Shin Pain

Shin pain is a common complaint especially among athletes. Shin pain can generally occur in one or more of three structures.

1. Tibia and fibula bone – stress fractures (“shin splints”)
2. Tenoperiosteum (connective tissue insertion of muscles into the bone) – tenoperiostitis
3. Muscle – Compartment syndrome

1. Shin splints – stress fracture of the tibia or fibula

The athlete with a stress fracture of the fibula or tibia would present with the following symptoms:

• Gradual onset of pain aggravated by exercise
• Pain that is localized and sharp
• Pain may be constant or increasing with exercise and worse with impact (e.g. running)
• There may be night aching and worsened pain in the mornings
• There is tenderness over the bone

Diagnosis and treatment

Your physiotherapist will be able to diagnose this condition from your presenting symptoms. If a stress fracture is suspected then you may be referred to your doctor for an x-ray or bone scan to confirm the presence of stress fractures. Your physiotherapist will also look at any biomechanical abnormalities e.g. over pronation that may be predisposing you to this injury.

The initial treatment of a stress fracture involves rest. Occasionally a period of non-weight bearing is required and thus you may be given crutches to use.
You should continue to rest from aggravating activities until there is no more tenderness of the bone. Your physiotherapist would be involved in your gradual return to sport, correction of any predisposing factors and treatment of any soft tissue thickening that may occur over the fracture site. They will also be able to assist you in finding alternate exercise to do in the initial stages when running is contra –indicated.

2. Tenoperiostitis

Tenoperiostitis is an inflammatory condition that occurs at the insertion of muscle through connective tissue into the bone. In the case of the shin it most commonly occurs at the medial (inside) border of the tibia at the site of muscle attachment.

Usually pain occurs at the medial border of the tibia. The pain typically decreases with warming up however can reoccur later after exercise especially being sore the following morning. There is also an area of tenderness along the medial border of the tibia. Often excessive pronation (turning out of the foot) is a predisposing factor.

Diagnosis and treatment

Your physiotherapist will be able to diagnose and treat shin pain. Your doctor may refer you for a bone scan as this would show the presence of this condition. Treatment would focus on initially reducing the inflammatory process. This would include rest from aggravating activities, electrotherapeutic modalities, and ice. Treatment would also include the use of soft tissue treatment such as deep tissue massage and release of the muscles attaching to the medial border of the tibia that are tight in this condition. Your therapist will also assess your other leg soft tissues and lower leg biomechanics. Often there may be tightness or weakness of other soft tissues that require treatment. In the case of abnormal foot biomechanics e.g.) over pronation a podiatry referral may be required to correct it, thus preventing reoccurrence of tenoperiostitis.

3. Compartment Syndrome

Within the leg there are a number of muscle compartments. These compartments are surrounded by inelastic fascia (connective tissue). If overuse of the leg occurs these compartments may become swollen and painful particularly if the inelastic connective tissue has excessive scarring.

Typically the pain will be of an ache quality and there is usually a tight, bursting feeling in the lower leg. The pain is worsened with exercise and relieved with rest. In some cases if nerve tissue becomes impinged, muscle weakness or sensory symptoms (eg. pins and needles, numbness) may occur. The leg is usually only mildly tender if at all.

Diagnosis and treatment of Shin Pain

There are two main compartments that may be affected by compartment syndrome –the deep posterior compartment and the anterior compartment. The posterior compartment usually presents as pain on the medial border of the tibia (shin bone) and calf whereas if the anterior compartment is affected pain is usually on the lateral aspect of the shin bone.

Your physiotherapist will be able to diagnose this condition. However the most definitive test for this is compartment pressure testing. In any case treatment consists initially of a conservative regimen. This would include reduced exercise and deep tissue therapy performed by your physiotherapist. Your physiotherapist would also assess your lower limb biomechanics and correct any abnormalities that may be predisposing this condition. If conservative management fails then surgery may be required to release the fascia (connective tissue) thus reducing the pressure in the muscle compartment.