Shin splints are a common cause of lower leg pain. Shin splints can be broken into two basic categories based upon the location of the leg pain;

Anterior Shin Splints -

Anterior shin splints are the most common cause of anterior shin pain.  Anterior shin splints are also called medial tibial stress syndrome (MTSS), exertional shin pain, medial periostalgia, medial tibial periostitis and traction periostitis.  MTSS is caused by overuse of the tibialis anterior muscle and tendon.  The function of the tibialis anterior is to decelerate the foot at heel strike during the gait cycle. The symptoms of MTSS occur at the origin of the tibialis anterior muscle and tendon. The origin of a muscle and tendon is usually the most proximal aspect of the muscle where it is firmly anchored to bone. In the case of MTSS, the origin is the tibia, or shin bone. MTSS pain is the result of the tibialis anterior muscle pulling the periosteum (surface lining of the bone) from the bone. 

Treatment of anterior shin splints

Diagnosis of anterior shin splints is usually based upon the location and character of the symptoms. Diagnostic testing may include x-rays, bone scans or MRI studies to rule out tibial stress fractures.

If we recognize the fact that anterior shin splints are a mechanical problem, we're safe to assume that treatment must include a mechanical solution. The key to treating anterior shin splints is to change the functional length of the tibialis anterior muscle and tendon, thereby weakening the pull of the muscle on the tibia. Pain and inflammation may also be treated concurrently, but if the mechanical component of anterior shin splints is not treated, recurrence of symptoms are likely with any increase in activities.

Biomechanical changes and changes in your training that may effect the tibialis anterior muscle are simple and include the following;

1. Decrease the length of stride - Taking shorter steps decreases the functional length of the tibialis anterior and subsequently reduces the pull of the muscle on the tibia.

2. Avoid running downhill - Running downhill will increase stride length.  Also, the excursion of the tibialis anterior increases with downhill running.

3. Modified arch support to decrease the functional length of the tibialis anterior - This can be accomplished by extending the arch of an arch support or orthotic distally to reach under the first metatarsal and big toe joint.  This modification is often called a Morton's extension. Changes should be made slowly and incrementally. As you build up and extend the arch, you are decreasing the functional length of the tibialis anterior.

4. Calf stretches - The tibialis anterior is the antagonist muscle to the calf (gastroc-soleal complex).  A tight calf will increase the work load applied to the tibialis anterior.  Calf stretching is a simple and effective way to regain balance between the tibialis anterior muscle (anterior leg) and calf (posterior leg).

5. Cross train - Vary your activities to decrease load applied to the tibialis anterior.  Alternate running with biking or swimming.

6. Range of motion exercise - Warming the tibialis anterior with range of motion exercise helps to improve strength and flexibility.  Use the ankle as the pivot point and write the alphabet with the foot, tracing an A, B, C, etc.

In addition to treating the mechanical aspects of anterior shin splints, inflammation of the tibia and tibialis anterior muscle can be address with these simple steps.

• Ice before and after activity helps to reduce the swelling of the muscle.

• Oral or topical anti-inflammatories will also reduce muscle swelling.

• Compression of the lower leg with an adjustable wrap can control swelling.

• Physical therapy to include range of motion exercises, deep tissue massage and ultrasound if possible.

• As a last resort, rest is helpful but never a final solution. Rest can be as simple as a decrease in activity, a walking cast or even a cast with crutches.

Posterior Shin Splints -

Posterior shin splints is a term used to define another, less common form of shin splints of the lower leg. The muscle and tendon that cause posterior shin splints are called the tibialis posterior. The role of the tibialis posterior is to support the arch as the body moves over the foot during the gait cycle. Posterior shin splint pain is usually specific to the medial ankle, just behind the medial malleolus.

Interestingly, in non-athletic circles, posterior shin splints is known as posterior tibial tendon dysfunction or PTTD. PTTD describes a progressive weakening of the tibialis posterior tendon. Severe cases of PTTD may result in a rupture of the tibialis posterior tendon. Knowing that the two conditions are synonymous, we can consider posterior shin splints stage 1 PTTD.

Treatment of posterior tibial shin splints

One of the keys to treating any form of tendonitis is to recognize that tendonitis is an overuse syndrome. Therefore, effective treatment lies either in modifying the way the tendon functions (biomechanical changes) or changing the activity that contributes to overuse. We know that the function of the tibialis poster tendon is to support the arch. Subsequently we can support the function of the tibialis posterior tendon by supporting the arch with a firm arch support. The tibialis posterior can also be helped by elevating the heel with a firm heel lift and by performing calf stretches to weaken the calf muscle.

• Ice before and after activity helps to reduce swelling of the muscle.

• Oral or topical anti-inflammatories will also reduce muscle swelling.

• Support of the tibialis posterior can be accomplished with elastic bracing.

• Physical therapy to include range of motion exercises, deep tissue massage and ultrasound if possible.

• As a last resort, rest is helpful but never a final solution. Rest can be as simple as a decrease in activity, a walking cast or even a cast with crutches.

Functional length of a tendon - every muscle and its' associated tendon have a normal range of excursion of length in which they are accustomed to working. This normal length is referred to as the functional length. Any activity that forces the muscle to exceed its' functional length will result in stress being applied to the origin of the muscle, the muscle, the tendon or the insertion of the tendon.

Insertion of a muscle - the insertion is normally the most distal aspect of the muscle/tendon complex where the tendon attaches to bone. In concentric muscle contraction, the insertion moves in a direction towards the origin of the muscle.

Muscle/tendon complex - muscles and tendons work together to perform work. When muscle contracts it apples tension on a tendon, thereby performing work.

MTSS - medial tibial stress syndrome.

Origin of a muscle - the origin of a muscle is usually the most proximal aspect of the muscle. Concentric contraction of the muscle works in a direction moving towards the origin.

Pathomechanics - biomechanical function that results in injury.

Periosteum - the surface lining of bone.

Periostitis - inflammation of the periosteum.

Shin - refers to the lower leg, more specifically, the tibia or larger bone of the leg.

Traction - to pull.  The term traction periostitis is used to describe how the tibialis anterior pulls the periosteum from the tibia.

Anterior shin splints -

Knowing the origin of the tibialis anterior muscle becomes important when trying to differentiate the many cause of shin pain. First, let's take a look at some simple anatomy. As we mentioned, the tibialis anterior muscle and tendon originate from the front of the tibia or shin bone. This origin begins just distal to the knee and continues halfway down the leg, therefore we can say that the origin of the tibialis anterior muscle is the proximal half of the tibia. Also, the origin is not just on the front of the tibia, but actually tucked a little under the lateral or outside edge of the tibia.

Posterior shin splints -

The posterior tibial muscle originates from the back of the tibia, deep to the calf muscle. As it descends the leg it narrows to become the posterior tibial tendon. As the posterior tibial tendon descends the leg, it follows a path immediately behind the posterior aspect of the medial malleolus (ankle bone) making an abrupt turn to continue to the medial arch. In the arch of the foot, the posterior tibial tendon branches into nine different insertions in the bottom of the foot. Posterior shin splints are a true form of tendonitis and occur in the body of the tibialis posterior tendon behind the medial malleolus (inside ankle bone).

Anterior shin splints -

Now let's talk biomechanics. As we walk or run, the tibialis anterior has two functions. The first occurs at heel contact when the tibialis anterior acts to slow the motion of the foot as it hits the ground. Without a tibialis anterior muscle and tendon, the foot would slap the floor at heel contact. This slowing action is referred to as deceleration and contributes to the controlled gradual motion of the ankle to which we are so accustomed. The second function of the tibialis anterior is to lift the foot during the swing phase of gait. Swing phase is the period when there is no weight on the foot following toe off and just prior to heel contact. During swing phase, the tibialis anterior lifts the foot to prevent it from dragging on the ground.

What causes anterior shin splints? Quite often the cause of anterior shin splints is over striding. Over striding increases the normal functional length of the tibialis anterior. Essentially, much of the range of motion of a muscle and tendon has to do with the changes in its' overall length. In the case of the tibialis anterior, we know that at heel contact, the muscle acts to decelerate the foot as it hits the ground. As the foot moves to hit the ground, the tibialis muscle and tendon lengthen. So, if we increase the length of stride, the tibialis anterior muscle and tendon lengthen more. In the case of anterior shin splints, the tibialis anterior muscle and tendon cannot keep up with the demands placed upon it and, as a result, the muscle is forced to find new ways to gain length. Quite often that additional length is gained by the muscle pulling away (traction) from it's origin. In the case of the tibialis anterior muscle and tendon, we call that traction periostitis.

We know that anterior shin splints are common in runners, but let's use an example found in everyday life. Bridgit is a new postal worker. She's 5'2 tall and she's training for a walking mail route in her home town. Her mentor is Jim who has worked the route for years. Jim is 6'3 tall. Jim and Bridgit begin to work together walking the eight mile route everyday. Bridgit really wants to get this new job, so she tries her hardest to keep up with Jim even though she has a hard time. Jim is so much bigger, and to simply keep up, Bridgit has to over stride to compensate for their physical differences. By the end of the first week, Bridgit is in trouble. She has pain in the front of her shins. She has anterior shin splints.

Posterior shin splints -

The tibialis posterior muscle and tendon acts as the primary support of the medial arch. The tibialis posterior muscle and tendon also acts to plantarflex the foot at the toe off phase of the gait cycle and assists the Achilles tendon in its' function to move our body's up and forward.

When we think about treating the symptoms of posterior shin splints, we need to consider the function of the posterior tibial tendon (PT tendon). Many cases of posterior shin splints are caused by increased activities with no control of pronation (flattening of the arch). The mid stance and toe off phases of gait place a significant load on the posterior tibial tendon. The PT tendon will attempt to maintain the normal height of the arch and aid in toe off, assisting the calf and Achilles tendon. If the loads applied to the PT increase faster than what the tendon can accommodate, tendonitis will result.

Anterior shin splints -

Earlier in this discussion we reviewed some anatomy and defined the origin of the tibialis anterior muscle and tendon on the anterior and antero-lateral aspect of the tibia. The symptoms of anterior shin splints are very specific to this location (refer to the blue area in the picture to the right). Swelling is uncommon. The inflamed area will be tender to touch.

In the early stages of anterior shin splints, pain is very similar to that of other forms of tendonitis. Sharp pain will be significant upon the onset of an activity. As the activity progresses, the pain subsides until the normal end of the activity is reached, at which time the same pain returns.

In advance cases of anterior shin splints, in addition to the pain with the onset of the activity, the origin of the tibialis anterior becomes inflamed and cannot heal. This results in chronic pain from inflammation at the origin of the tibialis anterior. Patients will describe pain with each and every step of the day.

Posterior shin splints -

The signs and symptoms of posterior shin splints are uniquely different from anterior shin splints. Posterior shin splints are the result of inflammatory pain of the posterior tibial tendon. The symptoms of posterior tibial shin splints occur 8-10m cm proximal to the most distal tip of the medial malleolus (inside ankle bone). This area is highlighted in orange on the picture to the right. Swelling is uncommon. Pain will present with direct palpation of the tendon.

Posterior shin splints also exhibit classic tendonitis symptoms as described above. In the early stages of posterior shin splints, pain is noted at the beginning of an activity and seems to 'warm up' over the first five minutes or so of the activity. In advanced cases, pain is constant and can be aggravated by any form of weight bearing.

Anterior shin splints

Compartment syndrome
Tibial stress fracture
Lumbar radiculopathy

Posterior shin splints

Tarsal tunnel syndrome
Sinus tarsi syndrome
Subtalar joint arthritis
Talar fracture
Talar dome fracture
Flexor tendonitis or flexor hallucis longus tendon rupture
Shepard's fracture

• Achilles Tendonitis

• Posterior Tibial Tendon Dysfunction

• Talar Dome Fracture

• Sinus Tarsi Syndrome

This article was written by Jeffrey A. Oster, DPM.  Dr. Oster is a board certified podiatrist and medical director of Myfootshop.com.  This article was last updated 5/1/08.  Additional references include;

1. Batt ME, Ugalde V, Anderson MW, Shelton DK.  A prospective controlled study of diagnostic imaging for acute shin splints.  Med Sci Sports Exerc 1998;30(11):1564-1571.

2. Moore MP.  Shin splint diagnosis, management, prevention.  Postgrad Med 1998;83(1):199-210.

3. Bruker P, Khan K, Bradshaw C. shin pain. In: Bruker P, Khan K, eds. Clinical sports medicine. 2nd ed. Sydney Aust.:Mcgraw Hill; 2001:508-523.