Aug. 30, 2004

Scott G. Spernoga, MEd, ATC
Assistant Athletic Trainer
Wake Forest University

With the start of the fall sports season, athletes are in a rush to get into playing shape. Coaches hope that each of their athletes have been training and conditioning throughout the summer months in preparation for the upcoming season. But even well-conditioned athletes place increased demands on their bodies at the start of each new season.

One of the most common and misunderstood injuries that typically occurs at the beginning of the season is "shin splints." However, if recognized and treated early, athletes can overcome their lower leg pain and enjoy a healthy season.

What exactly is shin splints?
The term "shin splints" is often incorrectly used to categorize a wide variety of lower leg conditions ranging from tendonitis to stress fractures. This term includes both bone and soft tissue problems. In the sports medicine setting, shin splints are better referred to as "Medial Tibial Stress Syndrome" (MTSS).

MTSS is defined as syndrome in which increased stress causes an injury to the medial or inside part of the lower leg. This overuse injury is frequently found in sports which involve repetitive running such as field hockey, soccer and cross country. Shin splints do not occur overnight, but over a period of time. Often this occurs in the initial 2-3 weeks of training.

Signs and Symptoms
The chief complaint of an athlete with shin splints is pain on the medial or inside of the lower leg. The pain starts as a dull ache and occurs in both legs. If ignored, the aching can become more intense with increased activity. The pain is worse with running and weight-bearing exercises. Swelling, which is due to inflammation of the periostium of the tibia (tissue surrounding the primary shin bone), may also be present. It is important to note that often shin splints will present the same signs and symptoms as tibial stress fractures. Usually, stress fractures are present in athletes with one-sided leg pain. Therefore, if the lower leg pain does not respond to rest and treatment, referral to a sports medicine professional is needed for further evaluation and testing.

What causes shin splints?
Shin splints most often arise when there are changes to specific aspects of an athlete's exercise regimen. Some of these factors include increased activity, changes in footwear, and training surfaces.

Increased Activity
Shin splints are commonly caused when the intensity or duration of activity is suddenly increased. This is often the case in the early stages of the sport season when athletes are not acclimatized to the stresses of their particular sport. However, overtraining at any point during the season can also be a factor.

Footwear
Due to the high impact force associated with running, worn or improper shoes can also increase the stress to the anterior leg muscles. Athletes should make sure that the shoe they wear best fits their foot type. To prevent injuries, most sports medicine professionals recommend changing running shoes every 200-400 miles.

Training Surfaces
Lower leg pain associated with shin splints may also be related to different training surfaces. Athletes conditioning on hard surfaces such as gym floors and tracks may be at greater risk. The short and tight turns common in indoor tracks place increased stress to the inside of the lower leg. Also, switching from one surface to another may be a contributing factor. For instance, college field hockey players do the majority of their conditioning on hard surfaces (tracks and concrete) and then play on a softer surface (artificial turf).

Management of Shin Splints
Treating shin splints can be very frustrating for the athlete as well as the athletic trainer or sports therapist. However, if the signs and symptoms of shin splints are recognized early on, athletes can overcome their early season setback and enjoy a healthy season.

Modify Activity
Perhaps the most important factor when managing shin splints is modifying an athlete's activity. Returning to a pre-injury level should be a gradual process. The frequency, intensity and duration of activity should not increase more than 15% per week. Cardiovascular endurance can be maintained by performing non-weight-bearing exercises such as riding a stationary cycle or swimming. Any activity causing increased pain should be eliminated.

Pain Management
Applying an ice bag for 20 minutes following exercise will help alleviate pain and soreness in the shins. Depending on the degree of pain and soreness, this process should be done 2-3 times per day. In addition, some athletes find relief by massaging an ice cup over the affected area on the shin for 5-10 minutes.

Stretching
Proper stretching of the calf muscles (gastrocnemius and soleus) can help prevent injury and decrease soreness. To stretch your calf, stand with both feet pointed forward and hands against a wall. Keep both heels on the ground and have one leg straight back. Then slowly bend the front leg to gently stretch the upper calf (gastrocnemuis). To stretch the lower calf muscle (soleus), slowly bend the back leg. These stretches should be held for approximately 20 seconds and done 3-5 times.

Taping
Some athletes find that the compression provided by tape decreases shin pain during activity.

Orthotics
Foot biomechanics should also be analyzed in athletes suffering from shin splints. Hyperpronation is often a cause of lower leg pain. This occurs as the foot flattens out when weight is applied causing the foot to roll inward. This action increases the stresses to medial structures of the lower leg. Orthotics are often used to help correct an athlete's foot from over-pronating.

Strengthening
Increasing the strength of lower leg muscles can help prevent shin splints from reoccurring.

Medication
Anti-inflammatory medication, such as ibuprofen, may be used to help alleviate pain and soreness. However, the use of medication may mask the pain and allow the injury to worsen if the activity is not modified or decreased. Ultrasound and electrical stimulation may also be used by the sports medicine professional to help reduce pain and inflammation.

Physician Referral
A physical examination by a sports medicine professional should be done to differentiate between shin splints and stress fractures (microscopic fractures in the bone). The "gold standard" for determining the presence of a stress fracture is a bone scan. The bone scan will detect "hot spots" or areas of increased uptake to indicate a stress fracture. Depending on the stage of the injury, shin splints can progress to a stress fracture. Physicians may also order x-rays to detect a more serious fracture.

Conclusion
Finally, "shin splints" is a common overuse injury that affects athletes early in the season. But with proper care and treatment, athletes can overcome this setback and enjoy a healthy and successful year on the playing field.