Many people ask whether shin splints are caused by trigger points. This may be because the leading book on trigger point self-treatment implies that shin splints are associated with trigger points. They are not, however, according to the leading authorities, Travell and Simmons. Before I explain about shin splints and trigger points, let’s discuss what trigger points are and what causes them. The first thing to understand is that they are not as specific as they seem.
Shin Splints is not an Accurate Term
If you ask a doctor what shin splints are you probably will not get a straight answer. That is because there are no straight answers to give. Shin splints is the generic name we use for any leg pain that is below the knee and above the ankle. The term is nondescriptive and does not refer to any one type of pain or pathophysiology. It is often called a “wastebasket” diagnosis.
Shin splints, therefore, should not be considered an adequate diagnosis of chronic lower leg pain as this will offer no guidance to treatment and avoidance. Basically, if your doctor tells you that you have shin splints they are basically telling you that you have shin pain, which you probably already knew!
Is There a Technical Name for Shin Splints?
However, there is a typical pain syndrome, called Medial Tibial Stress Syndrome, that can be considered somewhat synonymous with shin splints. This syndrome causes pain that usually occurs in the lateral front of the lower leg or more to the inside of the lower leg, called the “posteromedial” region. It is most common following repetitive running and jumping activities such as running, volleyball, and soccer. There are many articles that will run through all the complexities of shin pain and try to tell you the truth about shin splints by dumping data about all the many causes..but most of them are rare compared to MTSS.
Cause of Shin Splints
Medial tibial stress syndrome (MTSS), also called Medial Tibial Periostalgia or Medial Periostalgia, usually follows an abrupt increase in activity or training. The culprit, simply put, is doing too much too soon. Those who play seasonal sports but fail to train at a proper level off-season may suffer from them. Also, if you are used to only playing tennis for recreation and suddenly switch to long distance running, don’t be surprised by the abrupt appearance of shin splints. Therefore, this condition could be considered to be the bane of those who consider themselves in shape but forget that fitness is specific and all activities must be approached with a proper buildup in training level.
Running on hard surfaces and running on the toes of your feet are also associated factors. Besides running, any high impact activities, such as gymnastics and ballet dancing, are associated with this condition. If you are getting ready to go into military basic training, expect the possibility of shin splint pain due to marching in combat boots and hard shoes, often on hard surfaces, with no shock absorption capabilities.
At first, the pain may tend to decrease rapidly with rest but as it grows worse it becomes more persistent and severe. The pain may eventually occur even when the leg is not bearing weight.
Be aware that the onset of this syndrome may mimic that of stress fractures. However, stress fractures are associated with point tenderness over a specific area. With MTSS, the tenderness will occur over a much broader zone. It is also important that medial tibial stress syndrome not be confused with acute compartment syndrome, which is a much more serious condition. All three of these, MTSS, stress fracture, and compartment syndrome may be diagnosed under the blanket term “shin splints.” All three have been variously described as causes of shin splint in various articles and literature but this is improper since shin splints are usually thought of as a benign condition.
The American Medical Association has limited the definition of shin splints to musculotendinous inflammation, excluding stress fractures and acute and chronic compartment syndromes. This is proper since it is very foolish to lump a benign inflammatory condition like MTSS with conditions such as stress fractures, compartment syndromes, or other serious conditions. Ischemic disorders, popliteal artery entrapment or even fascial hernia are possible, any of which could be considered medical emergencies.
Even though MTSS may be the most common benign cause of shin splint symptoms, other causes of shin pain are still possible besides the above mentioned serious conditions. As well, the term has been applied to inflammation of the tendons of the anterior and posterior tibialis muscles and inflammation of the interosseous membrane between the fibula and tibia.
What is Medial Tibial Stress Syndrome (MTSS) Exactly?
The pathogenesis of MTSS is unknown although there are several common theories. Medial tibial stress syndrome is thought to be a periostitis. A periostitis is an inflammation of the periosteum. In MTSS, the inflammation occurs along the posteromedial border of the tibia, commonly in the distal third of the bone.
Previously it was thought that MTSS was due to myositis, fasciitis, or periostitis of the posterior tibialis muscle but now the soleus muscle, which covers the medial third of the heel core as it inserts into the calcaneus, is thought to be the culprit.
It may be caused by excessive stress on the medial tibial fascia by the deep posterior compartment muscles like the tibialis, soleus, and flexor digitorum longus. During overpronation, an eccentric contraction of the soleus occurs to control pronation, causing periostitis of the soleus insertion along the posterior medial tibial border. According to Detmer 1Detmer DE. Chronic shin splints: classification and management of medial tibial stress syndrome. Sports Med. 1986; 3:436-446., there is an actual separation of the periosteum from the tibial cortex due to rupture of the sharpey’s fibers (the fibers that actually attach the muscle to the periosteum). For this reason, some texts prefer the term medial periostalgia, medial tibial periostalgia, soleus periostalgia, or chronic periostalgia, etc. since the term periostalgia denotes a painful condition of the periosteum but not necessarily an inflammatory one.
The specific etiology of shin splints is yet to be pinned down. There are several biomechanical factors and external factors that may contribute to the syndrome.
- variations in foot structure and functions:
- rearfoot valgus – extremely rare but associated with severe tibial valgum (knock-knees) and excessive subtalar pronation. Footmaxx.com. 2The Five Most Common Pathomechanical Foot Types. Rep. Footmaxx.com. Web. 15 July 2011. <http://www.footmaxx.com/uploaded/product_category_pdf/file_22.pdf>.
- forefoot varus – inverted position of the forefoot relative to the rearfoot at the level of the midtarsal joint 3The Five Most Common Pathomechanical Foot Types. Rep. Footmaxx.com. Web. 15 July 2011. <http://www.footmaxx.com/uploaded/product_category_pdf/file_22.pdf>.
- weakness of lower leg musculature
- leg lenghth discrepancy
- tibial torsion – inward twisting of shin bones
- tibial varum (bow-leggedness, bandiness, bandy-leg, or tibia vara)
- excessive femoral anteversion
- increased Q angle
- tightness of gasrocneumeus and soleus muscles and limited ankle dorsiflexion
- worn or ill-fitting shoes and shoes with no shock absorption
What About Trigger Points? Do They Cause Shin Splints?
Shin Splints of MTSS origin are not associated with the referred pain from trigger points, although Davies misleadingly implies that they are by saying that trigger points in the shin muscles “result” in shin splints although this pain is “not the same as referred pain from trigger points,” a statement that makes no sense sense since an operating definition of a trigger point is a localized band of taut tissue that refers pain to other areas, rather than “chronic overload tension.” Although The Trigger Point Therapy Workbook is a fantastic resource and recommended highly, Davies had the unfortunate tendency to want MOST conditions to be related to trigger points and treatable by trigger point massage. 4Anderson, Marcia K. “Chp. 12: Lower Leg, Ankle, and Foot Conditions.” Fundamentals of Sports Injury Management. Philadelphia: Lippincott Williams & Wilkins, 2003. 227-28. Print.
Note that trigger points in the shin muscles themselves, the tibialis anterior, extensor digitorum longus, and extensor hallucis longus do not send pain to the medial mid shin area, as with MTSS shin splints, but to the top of the foot and toes. Trigger points in the soleus muscle sends pain to the calf area, the achilles tendon and heel area, and the medial ankle.
According to Travell and Simons “the strong relation of periostalgic shin splints [shin splints from MTSS] to the kind and amount of exercise, and the localization of pain and tenderness to the insertion of the overstressed muscle distinguishes this condition clinically from myofascial TrP syndromes.“5Micheo, William. “Medial Tibial Stress Syndrome.” Musculoskeletal, Sports, and Occupational Medicine. New York: Demos Medical, 2011. eBook. Why Davies chose to associate shin splints with trigger points is unknown. Nevertheless, general self-myofascial release of the shin muscles is recommended and could certainly be helpful. 6Travell, Janet G., and David G. Simons. “Chp. 22: Soleus and Plantaris Muscles (Shin Splints_.” Myofascial Pain and Dysfunction. the Trigger Point Manual : the Lower Extremities. Baltimore: Williams & Wilkins, 1992. 443. Print.
Symptoms and Presentation
The presentation of shin splints of MTSS origin can vary from person to person. Typically, however, the pain develops during later stages of training or exercise and gets better after rest. As the condition progresses the pain may develop earlier in the training session, may be more intense, and may linger after exercise. With severe and chronic cases, the pain may go away with rest only to come back later even if the leg is not bearing weight. As stated above, the presentation may be somewhat similar to stress fracture, at first, but the pain and tenderness from stress fracture is usually very focal and does not respond to rest and other treatment as quickly as MTSS. There may also be:
- tenderness over a broad zone of the tibia, usually the middle third
- mild swelling
Shin splints will generally respond to conservative treatment, modification of activity, and attention to proper footwear.
- Initially, only do activities or exercise that can be done without pain. For instance, if you have shin splints from running, switch to bike riding. If a simple reduction in volume (mileage) or intensity will allow you to exercise without pain, this is fine. Sometimes, it may be best to take a couple of weeks off from training, especially with more severe cases.
- For acute shin splints (MTSS) use RICE can be used although as stated above, the “Rest” portion may be relative rest. Ice can be useful for the acute pain symptoms, generally after exercise. Wrapping for support can help in severe cases. See Shin-Splint Taping Instructions below.
- NSAID’s (Nonsteroidal Anti-Inflammatories) can be used to control pain, initially. Avoid long-term use.
- Stretch the gastrocnemius and soleus, the achilles tendon, in general, the “anterior compartment” of the lower leg, to establish greater ankle dorsiflexion range of motion.
- Self-massage of the calf muscles and soleus are recommended. Use a tennis ball or self-massage tool like the Tiger Tail Stick Massager to work these muscles
- Engage in regular comprehensive mobility training with an emphasis on lower extremity mobility, including hip mobility as well as ankle mobility
- Strengthening the muscles at the front of the lower leg can be useful. Toe taps progressed to toe curls with very light weight and moderate volume can be used
- Consult a podiatrist for foot issues like flat feet, etc.
A compressive wrap around the lower leg can provide some gentle support and relief of pain for shin splints. The taping procedure is simple and will use 1.5 or 2-inch elastic or non-elastic athletic tape.
- If needed shave the skin, then wash and dry the area.
- And under-wrap can be used first, before taping, if desired. A spray adhesive can be applied to the skin prior to taping, to help the tape stick better.
- Prepare separate strips of tape long enough to wrap about the lower leg.
- Starting just above the achilles tendon, apply separate strips, overlapping each strip by half the width of the strip, to about 6 to 8 inches above the ankle
- Do not wrap the leg too tightly, only gentle support is needed!
7France, Robert C. Introduction to Sports Medicine & Athletic Training. Australia: Thomson/Delmar Learning, 2004. 240. Print.,8Behnke, Robert S. Kinetic Anatomy. Champaign, IL: Human Kinetics, 2001. 224. Print.,9Hammer, Warren I. “Chp. 7: The Knee and Leg.” Functional Soft-tissue Examination and Treatment by Manual Methods. Sudbury, MA: Jones and Bartlett Pub., 2007. 390. Print..
Instead of taping the lower legs, also available are shin splint compression sleeves. Many users report a good experience with these products.
Sources [ + ]
|1.||↲||Detmer DE. Chronic shin splints: classification and management of medial tibial stress syndrome. Sports Med. 1986; 3:436-446.|
|2, 3.||↲||The Five Most Common Pathomechanical Foot Types. Rep. Footmaxx.com. Web. 15 July 2011. <http://www.footmaxx.com/uploaded/product_category_pdf/file_22.pdf>.|
|4.||↲||Anderson, Marcia K. “Chp. 12: Lower Leg, Ankle, and Foot Conditions.” Fundamentals of Sports Injury Management. Philadelphia: Lippincott Williams & Wilkins, 2003. 227-28. Print.|
|5.||↲||Micheo, William. “Medial Tibial Stress Syndrome.” Musculoskeletal, Sports, and Occupational Medicine. New York: Demos Medical, 2011. eBook.|
|6.||↲||Travell, Janet G., and David G. Simons. “Chp. 22: Soleus and Plantaris Muscles (Shin Splints_.” Myofascial Pain and Dysfunction. the Trigger Point Manual : the Lower Extremities. Baltimore: Williams & Wilkins, 1992. 443. Print.|
|7.||↲||France, Robert C. Introduction to Sports Medicine & Athletic Training. Australia: Thomson/Delmar Learning, 2004. 240. Print.|
|8.||↲||Behnke, Robert S. Kinetic Anatomy. Champaign, IL: Human Kinetics, 2001. 224. Print.|
|9.||↲||Hammer, Warren I. “Chp. 7: The Knee and Leg.” Functional Soft-tissue Examination and Treatment by Manual Methods. Sudbury, MA: Jones and Bartlett Pub., 2007. 390. Print.|