Shin splints are injuries to the front of the outer leg most commonly in runners or aggressive walkers. They usually result from inflammation due to injury of the soft tissues in the front of the outer leg due to overuse. “The appropriate medical term for this condition is Medial Tibial Stress Syndrome (MTSS). Although not serious, it can be disabling and progress to serious complications like a fracture,” says Dr Biswajit Dutta Baruah, consultant orthopaedic surgeon, KIMS Oman Hospital.
Asif was referred by a friend from a local running group. He had recently joined an enthusiastic group of runners and started running daily. He even joined a competition that required daily running. After slogging it out at the office daily, running was to be the right outlet for his energy.
Asif had made a lot of new friends and running turned out to be a way to spend time with his friends. However, of late, he had started to develop pain and swelling around the lower leg and ankle regions. He had seen a local physician who ran the usual tests to see if he had elevated uric acid levels. His blood uric acid levels were normal but soon the swelling started to bother him. It is at this point that he visited my clinic.
“Doctor Sa’ab, you need to do something about this,” he blurted out. The desperation and frustration in his voice was obvious. “I used to be active in college. I was good at track events. After I joined work, this is the result,” he continued pointing at his belly. “I don’t want to give up running”, he pleaded. It was obvious that the previous physician had asked him to stop doing what he loved so much.
“Asif, we need to know the reason behind this. If we do that, then it's a matter of applying the solution.” I responded to his plea. I inquired into his running pattern making a note of the fact that he had started running long distances on a daily basis. On the preceding few days, he would start out fine and after about 5-6 km of running he had to slow down due to pain around the shin of his leg. He would walk for a few more minutes before returning home, and inevitably develop swelling around his ankle. It was frustrating that guys older than him were making it beyond the distances that he was capable of doing. “It’s likely that you have shin splints,” I told him.
The appropriate medical term for this condition is Medial Tibial Stress Syndrome (MTSS), however, it is commonly referred to as shin splints. Shin is a common term referring to the bony part felt right underneath the skin on the inner side of the lower leg. Pain on this part of the leg that comes with exertional activity, like running or brisk walking, is described as shin splints.
The important point differentiating it from other painful conditions is that it must arise or worsen in intensity following an activity. Although not serious, it can be disabling and progress to serious complications like a fracture.
Many surgeons believe that repetitive impacts on the leg, as it happens when running, puts the tibia (the major leg bone) under strain. This induces inflammation of the outer lining of the tibia (periostitis). At times, under chronic stress, there is remodelling of the bone in response to repetitive loading. In a small percentage of cases, this may end up as a stress fracture.
Too much, too fast
In the initial stages, pain subsides when the patient stops the activity. At later stages, pain may start early in the course of the activity and persist even at rest. Training errors appear to be the most common cause with athletes developing pain as they attempt to do 'too much, too fast'.
A recent onset of increased activity (increased mileage), increased intensity (running at high speeds or uphill and off road) or increased duration are common risk factors. Any individual runner doing more than 20 miles (32 km) is prone to develop this condition. Not only runners, but this can affect ballistic sports like football, basketball and dancing.
Ladies are at increased risk of the pain progressing into a stress fracture, given the higher incidence of diminished bone density and osteoporosis. Biomechanical alterations in the foot, like flat feet and muscle imbalance like overnight calf muscles (night leg cramps) can also lead to shin splints.
If the symptoms evolve into focal pain - intense pain at a single spot associated with local swelling - this may indicate a stress fracture. Presence of numbness in the feet or toes, or colour changes in the toes indicate conditions not related to shin splints.
Within the first 2-3 weeks of developing pain, X-rays could be negative. Bone formation underneath the bone capsule (periosteal reaction) or a black line may become apparent at later stages. Bone scans are used in older centres to confirm the diagnosis. MRI scans of the leg is more commonly done these days and is ordered to confirm or rule out shin splints.
In early stages, resting the limb and icing it is helpful in reducing the pain and swelling. However, rest is not necessary in those with mild pain and can be a detriment. In those in whom the pain is severe, cessation of the activity may be required for 4 to 6 weeks.
Anti-inflammatories can help control pain. Physical therapy in the form of ultrasound and electrical stimulation may aid in this phase. Decreasing the weekly duration, intensity and frequency of activity by 50% will help in quicker recovery. Runners are advised to avoid running on hard surfaces and uphills or go off-road, and prefer synthetic running tracks or a uniform surface. Cross training with other low impact exercises, like pool running, swimming, using an elliptical machine or cycling can be helpful.
Core body exercises
Strengthening the calf muscles and performing calf stretches are essential in restoring muscle balance. Doing regular core body exercises involving muscles of the hip, lower back, abdominal (stomach)and the gluteal (buttocks) are necessary. Appropriate footwear is also necessary. Balancing exercises like one leg stance or using wobble/balancing boards can help develop balance. In women with osteoporosis or osteopenia, vitamin D and calcium supplementation will be necessary. Use of crutches to unload the leg and avoid weight bearing will be necessary when there is an associated fracture. Applying a cast may be necessary in the extreme eventuality of a stress fracture.
Shockwave therapy is beneficial if there is associated tendon inflammation (tendinopathy). Other alternate remedies like dry needling, acupuncture or injections have failed to relieve symptoms, and are better avoided.
A vast majority of the patients improve with this line of treatment. Rarely is nailing required to stabilise the fracture. Releasing the tight compartment at the back of the lower leg (fasciotomy) and cauterising (burning with heat) the affected border of the tibia can be helpful.
Asif was advised scans due to the severity of his pain and swelling. However, he did not proceed with scans. Instead, he focused on reducing his activity. He turned to walking, and within a few months, his symptoms started to subsbide. These days, he's busy collecting medals, participating in virtual running events from all over the world.