fact — and from the entire lower leg in general. Without any give or elasticity in the surface, the only limitation on the force of the heel-strike is the muscle-controlled descent to flat-foot: a very high-velocity, high-load eccentric contraction of the tibialis anterior muscle, and a nearly perfect formula for delayed-onset muscle soreness… and “compartment syndrome,” too! Reducing this strain is exactly how Franklyn-Miller et al seemed to have success helping people with presumed compartment syndrome:

Freed from the restrictions of the compartment pressure model we have managed our patients with anterior symptoms by altering their running gait characteristics to reduce the load on the tibialis anterior.

Which is why they proposed that at least some compartment syndrome might be better described as “biomechanical overload syndrome,” and they were speaking specifically of tibialis anterior overload.

If a healthy tibialis anterior can be irritated by this process (and it certainly can), an exhausted one stands no chance at all, and the situation gets worse. Similarly, the yanking on attachments to bone is probably also a problem for MTSS.

Put a literal spring in your step

It’s a good rule of thumb that the overall amount of training you do is probably more important than any subtle adjustments you can make to how you run. But if you can adjust enough to make a little difference, why not? And some adjustments are probably better than others. Consider the trouble with regular running shoes. Despite all their methods of cushioning and “controlling” gait, they clearly don’t do much to prevent common running injuries.99

In particular, mass-produced running and walking shoes claim to absorb shock in all kinds of ways, but they aren’t springy. A spring gives energy back to you: it compresses, and then forcefully expands. Most shoes are mushy: they are made of foam, and foams absorb energy but don’t give much back. Running on foam is like landing on a trampoline that goes down but not up: it can’t toss you back up in the air. Ironically, there is some evidence that the mushy shock absorption of most running shoes might actually increase knee stresses — perhaps because they are actually interfering with the spring-like function of the arch, increasing the demand on other joints.100101

There is one type of shoe that is designed to simulate running on springier surfaces by literally putting a spring in your step. OESH Shoes (for women only) are a good example, and there are others based on springs.

Dr. Casey Kerrigan left her career in biomechanics research to found Oesh and make shoes that don’t just absorb impact energy, but give some of it back. The goal was to change your gait by effectively giving you a bouncier surface to run on — little carbon-fiber springboards. In theory, the springs will change the way we move, reducing the need to flex the joints of the legs and feet for shock absorption. Hips, knees, ankles, and arches do bend slightly less when you walk or run on a springier surface. Therefore, hopefully, more spring in the shoe means less spring in the joints — less bending, less effort and strain on tissues. There is some evidence that sprung shoes can do some of the work for you.102

But the effectiveness of spring-loaded shoes at actually preventing (or treating) injury is — of course — untested, unproven, and impossible to prove without a large trial that may never happen. However, the principle is an interesting and promising one. Claims of injury prevention rarely pan out, but in my opinion there’s a better-than-average chance that these kinds of shoes actually do reduce injury-causing forces more than other shoes; that was the whole point of a research-inspired design, and maybe they’re onto something. You can try them with less risk and radical departure from normal shoes than minimal/barefoot running (see next section), and with lower costs compared to any number of popular therapies. It’s a reasonable thing to try for any stubborn case.

Impact reduction take-home points

• Stay off concrete as much as possible. Prefer tracks and treadmills for the bounciest of all options, the best at giving you some of your impact energy back and reducing the load on your biomechanical spring. (Grass, sand, and chip trails are much softer than pavement, but are more like running on foam: mushy, not springy.) Do beware of hilly trails though — descending is harder on the tibialis anterior! And maybe everything else as well, because you’re “falling” more.

  I work just a couple blocks from a running track. I don’t usually walk there, because I’d far rather stick to tree-lined streets and parks. If I developed shin pain, I’d absolutely make walking on that track part of my rehab regimen, because that surface is obviously springier than anything else I can walk on regularly. Not everyone has such a convenient option, of course, but it’s an instructive idea.

• Try sprung shoes. If you can’t run on a springier surface, then try shoes based on springs, like OESH Shoes. Failing that, at least keep your regular running shoes fresh — the EVA foam in the midsole breaks down,103 and the biomechanics of running do shift in response. It probably does not matter a lot, but there’s also no need to take the risk.104 Although we’ve established that any non-spring shock absorption (mostly foam) is fundamentally different and probably not very helpful, if I run on foam I at least want it to be fresh foam!

• Run more gently. Avoid that jarring feeling! Experiment with your running style; do anything that feels less like you’re slamming your feet down. We can definitely run more softly if we try to,105 most easily by shifting to a forefoot impact and basically running more like a tiptoeing cartoon thief; barefoot running or minimal shoes help with this, as they strongly discourage heel impact and so we shift our impact to the forefoot. But there are trade-offs! Forefoot impact undoubtedly shifts the burden between tissues, which might help solve shin splints while risking new injuries. More about this in the next section.

  Alternatively, another strategy for running softer is probably less prone to dicey trade-offs: slow down and take smaller steps! Basically just run less aggressively, period.

• Avoid high-impact exercise like plyometric jumping, but also don’t worry about them much, and they can actually be reintroduced before running. This advice is based on Milgrom, who found that most seemingly “high-impact” exercises are “unlikely to place an athlete who is accustomed to fast running at higher risk for bone fatigue.”106

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