Detailed guides to painful problems, treatments & more

Shin Splints Treatment, The Complete Guide

An extremely detailed guide to all types of shin splints for both patients and professionals, including thorough reviews of every possible treatment option, and all about the nature of the beast

Paul Ingraham • 190m read
Photo of a male runner with shin splints, jogging away from the camera in a brightly sunlit empty garage.

Shin splints is a common & often chronic running injury, yet poorly understood by most health care professionals.

Shin splints is an extremely common repetitive strain injury in runners and running athletes. It can be impressively stubborn, because there are several possible overlapping types/causes, some more subtle and less “mechanical” than most people ever suspect. Shin splints treatment depends on what type you have.

“Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.”1 As many as 35% of those injuries are shin splints.23

“Shin splints” is a curiously old-fashioned term — like “lumbago” or “consumption.” Why does only shin pain get called “splints”?4 Because shin splints means painful shins — sort of5 — it’s a bit silly to offer it up as a diagnosis:

“Doctor, I have shin pain.”

“Ah, you have shin splints!”

“I just said that.”

Without a more specific diagnosis, shin splints should probably just be called “anterior lower leg pain” or “tibial pain syndrome” — unexplained pain around the tibia, the big shin bone.

Shin splints treatment is 90% about "rest" (load management), but what counts for chronic cases is that last 10%. So how do you help shin splints? What works, what doesn’t, and — most importantly — why? This tutorial reviews all of the treatment options, but you cannot treat what you do not understand, so we begin with the nature of the beast (etiology).

The major types of shin splints: compartment syndrome, medial tibial stress syndrome, and stress fracture

Which shin splints is the “real” one? The term 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 same label. All of these things (at least) are the “real” shin splints:

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 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.

Diagram of tibialis anterior anatomy, showing the location of a significant myofascial trigger point (muscle knot), an under-diagnosed and under-treated factor in many cases of shin pain.

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.


Shin pain is routinely misunderstood and mistreated

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 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 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


Danger! Please do not try to run through shin splints! Acute compartment syndrome can be extremely dangerous!

Photo of a hand superimposed over a stop sign, representing a warning about compartment syndrome.

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!

Photo of man in a hospital bed recovering from acute compartment syndrome.

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.

Gory trio of photos of surgical repair of acute compartment syndrome. Each photo shows a horrible bulging wound in the shin 6-12 inches long.

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.


Part 2


What causes shin splints?

Here are three main ways of thinking about the “cause” of shin pain (or any injury):

  1. the stress and risk factors that lead to injury — “I ran on hard pavement too much, and excessively pronated the whole time”
  2. what specific tissue fails and in what way — “my shin bone got a stress fracture in it”
  3. systemic vulnerability and chronic pain — “I was still hurting long after the bone should have healed”

In typical sports medicine and physical therapy, the first of these perspectives gets about 70% of the attention when it only deserves something more like 30%, and virtually all of the attention it does get is directed at alleged biomechanical problems rather than the part that actually matters: loading, loading, loading! The overall volume of loading is more important than minor variations in how you are loading. Anything will wear out if you use it hard enough and long enough, and reasons for wearing out slightly faster are not the “cause” of the problem.

The second is often neglected because no one can actually be sure of what tissue is specifically the problem. Or, even when a blatant tissue issue can be identified, it’s often not the real issue, something that commonly occurs even in healthy people. This is a vital principle for troubleshooting all kinds of stubborn injuries — plenty more about this as we go.

So what is the “real issue” in broad strokes? The third perspective is the elephant in the room, which gets about 5% of the attention but deserves more like 80%. This is where you find the difference between patients who recover just fine (or never get injured in the first place), and the patients who do poorly and end up still desperately trying to get back to running two years later.

Some key shin splints terminology
“splints” just an old-timey word for “pain”
tibia big shin bone (the sharp leading edge of the shin is the tibia)
fibula little shin bone
tibialis anterior the main shin muscle
syndrome a pattern of unexplained symptoms
compartment syndromeswelling in the “sausage wrapping” around a muscle or group of muscles
chronic shin splints >3 months, increasingly “illogical”12

The main risk factor for shin splints: overload!

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.”13 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 that 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.14 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 involves tissue overloading, but most probably do. And not every case 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 …


Introducing several other possible causes of shin splints

There is considerable scientific controversy and confusion about the other risk factors and stresses that might cause or contribute to shin splints.

Almost everyone who has ever sought professional help for a stubborn pain in their body has been told that they are deformed and fragile, that the root cause is some kind of “mechanical” glitch — not in such insensitive words, exactly, but that’s the take-home message. Physical therapists, massage therapists, and chiropractors in particular tend to blame pain on our “structural” problems. In the case of shin splits, the usual structural suspects are:

And one more, in a related category:

There is certainly such a thing as a structural or biomechanical problem, but there are also some serious concerns about trying to blame injuries on factors like these…


Purchase full access to this tutorial for USD$1995. Continue reading this page immediately after purchase. A second tutorial about muscle pain is included free. See a complete table of contents below. Most content on is free.?

Almost everything on this website is free: about 80% of the site by wordcount, or 95% of the bigger pages. This page is only one of a few big ones that have a price tag. There are also hundreds of free articles. Book sales — over 69,800 since 2007?This is a tough number for anyone to audit, because my customer database is completely private and highly secure. But if a regulatory agency ever said “show us your math,” I certainly could. This count is automatically updated once every day or two, and rounded down to the nearest 100. It includes all individual and bundled books for sale on since 2007, and excludes a trickle of earlier sales, donations, and gifts. — keep the lights on and allow me to publish everything else (without ads).

Q. Ack, what’s with that surprise price tag?!

A. I know it can make a poor impression, but I have to make a living and this is the best way I’ve found to keep the lights on here.

Logos for Visa, Mastercard, and Amex.

Paying in your own (non-USD) currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.

Example: as a Canadian, if I pay $19.95 USD, my credit card converts it at a high rate and charges me $26.58 CAD. But if I select Canadian dollars here, I pay only $24.95 CAD.

Why so different? If you pay in United States dollars (USD), your credit card will convert the USD price to your card’s native currency, but the card companies often charge too much for conversion — it’s a way for them to make a little extra money, of course. So I offer my customers prices converted at slightly better than the current rate.

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refunds 100%, no time limit +Customers are welcome to ask for a refund months after purchase — I understand that it can take time to decide if information like this was worth the price for you.
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Plus …

How can you trust this information?

I apply a MythBusters approach to health care (without explosives): I have fun questioning everything. I don’t claim to have The Answer for shin pain. When I don’t know, I admit it. I read scientific journals, I explain the science behind key points (there are more than 140 footnotes here, drawn from a huge bibliography), and I always link to my sources.

For instance, there’s good evidence that educational tutorials are actually effective medicine for pain.?Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902 ❐ Researchers tested a series of web-based pain management tutorials on a group of adults with chronic pain. They all experienced reductions in disability, anxiety, and average pain levels at the end of the eight week experiment as well as three months down the line. The authors concluded: “While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit.” Good information is good medicine!

So all the science and all the options for shin splints treatment are here. If you’ve been struggling with pulled muscle injury, I think this tutorial will feel like a “good find” to you!

As with all the tutorials on, I’ve worked hard to provide you with the best information available anywhere — not just better researched and referenced, but also regularly updated, and presented in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered. For a fraction of the cost.

Logos for Visa, Mastercard, and Amex.

Paying in your own (non-USD) currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.

Example: as a Canadian, if I pay $19.95 USD, my credit card converts it at a high rate and charges me $26.58 CAD. But if I select Canadian dollars here, I pay only $24.95 CAD.

Why so different? If you pay in United States dollars (USD), your credit card will convert the USD price to your card’s native currency, but the card companies often charge too much for conversion — it’s a way for them to make a little extra money, of course. So I offer my customers prices converted at slightly better than the current rate.

read on any device, no passwords
refund at any time, in a week or a year
call 778-968-0930 for purchase help

Part 2.3


Reader feedback … good and bad

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 as 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 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 dissatisfied customers have strong themes:



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. 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.


What’s new in this tutorial?

Regular updates are a key feature of 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 59 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

Jan 20, 2021 — Improvements: A bit more and clearer information on the role of radiculopathy/sciatica in differential diagnosis of shin pain. [Updated section: Other causes of shin pain.]

2020 — New chapter: No notes. Just a new chapter. [Updated section: Steroid injections: a complicated mix of certain risks and uncertain rewards.]

2020 — Minor new sub-topic: [Updated section: Stripping: a popular massage techique for the shins.]

2020 — Science update: Cited Milgrom et al on seemingly high-impact exercises actually being not so high impact, and Barton et al on the value of running technique [Updated section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2020 — Major improvements: Substantial editing and elaboration. The chapter is now bigger and better. [Updated section: Introducing several other possible causes of shin splints.]

2020 — Science update: Added some more recent citations, some more detail, and a photo. [Updated section: The great pronation fizzle.]

2020 — 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.]

2020 — 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.]

2020 — 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.]

2020 — 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 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.]

Archived updates — All updates, including 39 older updates, are listed on another page.

2007 — Publication.



  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” — 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. This reference is getting old, but nothing has really changed. 😜
  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. Acute pain usually “makes sense,” in that the cause is relatively obvious: stress and strain on the tissue. Chronic pain is a bit of a vicious cycle that, to some degree, persists regardless of physical stresses. Chronic pain often seems to have a bit of a life of its own.
  13. — 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.

  14. 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.
  15. Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med. 2004 Apr-May;32(3):772–780. PainSci #55469 ❐ “Recruits with a pronated foot type were almost twice as likely to develop medial tibial stress syndrome than were those with a normal or supinated foot posture.” The actual risk factor determined by this study was 1.7. This has been a common sort of finding in the history of shin pain research, but it also has to be taken with a grain of salt. More about pronation ahead.
  16. What is “valgum”? What is “varus”? Valgum and varus mean “twisted away/towards” the midline. So a forefoot varus is a forefoot that is twisted towards the midline, while a genu valgum is a lower leg that is bent away from the midline (knock knees).

There are 125 more footnotes in the full version of the book. I really like footnotes, and I try to have fun with them.

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