Shin Pain (Care of the Young Athlete)

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Shin pain occurs most frequently in athletes
involved in running, jumping, or high-impact sports. Shin pain can be caused by
shin splints (also called medial tibial stress syndrome), a
stress fracture of the tibia or fibula, or compartment syndrome (Figure 1). The
most common source of shin pain in runners is shin splints.

Figure 1: Location of common causes of shin pain. A.
shin splints, B. compartment syndrome, and C. stress fracture; fibula and
tibia.

Symptoms

For all of the different causes of shin pain,
athletes often complain first of pain, burning, or tightness along the shin. The
following are symptoms of bone-related and muscle-related shin pain.

Symptoms of bone-related shin pain may
include

  • Pain in a very focal area of the
    shin

  • Pain during and after running

  • Pain that gets worse over time

Symptoms of muscle-related shin pain may
include

  • Mild soreness

  • Tightness or pressure in shins with
    running

  • Pain only with running, relieved by
    rest

  • No pain when pushing on the bone

  • Numbness, tingling, or weakness in the
    foot

Causes

Shin pain is generally the result of one or more
of the following issues:

  • Body mechanics refers to
    the way the body moves while in motion. Athletes may experience pain due
    to poor body mechanics. The way the body moves can be influenced by
    different factors. For example, how a runner runs may be affected by
    foot type, running style, and hip and core (abdominal and back) muscle
    strength.

  • Too much exercise can
    become a problem if athletes increase too quickly. A helpful reminder is
    the “10% Rule”: no more than a 10% increase
    in frequency, duration, or intensity of exercise per week.

  • Bone density (bone
    strength).
    Softer bones break easier, so if there is a stress
    fracture that is not explained by poor mechanics or rapid increases in
    training, bone density might be the problem. The causes of low
    bone density
    include

    • Genetics (it tends
      to run in families)

    • Not enough calcium
      in the diet (more than 1,300 mg/day is the recommended daily
      amount, equal to 3 to 4 servings of milk, yogurt, cheese, or
      other sources)

    • Irregular periods
      (no menstrual period for more than 6 months in a row), which
      causes low levels of the hormone estrogen

Tests

Shin splints can be diagnosed by their
characteristic symptoms and physical examination findings. A stress fracture is
suspected when shin pain becomes more severe, more localized (in a focal area),
or if there are risk factors for weaker bones such as the female athlete triad.
X-rays may show a stress fracture if the problem has been present long enough to
see a healing response (4–6 weeks). However, x-rays can appear normal
even when a stress fracture is known to be present. In order to confirm the
presence of a stress fracture, it may be necessary for magnetic resonance
imaging (MRI).

Athletes with compartment syndromes will have
normal x-rays and no evidence of bony abnormalities with bone scan or MRI.
Compartment syndrome is confirmed by taking a pressure measurement through a
needle inserted into the muscle both before and after exercise.

Treatment

A period of rest from running may be needed for
the stress fracture or shin splints to heal. Although the athlete may be able to
run with shin splints, continuing to do so may cause the shin splints to
progress to a stress fracture. During rest, cross-training with nonimpact
activities (such as using an elliptical machine, biking, swimming, and weights)
can be done if the athlete is pain-free. Ice and acetaminophen are effective for
pain, but nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or
naproxen may actually slow the healing of some stress fractures. Other
treatments like bone stimulators are controversial. In very rare cases rest is
not enough for a fracture to heal, and surgery is needed.

Prevention

Shin splints and stress fractures can be reduced
by allowing time to gradually build up to higher levels of impact activity
(increase by no more than 10% per week). If an athlete has flat feet or
high-arched feet, a proper shoe and/or shoe insert may be helpful. Since stress
fractures in the shin usually start with shin splints, identifying and treating
shin splints—before they progress—can prevent the development of
stress fractures. Maintaining healthy bone through good diet (high in vitamin D
and calcium), safe weight loss practices, and attention to any menstrual
problems may also reduce the risk of stress fracture.

Compartment syndromes are more difficult to
prevent. However, balancing low-impact conditioning with high- impact
conditioning, selecting softer surfaces for running, and using a properly
cushioned running shoe may help.