Shin Pain- the curse of pre-season training
Shin pain is common for individuals who participate in running sports and is frequently experienced by football players participating in pre-season training. This is partly due to an increased volume of running typically on hard surfaces. There are many conditions that can cause shin pain but the three most common are:
- Bone stress reaction/stress fracture of the tibia
- Medial tibial stress syndrome
- Chronic exertional compartment syndrome
Less common causes of shin pain that need to be considered include; acute fractures, insufficient blood flow (claudication), muscle tendon injuries, muscle herniations and in rare cases bone tumours. For the purpose of this article, the 3 main conditions will be discussed.
Bone stress reaction of the tibia
A bone stress reaction occurs when a bone cannot withstand repetitive loading causing localised bone fatigue and pain. If left untreated it can eventually develop into a stress fracture, which typically occurs in the posteromedial or anterior region of the tibia. An individual with this condition will report constant or increasing pain with exercise that worsens with impact. Pain is usually sharp and localised to one specific point on the tibia. An MRI or isotopic bone scan can also inform diagnosis.
Posteromedial stress fractures require an initial period of rest with the use of a pneumatic brace (Figure 1). Once pain is controlled a gradually increase in activity can occur, which is generally after 4-8 weeks of rest (more rest time is required in more severe cases).
Anterior stress fractures of the tibia are far more difficult to manage. They also require a pneumatic brace but need up to 12 months off sport for an optimal recovery.
Figure 1: An aircast used for a tibial stress fracture
Medial tibial stress syndrome
Medial tibial stress syndrome develops as the deep posterior muscles of the leg cause repetitive traction on their attachment along the medial tibia, resulting in stress injury to the tibia. It behaves in a typical inflammatory pattern and individuals will describe pain along the medial border of tibia which decreases during exercise (after warming up) but worsens afterwards or even the following day. The risk factors that lead to this condition include:
- Excessive foot pronation
- Inappropriate footwear
- A sudden increase in running/training
- Running on harder surfaces
Higher body mass
Increased calf girth
Muscle tightness and poor flexibility
Treatment involves addressing the above factors. Physiotherapy treatment can include soft tissue massage and stretching of tight muscles. A detailed assessment of foot alignment and gait mechanics is very important, as foot pronation is one of the main causes for muscles to traction the medial tibial surface. Taping techniques for excessive foot pronation can be useful and referral to a podiatrist for orthotics and foot ware advice should also be considered.
Chronic exertional compartment syndrome
There are a number of muscle compartments that make up the lower leg (Figure 2). Each of these compartments are surrounded by fascia, fibrous tissue that contains the muscles within their respective compartments.
Figure 2: Superior cross sectional view of the muscle compartments in a left lower leg.
Repetitive overuse and inflammation within these compartments can result in increased pressure, otherwise known as compartment syndrome. Individuals will report an ache, tightness or pressurised feeling in the lower leg that gradually builds during exercise (typically 10-15 minutes in) and subsides several minutes after resting. Intracompartmental pressure testing is the most accurate way to diagnose and measure compartment syndrome. Mild cases can be treated with:
- Reduced exercise
- Deep tissue massage
- Dry needling
- Correction of biomechanics
- Correction of footwear
Moderate to severe cases that are not responsive to conservative treatment usually require surgical fascial release. 80-90% of surgical cases for chronic exertional compartment syndrome have successful outcomes.
If you are experiencing shin pain see a physiotherapist or sports physician for a detailed assessment and treatment plan.
Daniel Di Mauro is a physiotherapist with Advance Healthcare in St Albans. Daniel has a special interest in complex spinal and back pain, as well as lower limb sporting injuries. Daniel provides physiotherapy services to St Albans, Sunshine, Caroline Springs and surrounding areas.