Editing Shin splints

{{Short description|Inflammation of the inner edge of the shin bone (tibia)}}
{{Use dmy dates|date=September 2021}}
{{Infobox medical condition (new)
| name            = Shin splints
| synonyms        = Medial tibial stress syndrome (MTSS),<ref name=OI2019/> soleus syndrome,<ref name=Res2012/> tibial stress syndrome,<ref name=Res2012/> periostitis<ref name=Res2012/>
| image           = Tibia - frontal view2.png
| alt             =
| caption         = Red area represents the [[tibia]]. Pain is generally in the inner and lower 2/3rds of tibia.
| pronounce       =
| field           = [[Sports medicine]]
| symptoms        = Pain along the inside edge of the shinbone<ref name=OI2019/>
| complications   = [[Stress fracture]]<ref name=Res2012/>
| onset           =
| duration        =
| types           =
| causes          =
| risks           = Runners, dancers, military personnel<ref name=Res2012/>
| diagnosis       = Based on symptoms, [[medical imaging]]<ref name=Res2012/>
| differential    = [[Stress fracture]], [[tendinitis]], [[exertional compartment syndrome]]<ref name=OI2019/>
| prevention      =
| treatment       = Rest with gradual return to exercise<ref name=OI2019/><ref name=Res2012/>
| medication      =
| prognosis       = Good<ref name=Res2012/>
| frequency       = 4% to 35% (at-risk groups)<ref name=Res2012/>
| deaths          =
}}
<!-- Definition and symptoms -->

A '''shin splint''', also known as '''medial tibial stress syndrome''', is pain along the inside edge of the shinbone ([[tibia]]) due to inflammation of tissue in the area.<ref name=OI2019>{{cite web |title=Shin Splints |first=Michael J. |last=Alaia |publisher=American Academy of Orthopaedic Surgeons |url=https://orthoinfo.aaos.org/en/diseases--conditions/shin-splints |website=OrthoInfo |date=August 2019 |access-date=15 November 2020}}</ref> Generally this is between the middle of the lower leg and the ankle.<ref name=Res2012/> The pain may be dull or sharp, and is generally brought on by high-impact exercise that overloads the tibia.<ref name=OI2019/> It generally resolves during periods of rest.<ref name=Stat2019/> Complications may include [[stress fracture]]s.<ref name=Res2012/>

<!-- Cause and diagnosis -->
Shin splints typically occur due to excessive [[physical activity]].<ref name=OI2019/> Groups that are commonly affected include runners, dancers, gymnasts, and military personnel.<ref name=Res2012>{{cite journal |last1=Reshef |first1=N |last2=Guelich |first2=DR |title=Medial tibial stress syndrome. |journal=Clinics in Sports Medicine |date=April 2012 |volume=31 |issue=2 |pages=273–290 |doi=10.1016/j.csm.2011.09.008 |pmid=22341017|s2cid=262469440 }}</ref><ref>{{Cite journal |last=Lovalekar |first=Mita |last2=Hauret |first2=Keith |last3=Roy |first3=Tanja |last4=Taylor |first4=Kathryn |last5=Blacker |first5=Sam D. |last6=Newman |first6=Phillip |last7=Yanovich |first7=Ran |last8=Fleischmann |first8=Chen |last9=Nindl |first9=Bradley C. |last10=Jones |first10=Bruce |last11=Canham-Chervak |first11=Michelle |date=2021-10-01 |title=Musculoskeletal injuries in military personnel—Descriptive epidemiology, risk factor identification, and prevention |url=https://www.sciencedirect.com/science/article/pii/S1440244021000803 |journal=Journal of Science and Medicine in Sport |volume=24 |issue=10 |pages=963–969 |doi=10.1016/j.jsams.2021.03.016 |issn=1440-2440}}</ref> The underlying mechanism is not entirely clear.<ref name=Res2012/> Diagnosis is generally based on the symptoms, with [[medical imaging]] done to rule out other possible causes.<ref name=Res2012/>

<!-- Treatment and epidemiology -->
Shin splints are generally treated by rest followed by a gradual return to exercise over a period of weeks.<ref name=OI2019/><ref name=Res2012/><ref name=Stat2019/> Other measures such as [[nonsteroidal anti-inflammatory drug]]s (NSAIDs), cold packs, [[physical therapy]], and [[compression bandage|compression]] may be used.<ref name=OI2019/><ref name=Res2012/> [[Shoe insoles]] may help some people.<ref name=OI2019/> Surgery is rarely required, but may be done if other measures are not effective.<ref name=Res2012/> Rates of shin splints in at-risk groups range from 4% to 35%.<ref name=Res2012/> The condition occurs more often in women.<ref name=Res2012/> It was first described in 1958.<ref name=Res2012/>

==Signs and symptoms==
Shin splint pain is described as a recurring dull ache, sometimes becoming an intense pain, along the inner part of the lower two-thirds of the tibia.<ref>{{Cite journal |pmid=18544325|year=2008|last1=Carr|first1=K.|title=Clinical inquiries. How can you help athletes prevent and treat shin splints?|journal=The Journal of Family Practice|volume=57|issue=6|pages=406–408|last2=Sevetson|first2=E.|last3=Aukerman|first3=D.}}</ref> The pain increases during exercise, and some individuals experience swelling in the pain area.<ref>{{Cite journal |pmid = 18347118|year = 2008|last1 = Tweed|first1 = J.L.|title = Etiologic factors in the development of medial tibial stress syndrome: A review of the literature|journal = Journal of the American Podiatric Medical Association|volume = 98|issue = 2|pages = 107–111|last2 = Avil|first2 = S.J.|last3 = Campbell|first3 = J.A.|last4 = Barnes|first4 = M.R.|doi = 10.7547/0980436}}</ref> In contrast, [[stress fracture]] pain is localized to the fracture site.<ref>{{Cite journal | doi=10.1177/0363546505278305| pmid=16061959|title = A Practical Approach for the Differential Diagnosis of Chronic Leg Pain in the Athlete| journal=The American Journal of Sports Medicine| volume=33| issue=8| pages=1241–1249|year = 2005|last1 = Edwards|first1 = Peter H.| last2=Wright| first2=Michelle L.| last3=Hartman| first3=Jodi F.| s2cid=7828716}}</ref>

Women are several times more likely to progress to stress fractures from shin splints.<ref name= "YatesWhiteWhite2004"/><ref name="BennettPluemer2001">{{Cite journal | doi=10.2519/jospt.2001.31.9.504| pmid=11570734|title = Factors Contributing to the Development of Medial Tibial Stress Syndrome in High School Runners| journal=Journal of Orthopaedic & Sports Physical Therapy| volume=31| issue=9| pages=504–510|year = 2001|last1 = Bennett|first1 = Jason E.| last2=Reinking| first2=Mark F.| last3=Pluemer| first3=Bridget| last4=Pentel| first4=Adam| last5=Seaton| first5=Marcus| last6=Killian| first6=Clyde}}</ref><ref>{{Cite journal |doi=10.1001/jama.1976.03270020033020 |title=Susceptibility of women athletes to injury. Myths vs reality |journal=Journal of the American Medical Association |volume=236 |issue=2 |pages=163–165 |year=1976 |last1=Haycock |first1=Christine E. |last2=Gillette |first2=Joan V. |pmid=947011}}</ref> This is due in part to women having a higher incidence of diminished [[bone density]] and [[osteoporosis]].<ref>Healthwise Staff. (7 December 2020). ''Low bone density''. University of Michigan Health. Retrieved 26 June 2021, from https://www.uofmhealth.org/health-library/tp23004spec</ref>{{cn|date=October 2020}}

==Causes==
Shin splints typically occur due to excessive [[physical activity]].<ref name=OI2019/> Groups that are commonly affected include runners, dancers, and military personnel.<ref name=Res2012/>

Risk factors for developing shin splints include:
* [[Flat feet]] or rigid arches<ref name=OI2019/>
* Being [[overweight]]<ref name=Stat2019>{{cite journal |last1=McClure |first1=CJ |last2=Oh |first2=R |title=Medial Tibial Stress Syndrome |date=January 2019 |pmid=30860714 |website=NCBI Bookshelf |url=https://www.ncbi.nlm.nih.gov/books/NBK538479/ |url-status=live |archive-url=https://web.archive.org/web/20230329231917/https://www.ncbi.nlm.nih.gov/books/NBK538479/ |archive-date= Mar 29, 2023 }}</ref>
* Excessively tight calf muscles (which can cause excessive [[Pronation of the foot|pronation]])<ref>{{Cite journal | doi=10.1249/00005768-200003001-00001|title = Exercise-related lower leg pain: An overview| journal=Medicine & Science in Sports & Exercise| volume=32| pages=S1–S3|year = 2000|last1 = Brukner|first1 = Peter|issue = 3 Suppl|pmid = 10730988|doi-access = free}}</ref>
* Engaging the anti-pronatory (supinating) muscles in excessive amounts of eccentric muscle activity<ref name= "YatesWhiteWhite2004">{{cite journal |last1=Yates |first1=B. |last2=White |first2=S. |year=2004 |title=The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits |journal=American Journal of Sports Medicine |volume=32 |issue=3 |pages=772–780 |pmid=15090396 |doi=10.1177/0095399703258776|s2cid=24603853 }}</ref>
* Undertaking high-impact exercises on hard, [[Compliant mechanism|non-compliant]] surfaces (such as running on asphalt or concrete)<ref name= "YatesWhiteWhite2004"/>

People who have previously had shin splints are more likely to have them again.<ref name=Moen2009/>

==Pathophysiology==
While the exact mechanism is unknown, shin splints can be attributed to the overloading of the lower leg due to biomechanical irregularities resulting in an increase in stress exerted on the tibia. A sudden increase in intensity or frequency in activity level fatigues muscles too quickly to help shock absorption properly, forcing the tibia to absorb most of the impact. Lack of cushioning footwear, especially on hard surfaces, does not absorb transmitting forces while running or jumping.<ref name="De Permentier">{{Cite journal|last=De Permentier|first=Patrick|date=2014|title=An Anatomical and Physiological Evaluation of the Periosteal Layer Surrounding Bone and Its Implication in Massage Therapy|url=https://search.informit.com.au/documentSummary;dn=948539851010133;res=IELHEA|journal=Journal of the Australian Traditional-Medicine Society|volume=20|pages=272–277}}</ref> This stress is associated with the onset of shin splints.<ref name="Craig, D. I. 2008">{{Cite journal | doi=10.4085/1062-6050-43.3.316| pmid=18523568| pmc=2386425|title = Medial Tibial Stress Syndrome: Evidence-Based Prevention| journal=Journal of Athletic Training| volume=43| issue=3| pages=316–318|year = 2008|last1 = Craig|first1 = Debbie I.}}</ref> Muscle imbalance, including weak core muscles, inflexibility and tightness of lower leg muscles, including the [[gastrocnemius muscle|gastrocnemius]], [[soleus muscle|soleus]], and [[plantar]] muscles (commonly the [[flexor digitorum longus]]) can increase the possibility of shin splints.<ref name=Galbraith>{{Cite journal| doi = 10.1007/s12178-009-9055-6| issn = 1935-973X| volume = 2| issue = 3| pages = 127–133| last1 = Galbraith| first1 = R. Michael| last2 = Lavallee| first2 = Mark E.| title = Medial tibial stress syndrome: conservative treatment options| journal = Current Reviews in Musculoskeletal Medicine| date = 7 October 2009| pmid = 19809896| pmc = 2848339}}</ref> The pain associated with shin splints is caused from a disruption of [[Sharpey's fibres]] that connect the medial soleus [[fascia]] through the [[periosteum]] of the tibia where it inserts into the bone.<ref name="Craig, D. I. 2008" /> With repetitive stress, the impact forces eccentrically fatigue the soleus and create repeated tibial bending or bowing, contributing to shin splints. The impact is made worse by running uphill, downhill, on uneven terrain, or on hard surfaces. Improper footwear, including worn-out shoes, can also contribute to shin splints.<ref>{{cite web|last=Lobby|first=Mackenzie|date=9 September 2014|title=Running 101: How To Select The Best Pair Of Running Shoes|url=http://running.competitor.com/2014/09/shoes-and-gear/running-101-how-to-select-the-best-pair-of-running-shoes_49598|url-status=live|archive-url=https://web.archive.org/web/20140913081223/http://running.competitor.com/2014/09/shoes-and-gear/running-101-how-to-select-the-best-pair-of-running-shoes_49598/2|archive-date=2014-09-13|website=Competitor.com}}</ref><ref name="webmd.com">{{cite web|url=http://www.webmd.com/fitness-exercise/shin-splints#2|title=Shin Splints Symptoms, Treatment, Recovery, and Prevention|website=WebMD}}</ref>

==Diagnosis==
[[File:Shinsplint-mri.jpg|thumb|150px|[[Magnetic resonance image]] of the lower leg in the [[coronal plane]] showing high signal (bright) areas around the tibia as signs of shin splints.]]
Shin splints are generally diagnosed from a history and [[physical examination]].<ref name=Stat2019/> The important factors on history are the location of pain, what triggers the pain, and the absence of cramping or numbness.<ref name=Stat2019/>

On physical examination, gentle pressure over the tibia will recreate the type of pain experienced.<ref name=Moen2009/><ref name=AFP2011>{{Cite journal|last1=Patel|first1=Deepak S.|first2=Matt |last2=Roth |first3=Neha |last3=Kapil |year=2011|title=Stress fractures: diagnosis, treatment, and prevention|journal=American Family Physician |volume=83|issue=1|pages=39–46|pmid=21888126 |s2cid=1736230|url=https://pdfs.semanticscholar.org/88f1/b393118138d72106901d0a3a5dd2984662f5.pdf|archive-url=https://web.archive.org/web/20190212011833/https://pdfs.semanticscholar.org/88f1/b393118138d72106901d0a3a5dd2984662f5.pdf|url-status=dead|archive-date=12 February 2019}}</ref> Generally more than a 5 cm length of tibia is involved.<ref name=Moen2009>{{cite journal |last1=Moen |first1=MH |last2=Tol |first2=JL |last3=Weir |first3=A |last4=Steunebrink |first4=M |last5=De Winter |first5=TC |title=Medial tibial stress syndrome: a critical review. |journal=Sports Medicine (Auckland, N.Z.) |date=2009 |volume=39 |issue=7 |pages=523–546 |doi=10.2165/00007256-200939070-00002 |pmid=19530750|s2cid=40720414 }}</ref> Swelling, redness, or poor pulses in addition to the symptoms of shin splints indicate a different underlying cause.<ref name=Stat2019/>

===Differential diagnosis===
Other potential causes include [[stress fractures]], [[compartment syndrome]], [[nerve entrapment]], and [[popliteal artery entrapment syndrome]].<ref name=AFP2011/> If the cause is unclear, medical imaging such as a [[bone scan]] or [[magnetic resonance imaging]] (MRI) may be performed.<ref name=Stat2019/> Bone scans and MRI can differentiate between stress fractures and shin splints.<ref name=Moen2009 />

==Treatment==
It is important to reduce significantly any pain or swelling before returning to activity. 

Treatments include rest, ice, and gradually returning to activity.<ref name=Galbraith /> Rest and ice help the tibia to recover from sudden, high levels of stress and reduce inflammation and pain levels.

Strengthening exercises should be performed after pain has subsided, on [[Calf (leg)|calves]], [[Quadriceps femoris muscle|quadriceps]] and [[Gluteal muscles|gluteals]].<ref name=Galbraith /> Cross training (e.g., cycling, swimming, boxing) is recommended in order to maintain aerobic fitness.<ref>{{Cite journal|title=Tibial Stress Injuries: Decisive Diagnosis and Treatment of 'Shin Splints'|journal = The Physician and Sportsmedicine|volume = 30|issue = 6|pages = 29–36|last=Couture|first=Christopher|doi=10.3810/psm.2002.06.337|pmid = 20086529|year = 2002|s2cid = 39133382}}</ref> 

Individuals should return to activity gradually, beginning with a short and low intensity level. Over multiple weeks, they can slowly work up to normal activity level. It is important to decrease activity level if any pain returns. Individuals should consider running on other surfaces besides asphalt, such as grass, to decrease the amount of force the lower leg must absorb.<ref name="YatesWhiteWhite2004" />

[[Orthoses]] and insoles help to offset biomechanical irregularities, like pronation, and help to support the arch of the foot.<ref>{{Cite journal | doi=10.1177/1938640009355659| pmid=20400435|title = Use of Foot Orthoses and Calf Stretching for Individuals with Medial Tibial Stress Syndrome| journal=Foot & Ankle Specialist| volume=3| issue=1| pages=15–20|year = 2010|last1 = Loudon|first1 = Janice K.| last2=Dolphino| first2=Martin R.| s2cid=3374384}}</ref> 

Other conservative interventions include improving form during exercise, footwear refitting, [[orthotics]], [[manual therapy]], [[Balance (ability)#Balance training|balance training]] (e.g., using a [[balance board]]), [[cortisone]] injections, and [[calcium]] and [[vitamin D]] supplementation.<ref name=Galbraith />

[[Deep tissue massage]] is one of the massage techniques that may be useful. A technique such as deep transverse friction to relieve muscle tightness will help stop the build-up of scar tissue. This can overall release tension in the calf muscle area, relieving pressure that is causing pain.<ref name="De Permentier"/>

Less-common forms of treatment for more-severe cases of shin splints include [[extracorporeal shockwave therapy]] (ESWT) and surgery.<ref>{{Cite journal | doi=10.1177/0363546509343804| pmid=19776340|title = Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Medial Tibial Stress Syndrome| journal=The American Journal of Sports Medicine| volume=38| issue=1| pages=125–132|year = 2010|last1 = Rompe|first1 = Jan D.| last2=Cacchio| first2=Angelo| last3=Furia| first3=John P.| last4=Maffulli| first4=Nicola| s2cid=21114701}}</ref> Surgery does not guarantee 100% recovery, and is only performed in extreme cases where non-surgical options have been tried for at least a year.<ref>{{Cite journal | doi=10.2106/00004623-200310000-00017|pmid = 14563807|title = Outcome of Surgical Treatment of Medial Tibial Stress Syndrome| journal=The Journal of Bone and Joint Surgery. American Volume| volume=85| issue=10| pages=1974–1980|year = 2003|last1 = Yates|first1 = Ben| last2=Allen| first2=Mike J.| last3=Barnes| first3=Mike R.}}</ref>

==Epidemiology==
Rates of shin splints in at-risk groups are 4% to 35%.<ref name=Res2012/> Women are affected more often than men.<ref>{{Cite journal |last1=Newman |first1=Phil |last2=Witchalls |first2=Jeremy |last3=Waddington |first3=Gordon |last4=Adams |first4=Roger |year=2013 |title=Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis |journal=Open Access Journal of Sports Medicine |volume=4 |pages=229–241 |doi=10.2147/OAJSM.S39331 |issn=1179-1543 |pmc=3873798 |pmid=24379729 |doi-access=free }}</ref><ref>{{cite journal | vauthors = Macleod MA, Houston AS, Sanders L, Anagnostopoulos C | title = Incidence of trauma related stress fractures and shin splints in male and female army recruits: retrospective case study | journal = BMJ | year=1999 | volume = 318 | issue = 7175 | page = 29 | doi=10.1136/bmj.318.7175.29 | pmid = 9872880| pmc = 27673 }}</ref>

==References==
{{Reflist}}

== External links ==
{{Medical resources
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|  ICD10           = {{ICD10|M79.6}}
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{{Dislocations, sprains and strains}}

{{DEFAULTSORT:Shin Splints}}
[[Category:Overuse injuries]]
[[Category:Dislocations, sprains and strains]]