Save Yourself from Shin Splints!

The term “shin splints” has multiple personality disorder: it might refer to nearly any of several problems that cause shin pain, depending on what you read or who you talk to. This extremely detailed tutorial aims to help readers, both professionals and patients, with all the different shin pain problems that get stuck with the label “shin splints.” All of these things (at least) are the “real” shin splints:

• compartment syndrome
• medial tibial stress syndrome
• tibial stress fracture

People often mistakenly believe that the real shin splints is limited to just one of these. For instance, medial tibial stress syndrome — irritation and degeneration of the shin bone, and/or the soft tissue around it — is probably what most professionals think shin splints is these days, and it probably is the most common type of shin pain. But it is definitely not the only kind.

The confusion about the naming of shin pain probably can be traced to the truly deep and cosmic mysteries that surround shin pain. Many cases defy easy classification. Either they seem to possess the symptoms of several different problems, or they actually are more than one problem.6 Many scientific studies of shin pain have created more questions than they answered. Diagnosis and treatment can be difficult, and some cases of shin splints are almost freakishly severe.

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

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

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Sports medicine in general is amazingly primitive considering how much potential funding it has. You’d think anything affecting elite athletes with huge audiences would be getting more attention! The situation is improving, but only recently and it still has a long way to go.7

And there are certainly no “shinologists.” Feet have entire professions devoted to them, but not shins! For most professionals, shin pain is just one of a list of hundreds of common pain problems they deal with, and they are more or less completely unaware of the finer points of the subject, particularly recent scientific research. A typical orthopedics text devotes only a paragraph to shin pain; most web pages are brief and crappy, barely scratching the surface of the topic.8 And so, in many cases the only thing professionals know is quarter-century old conventional wisdom. Such large gaps in professional knowledge make it tough for patients to find competent help for more severe and stubborn cases of shin pain. There are several shin splints issues that doctors and therapists are particularly uninformed about, and often fail to consider:

1. Unfortunately, many pros do not appreciate how dangerous acute compartment syndromes are, and often fail to recognize them and give appropriate warnings to patients.
2. Tissue fatigue is a critical shin splints concept, and yet the majority of professionals have rarely or never thought of it in this way, especially thinking only in terms of relatively simplistic biomechanical stresses rather than the more subtle and complicated biological vulnerabilities and the weirdness of chronic pain that are more important.9
3. Progressive rehab is a sound principle — the heart of all injury recovery — but it is often rushed, and the importance of initial resting seriously underestimated and poorly handled. Often the only problem with a rehab plan is that it was started too aggressively.
4. Muscle pain is probably a significant factor in many cases of shin pain, but this is almost always missed or underestimated — health care has a huge blind spot for muscle, and often just ignores the role of muscle in injuries.10

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

Compartment syndrome — high-pressure swelling, fluid that’s trapped in a limb — is one kind of tissue failure that mostly afflicts lower legs.11 It’s extremely dangerous when acute. Compartment syndrome involves a vicious cycle which is not necessarily self-limiting (as many other injuries are). Once it starts, it may spiral out of control and literally kill the affected muscles, causing permanent deformity and disability at the very least, and even risk lethal infection. Triple yikes! This is absolutely serious, and unlike most other athletic injuries.

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

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

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

But compartment syndrome was his worst problem!

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

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

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

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

Acute compartment syndrome is no joke

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

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Runners with “perfectionist tendencies” are 17 times more likely to get injured, which seems rather odd and suspiciously psychological. Stress fractures aren’t psychosomatic … right? It’s not that kind of stress! “Still, for anyone who’s been around runners,” says sports science journalist Alex Hutchinson, “it’s not hard to believe that there are some personality traits that are associated with injury risk.”12 Indeed.

It’s probably just that perfectionists push themselves harder. Perfectionism is a proxy for stereotypical athletic ambition: intense, driven, a bit reckless, likely to ignore warning signs.

There’s only one major risk factor for shin pain is known with any confidence:

1. excessive loading

But it’s definitely not just that. First of all, not all loading is physical or simple.13 Shin splints is routinely defined as an overload, overuse, or exercise-induced problem, and this is correct — but it’s also not the whole story. Not every case of shin splints involves tissue overloading, but most probably do. And not every case of shin splints only involves tissue overload.

There are deep mysteries about why shin splints happen to some people and not others, and in which tissues it is actually affecting and how. Tissue fatigue has clinical implications that are often underestimated (and which make up a good part of this tutorial). Despite their willingness to define shin splints as mainly a tissue fatigue problem, few professionals are willing to actually study it or treat it that way. If overuse is the primary problem, then rest is probably the highest priority in recovery — but rest tends to be marginalized and underestimated as a treatment option, in favour of a wide array of “fancier” theories and therapies, mostly aimed at “correcting” alleged non-obvious sources of physical stress …

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

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

Thank you so much for taking the time to put this book together, and in a way that makes it feel like you wrote it just for me! You have a great writing style.

~Chyna Pittman

Thanks for the great tutorial! Much more helpful than any of the professionals I’ve seen for my chronic running-induced shin pain — all the doctors, sports massage therapists, chiropractors, and physical therapists!

~Cassandra Clarke

I was so sick of reading crappy little articles with the same old advice. Seems like there’s about ten thousand that all say the same useless things. Thanks for the deep dive!

~Sandra Frank, Ottawa, Ontario

A year of shin pain and hardly anything but painkillers and ultrasound from doctors and physios. I was giving up! I thought I’d never have a nice long walk again. Actually I was even more discouraged after reading this book, because so many treatments are apparently bullshit. But then I started experimenting with some of the massage ideas, and bam! The nightmare ended! Unbelievable!

~Alison Fromer, “just a serious walker”

My shin pain has been very stubborn. I know as well anyone there’s no easy way to deal with this, and this book confirmed that! But I really appreciate the education. Even after a couple years of dealing with shin splints, I still had a bunch of nagging questions that this book really helped to clear up. That alone was worth the price, but there were also a couple rehab ideas I’d never come across. Totally worth it.

~Andy Flaco, New York runner

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

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

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

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

• Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
• Too negative specifically. Some are offended by about a treatment option that they personally use and like. Or sell.
• Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
• Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

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Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

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Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 54 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

June — Science update: Added some more recent citations, some more detail, and a photo. [Updated section: The great pronation fizzle.]

June — Upgraded: Added more detail, especially about trigger points and minor muscle injury, with a couple new citations. [Updated section: Strengthening can’t “fix” shin pain, but still has a vital role in rehab.]

May — Upgraded: More and better information, and also probably mostly complete now. There might be some other ridiculous treatments for shin splints, but probably none that are popular enough to bother writing a paragraph about. [Updated section: Hall of treatment shame: the most bogus shin splints treatments.]

January — Expanded: Added sub-topic: “More ways to go wrong getting strong (especially with shin pain)” [Updated section: Strengthening can’t “fix” shin pain, but still has a vital role in rehab.]

January — Science update: Expanded on the sub-topic of hip strength, based on three new studies. [Updated section: Strengthening can’t “fix” shin pain, but still has a vital role in rehab.]

2019 — Major upgrade: Completely rewritten and greatly expanded. Previously this chapter was just a brief dismissal of the value of corrective strength training for shin splints — which wasn’t wrong in itself, but it was inadequate, and in particular it neglected the genuinely valuable role that strength training can play in rehab, even if it can’t “fix” anything. [Updated section: Strengthening can’t “fix” shin pain, but still has a vital role in rehab.]

2019 — Expanded: Added radiculopathy, tendinopathy, and more detail about specific peripheral neuropathies. [Updated section: Other causes of shin pain.]

2019 — Big new chapter: No notes. Just a new chapter. [Updated section: The role of fascia in compartment syndrome.]

2019 — Science update: Quirky sidebar about the relationship between running softly and quietly. [Updated section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2018 — Modernization: Added clearer and more detailed acknowledgement of the controversies and scientific uncertainties about trigger points. [Updated section: Trigger points complicate nearly every case of shin splints, and sometimes they are the whole problem.]

2018 — Science update: Important and interesting expansion of the section inspired by odd science news about the role of perfectionism. [Updated section: The main risk factor for shin splints: overload!]

2018 — New section: A new standard chapter for most PainScience.com tutorials summarizing several key concepts about placebo. [Updated section: Some important things to keep in mind about placebos.]

2018 — Science update: A small but good update giving some good scientific support to the rationale for reducing tibialis anterior loading. That was already recommended, but it’s on firmer foundations now. [Updated section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2017 — New section: No notes. Just a new chapter. [Updated section: No pressure! Not compartment syndrome, but “biomechanical overload” syndrome.]

2017 — Like new: Rewrote discussion of shoes, surfaces, impact, etc. Several new references; recommendations haven’t changed much, but the explanation for them is greatly improved. [Updated section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2016 — New section: Added a great, practical new tip for diagnosing and predicting medial tibial stress syndrome. [Updated section: Two really easy tests to both diagnose and predict medial tibial stress syndrome.]

2016 — Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention. [Updated section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2016 — Minor science update: Citation of Collins 2008, a review of icing evidence (or the lack of it), plus related editing. [Updated section: Icing for MTSS and compartment syndrome.]

Archived updates — 36 additional older updates are listed on another page. ❐

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1. From a fascinating talk about the athletic toughness of human beings, Brains Plus Brawn, by Dr. Daniel Lieberman, evolutionary biologist of “Born to Run” fame.
2. Estimates run as high as 35% in some studies (see Yates), which found shin pain in more than a third of naval recruits at the end of basic training. This is the highest figure ever reported, but other studies have also reported quite high numbers. Shin pain clearly ranges anywhere from “pretty darned common” to “rather shockingly frequent.”
3. As are all knee injuries from the knee down. Ferber et al estimated in 2009 that about 80% of all running injuries occur in the knee and lower leg. 50% of those are in the knee, while “injuries to the foot, ankle, and lower leg—such as plantar fasciitis, Achilles tendinitis, and medial tibial stress syndrome (also known as shin splints)—account for almost 40% of the remaining injuries.”
4. Back splints, anyone? Shoulder splints? Head splints? I’ve been wondering about this little bit of language oddity for years now, but I still can’t dig up anything about the origins of “splints” and why it’s apparently exclusive to shin pain.
5. Batt ME. Shin Splints — A Review of Terminology. Clin J Sport Med. 1995;5(1):53–57. “Currently the term [shin splints] is used widely and variably, with little consensus of definition. Broadly, it denotes the occurrence of exertional lower leg pain … ”
6. Edwards PH, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. 2005 Aug;33(8):1241–1249. PubMed #16061959 ❐ The authors of this paper describe several common lower leg pain problems (several of which are covered by this tutorial, and including at least three types of shin splints) and then comment that “symptoms associated with these conditions often overlap, making a definitive diagnosis difficult.”
7. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781 ❐

   Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine …

8. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al.
9. Generally speaking, medical philosophy about overuse injuries is significantly bogged down by a simplistic over-emphasis on “mechanical” risk factors such as various kinds of crookedness. Shin pain is certainly blamed on a variety of common anatomical scapegoats (like excessive foot pronation), none of which have ever really been established scientifically. Much more about all this below!
10. The importance of muscle dysfunction is a recurring theme throughout this website. It’s not relevant to every injury, but it is involved to some degree in most kinds of injuries, either as a root cause or a significant complicating factor. I’ll explore this in much greater detail below.
11. Compartment syndromes outside of the calf are rare, because it’s all about plumbing: it’s harder to pump tissue fluid out of the lowest (most distal) large tissue compartments in the body. Once in a while there's a compartment syndrome in the forearm, because it has the same plumbing problem to a lesser degree. Compartment syndromes elsewhere in the body probably only occur in unusual circumstances involving very specific or serious injury.
12. OutsideOnline.com — SweatScience [Internet]. Hutchinson A. Why Perfectionists Get More Shin Splints; 2018 October 19 [cited 18 Oct 27].

    Alex speculates:

    Do perfectionists simply train harder, and get injured more as a result? If so, it’s possible that their lofty goals produce faster race times despite the heightened injury risk, in which case it’s not clear this is a problem. But it’s also possible that perfectionists are more susceptible to bad training decisions—refusing to take a day off in the early stages of an injury, or ramping up training more quickly than their body can handle.

13. Soligard T, Schwellnus M, Alonso JM, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016 Sep;50(17):1030–41. PubMed #27535989 ❐ “Load” can also refer to life stress and “internal” loads, which are legion. Psychology, for instance, probably does matter, and not just perfectionism leading to pushing too hard: anything from daily hassles to major emotional challenges, as well as stresses related to sport/competition itself. These squishy, messy things almost certainly are actually risk factors for injury and — crucially — for how stubborn injuries are. These are the factors that could make the difference between someone who gets a touch of the shin splints versus someone who simply cannot shake the condition.

There are 112 more footnotes in the full version of the book.

 

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