Shin pain is a common complaint often called “shin splints.” The most common cause is inflammation of the periosteum, which is a fibrous covering of bone where the muscles attach.  The term used to describe this is medial tibial stress syndrome.  Shin pain can also be caused by micro fracturing – stress fracturing of the tibial area.  The third potential cause is called chronic compartment syndrome. During exercise, muscles will increase in size due to an increased blood flow to the muscle. If the fascial compartment in which a muscle is contained is not large enough, it will result in pain. These injury processes can occur separately, or a component of each can co-occur, making diagnosis difficult. The various pathologic processes can be differentiated by examination and investigation.

Symptoms associated with medial tibial stress syndrome are pain along the lower 1/3 of the tibia, which is induced by exercise but generally settles down after warming up and may return after exercise.

The pain associated with stress fractures is generally much more localized and intense. It is also more of a continuous pain that is worse with the impact of running. Plain X-rays will not show any changes in the early stages of stress fractures.

Chronic compartment syndrome causes aching and tightness, which increases with exercise and decreases with rest. Compartmental pressure before, during, and after exercise can be used to diagnose it.

Biomechanical factors have been shown to contribute to the development of medial tibial stress syndrome significantly. Poor core stability, inward foot rolling, and muscle conditioning are potent causes. The large, deep calf muscle (soleus muscle) undergoes a muscular eccentric contraction when walking and running. Prolonged eccentric contraction can occur to control the excessive inward rolling of the foot, placing an abnormal amount of stress on where the muscles attach to the bone, leading to inflammation.

Two mechanisms hypothesized as leading to tibial stress fractures are weakening of the bone due to chronic inflammation of the muscle attachments to the tibia and excessive forward bending of the tibia as the foot impacts the ground during running.  Due to its strength and significant attachment area on the back of the tibia, the soleus will prevent the tibia from bending forward. It can become fatigued because of prolonged eccentric contraction, allowing more forward bending of the tibia and resulting in microfracture in the front of the tibia.

Treating shin pain involves reducing the load by resting and encouraging activities that don’t stress the shin, such as swimming, cycling, or low-impact gym training.

Ice massage for 20 minutes over the painful area immediately after activity reduces inflammation and alleviates symptoms.

Non-steroidal anti-inflammatory drugs, such as Nurofen, and deep soft tissue massage are also helpful. The most effective treatment to prevent shin pain from reoccurring is to address the underlying cause of shin splints.

Once the initial pain and inflammation have settled, a stretching and strengthening program can begin. Return to activity needs to be graduated while monitoring symptoms.

Compression sleeves around the lower leg can help reduce swelling and provide support during healing.

Correcting abnormal biomechanics using orthoses, footwear, and exercises to restore normal function will help reduce the prolonged eccentric contraction of the deep calf muscles.

If chronic compartment syndrome is confirmed with compartmental pressure testing, the only treatment other than abstaining from physical exercise is surgical release of the tight fascial compartment surrounding the muscle. Still, fortunately, this is not very common.