Shin Splints Physiotherapy Treatment: What We Do And What You Can Do

What Are Shin Splints?

Shin splints in plain English simply means shin bone pain. Something somewhere very close to or on the shin bone (tibia) will be hurting. There are 3 shin splint type conditions that have been categorised. Medial Tibial Stress Syndrome (MTSS), Anterior Compartment Syndrome and Deep Posterior Compartment Syndrome. We’ll touch on aspects of each of these in this article but if you’d like more details you can read more here at the NHS site to find an in depth medical description of these conditions.

What Are The Symptoms Of Shin Splints?

Medial Tibial Stress Syndrome is usually felt along the inside of the shin. In a specific area, or possibly two, somewhere along the length of the tibia. Most commonly it’s in the lower third of the tibia.

Deep Posterior Compartment Syndrome usually presents as pain along the whole length of the inside of the tibia. The deep posterior compartment comprises of the muscles that curl your foot, toes and big toe downwards. Namely Tibialis Posterior, Flexor Digitorum Longus and Flexor Hallucis Longus.

Anterior Compartment Syndrome is normally pain along the whole of the outside shin muscle. These are the muscles that lift your foot, toes and big toe up. These are called Tibialis Anterior, Extensor Digitorum Longus and Extensor Hallucis Longus.

Symptoms of all of these conditions can vary. The compartment syndromes can feel like a pressure pain. Almost as if your muscles is too big to fit into your skin. Medial tibial stress can feel a bit like that too but feels like more of a bone pain and can be quite sharp and pin point.

Why Do I Have Shin Splints?

Most likely because you increased your level of activity too quickly. You increased your training at a rate you were not able to adapt too and the associated muscles are struggling with overload. Another lesser considered option in physiotherapy treatment is that perhaps you didn’t increase your training load but your emotional load has increased.

What I mean by this is that stress levels, either obvious, or cumulative, have increased the sensitisation of your nervous system and what was previously physcially easy or a mere niggle has suddenly become painful. Your resilience to pain has reduced. We talk a lot about this in our previous article What Is Pain.

You could fall into a further category in that you’re returning from another injury and your body is not able to cope with what it once could. This would suggest there’s still a compensatory movement pattern (whether you’re aware of it or not) as a result of your old injury which is leading to overuse of the muscles that lead to the shin splint pains.

Most people we see at the clinic seeking physiotherapy shin splint treatment fall into one or more of these sweeping categorisations. For the most part of this article I will continue to mostly talk about the biomechanical causes of the pain of shin splints. But we always need to be aware, and ideally addressing, the causes of our emotional sensitisation.

Can There Be Any Complications From Shin Splints?

Yes. Stress fractures. Please don’t read that as “if I have shin splints then it will develop into a stress fracture”. These are the exception rather than the rule. I’ve only seen a couple in 18 years out of hundreds of cases of shin splints. But it is a risk.

Generally speaking if your condition is getting progressively worse then you’ll need to seek advice and treatment anyway. If your pain is fairly low grade there is a smaller chance you will develop a stress fracture. But we’d still advise to get things checked out earlier rather than later.

Just a word of warning here. There is a rare but potentially urgent case that needs to be mentioned. If the front of your shin literally feels like it’s about to explode and you’re in so much pain you can’t walk – just pop yourself up to A&E would you? It’s rare, I’ve never seen it, but I feel I should just mention it. If you’re in any doubt call 111 to rule out anything more serious.

These rare complications from shin splints largely result from pushing through things too much for too long. Pushing through the pain without seeking appropriate advice or shin splint treatment. You have been warned.

What Causes The Shin Splints Pain?

Now you’d think I’d learn by now to stop asking questions we don’t know the answers to! As with many of these things we don’t truly “know” which structures are causing the pain. Traditionally it was hypothesised that pain was caused by the traction of the muscle on the surrounding connective tissue (fascia) wrapper of the bone (periosteum). Pain was thought to be periostitis – inflammation of the periosteum.

This piece of research here suggests there is no evidence for this and suggests instead that it is “caused by bony resorption that outpaces bone formation of the tibia.” As in the bone is being worn away by the excessive use of the muscle quicker than the bone can be regenerated. As someone who knows shin splint pain well this can be what it feels like.

I should point out this research is talking about medial tibial stress syndrome rather than the other shin splints, anterior compartment syndrome and deep posterior compartment syndrome. It’s probably easiest to consider the pain from these conditions are a pure muscular overuse sensations with varying degree of increased sensitisation of the local nerves.

In my clinical experience the reason and cause of each individuals shin splint pain is entirely unique. For me this is the challenge and the fun bit. There are many common causative factors of these symptoms but everyone seems to have a unique combination of these and often a few new ones just keep me on my toes!

What Are The Factors That Lead To Shin Splints?

Having said each case is unique there are some more likely contributors to the shin pain than others. From a research perspective this piece here suggests a limitation of internal rotation at the hip can be a factor and along with increased range of movement as we point our toes (plantarflexion). Consistently flat feet, or pronation is cited in various pieces of research as a factor affecting the likelihood of developing shin splints. Gender too seems to be a factor with women more likely to develop it than men.

Putting the hip internal rotation limitation and flat feet in together in my view goes hand in hand. With pronation at the foot comes a natural internal rotation in the hip. You can try this standing up yourself. Just roll your feet inwards to go into a flat footed position and you may be able to feel how your hip joint will also roll inwards. Therefore we’re already getting closer to the end of range of internal rotation.

Having spoken about pronation I find that the opposite is often true. High arches or supination of the foot are often a facto in shin splint too. Especially in anterior compartment syndrome. It is the these muscles at the front of the shin that pull that foot into a supinated position.

Coming back to gender for a moment all of the above may be more common in women due to their relatively wider pelvis adapted for child birth. This is referred to in the physiotherapy trade as the Q-angle. As shown in the diagram to the left here.

All of these factors will seem to impact the tension in the muscles that attach to the tibia and so make the development of symptoms more likely.

Calf tension has long been cited as causative factor in shin splint conditions. That said I found very little evidence for it in the my research for this piece. Your calves are likely to feel tight with any shin splint condition as one they oppose the muscles thta cause pain in anterior compartment syndrome. And two, the deep posterior compartment sits behind the main calf muscles so when you do a calf stretch you are likely feel the tension in the deep posterior compartment rather than the calf itself.

Shin Splints Physiotherapy Treatment: What We Do

This could all very complicated and all very technical very quickly. So I’m going to give you an idea of what we would do with a case of shin splints. I do so for many reasons. Firstly, so any prospective clients get a good idea of what we do and can make an informed decision as to whether our approach is aligned with their views and needs. Secondly, for those not able to get to us for reasons of cost or geography, as inspiration of ideas to look at that go beyond the standard physiotherapy text book.

We go beyond the text book as the standard stuff rarely works! As this research concludes there is no impartial research for any of the old fashioned treatments. And this piece concludes rest as good as any of the interventions. Clinically we also find rest effective for calming symptoms. However, when training is increased again the symptoms tend to come back if nothing else, lifestyle or biomechanics, have changed.

Onto what we do. We’ll assume medial tibial stress syndrome for the sake of ease of explanation but the same principles will apply to the compartment syndromes too. We need to consider the Anatomy Trains deep front line which we show here to the left.

The muscles behind the shin bones here are the deep posterior compartment. You can see how they are continuous with a whole bunch of muscles that run through the whole body. Tension in the deep posterior compartment muscles can be  a compensation for dysfunction in any of the muscles on this deep front line. Most commonly the hip flexors, those large muscles in the stomach that lift the leg up.

These muscles will also be overworked when increasing activity too quickly. They will also become short and tight with increased stress levels. Pull yourself into a stressed, protective posture of your abdomen and perhaps you can feel these biomechanics at work.

Furthermore these deep muscles within the stomach are the where the nerve (femoral) that gives sensation on the inside of the tibia originates. We have seen many cases whereby releasing tension and therefore sensitivity of this nerve has helped many people’s symptoms.

This concept is well explained by the following picture:

We release all of these areas that can be a factor in your symptoms and re-test. Has it made things better? If yes, great. That helps us shape your individual rehab plan. If no, we move on to the next most likely factor.

Sometimes the foot position will also need to be improved. Again we’ll test before and after work on the foot to test how important that is in your rehab. Before finally moving onto the muscles causing the symptoms along your tibia we consider all the muscles in-between. The adductor on the inside of the leg being a potentially important one that contributes to pronation and also has the femoral nerve running through it as shown in the picture above.

I summarise these concepts on causes of shin splint pain in the video below:

Having considered all, or at least as many as we can think of, reasons why those shin splint muscles are tight we should have altered the way in which you move. Meaning releasing those specific muscles will be easier, less sensitive and longer lasting. Then it’s over to you to keep it that way with a combination of exercises for your biomechanics and practical wellbeing measures (where appropriate) to keep your nervous system nice and calm. Then it’s onto coming up with a progressive training plan to get you back to where you want to be. Whether that’s running a marathon or walking to the shops! And you thought it was just pain in your shins.

Are There Any Exercises That Can Help Shin Splints?

Yes but to be sure we’d need to go through the process we describe above to find out which ones will definitely work for you. This might be why in the previous research we cited stretching and strengthening the specific muscles involved with shin splints doesn’t seem to make a difference. Why would training a muscle that’s already overworking help? Why would stretching a muscle that is held tight in compensation for something else suddenly want to release?

Which is why we need to work it out. Here are a couple of the more common ways we help out clients on the exercise side of things. Firstly try stretching that deep posterior compartment as shown in the video below:

You can also modify this by placing a small wedge under your big toe or under your other four toes (only a centimetre or so) to see if that changes the effect of the stretch. With stretching never to pain. Always to comfort.

For anterior compartment syndrome stretching the quadriceps can be a good option as the quads are continuous with the tibialis anterior, the muscle of the front of the shin. This concept is another from Anatomy Trains and shown here.

And finally using the concept regarding the femoral nerve we speak about above this is a good complimentary stretch for quadriceps to more specifically target that tension along the line of the femoral nerve:

What Should I Do About Shin Splints?

Whatever it is you need to do something different to what you are currently doing otherwise you won’t see change. Perhaps give yourself a couple of weeks rest, reduce your training a little, mix up your training with some more variety or come and see someone like ourselves for that specific bespoke approach.

The truth is that after 18 years, and no more shaving of legs, each case of shin splints I have seen has been entirely unique. You can try the exercises mentioned above, you can read all you can on-line about them and that might help. But the best way to get this annoying condition sorted for good is to make changes.

So please do what you can based on all of the information we’ve outlined above. If you’d like to discuss any of this or you own personl condition in more detail then please press the Contact Us button below to arrange to speak to us:

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