Shin splints

Shin splints: causes, symptoms, and complete treatment

Shin splints (tibial periostitis) are an inflammation of the periosteum, the membrane that covers the shin bone (tibia). This overuse injury primarily affects runners and causes pain on the inner side of the leg. Physiotherapy leads to a full recovery in the vast majority of cases.

What are shin splints (tibial periostitis)?

Tibial periostitis is an inflammation of the bone covering of the shin bone (tibia). It occurs when leg muscles repeatedly pull on this membrane, causing a gradual irritation of the periosteum.

The periosteum is a thin membrane containing blood vessels and nerves. These structures nourish the bone and allow it to repair itself. When the periosteum becomes irritated, it becomes sensitive and painful. This inflammation can also affect the areas where muscles attach to the bone.

Several muscles attach to the inner side of the shin bone. The soleus (deep part of the calf), posterior tibialis, and toe flexor muscles exert a pull on the periosteum with each step. When this pulling action is repeated too often or too forcefully, inflammation gradually develops.

Shin splints account for 13 to 17% of running injuries.¹ They affect between 4% and 35% of runners, depending on the study, and up to 35% of military recruits.² This significant variation depends on activity level, running technique, and injury history.

Anatomy of the Shin Bone (Tibia) and Periosteum

The tibia is the main bone in the leg, supporting about 85% of body weight when standing. The periosteum that covers it plays a crucial role in bone repair and transmitting muscle forces. This membrane contains many nerve endings, which explains why periostitis is so painful.

What Causes Shin Splints?

Shin splints occur when the leg muscles experience too much repetitive stress. The main causes include a sudden change in training, improper running technique, or worn-out shoes. Several factors often contribute simultaneously to the development of this injury.

Training errors

Increasing your running volume too quickly is the most common cause. Adding more than 10% distance per week often exceeds the tissues' ability to adapt. Changing surfaces (like going from trails to concrete) or intensity can also trigger the injury.

Runners who start an intensive training program without gradual progression are particularly at risk. Suddenly switching from walking to running, or adding interval training without adequate preparation, quickly overloads the leg structures. Knee pain can also appear simultaneously if the training load increases too quickly.

Biomechanical factors

Excessive pronation increases the pull on the inner side of the shin bone. A valgus knee (knock-knee) amplifies this problem. Ground impact generates forces 2 to 3 times your body weight with each stride.³ A low cadence (fewer than 160 steps per minute) significantly increases these impact forces.

Weakness in the hip stabilizing muscles can also contribute. When the gluteal muscles and external hip rotators are weak, the knee tends to collapse inward (dynamic valgus), increasing stress on the shin bone. This weakness can also lead to other injuries like patellofemoral pain syndrome.

Inappropriate Footwear

Running shoes lose 25% to 40% of their cushioning capacity after 500 to 800 km of use. Worn-out shoes or those not suited for your foot type contribute to the problem. Wearing shoes that are too rigid or too flexible for your foot type can also create problematic biomechanical compensations.

Using minimalist shoes without gradual adaptation is a common cause of shin splints. The sudden switch to shoes with less cushioning increases stress on the calf and shin bone.

Training Surfaces

Running exclusively on hard surfaces like concrete or asphalt increases impact forces. Varying your training surfaces (trails, track, grass) helps distribute stress differently and reduces the risk of overuse injuries.

What Are the Symptoms of Shin Splints?

Shin splints cause a dull pain along the inner side of the shin bone, especially during running. The pain worsens with activity and lessens with rest. The shin bone may be tender to the touch over several centimeters.

Typical location

The pain is located on the postero-medial side of the tibia (inner side). It covers an area of 5 to 15 cm, in the middle or lower third of the leg. This area corresponds to where the deep foot flexor muscles attach.

Unlike calf muscle pain, shin splint pain is located directly on the bone, not in the muscle belly. Pressing along the inner edge of the shin bone reproduces the pain.

Characteristic pain pattern

The classic pattern of shin splints follows this progression:

• Pain at the start of a run
• Decreases during warm-up
• Returns if activity continues
• Disappears with rest

In severe cases, the pain persists after exercise or appears when walking. Pain can also occur in the morning upon waking or after a prolonged period of sitting. These symptoms indicate more significant inflammation that requires immediate attention.

Signs to watch for

Shin splints do not cause visible swelling or local warmth. If you experience numbness, tingling, or pins and needles in your leg, you might have leg neuralgia. These neurological symptoms suggest nerve involvement rather than inflammation of the periosteum.

If you notice significant swelling or local redness, seek medical attention promptly. These signs could indicate a complication like compartment syndrome or an infection, although these conditions are rare.

Difference from Other Leg Pains

Shin splints are different from a calf strain because the pain is located on the bone rather than in the muscle. They also differ from Achilles tendonitis, which causes pain at the back of the ankle instead of on the shin bone.

How to Differentiate Shin Splints from a Stress Fracture?

Shin splints cause a widespread pain along several centimeters of the shin bone. A stress fracture, however, results in localized pain at a specific spot and can hurt even at rest, sometimes during the night.

When Medical Imaging is Needed

X-rays are often normal in both cases initially. If your physiotherapist suspects a stress fracture after evaluation, an MRI can confirm the diagnosis.⁴ This imaging allows for the detection of changes in the bone before they are visible on a standard X-ray.

A tuning fork test is sometimes used in a clinical setting to distinguish between shin splints and a stress fracture. When a vibrating tuning fork is placed on the shin bone, it will significantly reproduce pain if a fracture is present, but not if it's shin splints.

What are the risk factors?

Key risk factors include a rapid increase in running volume, poor biomechanics, and a history of similar injuries. Women and new runners are particularly at higher risk.

Modifiable factors

• Increasing volume or intensity by more than 10% per week
• Worn-out shoes (used for over 500-800 km)
• Running exclusively on concrete without varying surfaces
• Weakness in calf and foot muscles
• Low running cadence (fewer than 160 steps per minute)
• Lack of complementary strength training
• Poor running technique (e.g., a pronounced heel strike)
• Insufficient recovery between workouts

Non-modifiable factors

• Female gender (1.5 to 3 times higher risk)
• History of shin splints (the main factor for recurrence)
• Structural overpronation of the foot
• Knee valgus (knock-knees)
• Tibial dysfunction (excessive internal tibial twist)

Nutritional Factors

A deficiency in vitamin D or calcium can impact bone health and raise the risk of stress injuries. Poor nutrition, particularly in female athletes, can also compromise bone density and hinder recovery.

How Does Physiotherapy Treat Shin Splints?

Physiotherapy treatment involves a running analysis, strengthening exercises, and a gradual management of your training load. The goal is to address the root cause, not just the pain itself.

Comprehensive assessment

Your physiotherapist will assess:

• Your recent running and training history
• The mobility of your ankle and foot
• The strength of your calf, foot, and hip muscles
• Your running technique (with video analysis if recommended)
• Contributing biomechanical factors (pronation, valgus)
• Leg muscle flexibility
• Trunk and pelvis stability

This assessment helps identify the specific factors that contributed to your injury. A detailed biomechanical evaluation can reveal muscle imbalances or compensations that need to be corrected.

Personalized Treatment Plan

Treatment progression

Progression generally follows these steps:

• Acute phase (weeks 1-2): Reducing inflammation, modifying activities

• Strengthening phase (weeks 3-4): Exercise progression, gradual return to activity

• Functional phase (weeks 5-6): Gradual return to running, optimizing technique

• Prevention phase (week 7+): Maintaining gains, controlled progression

What exercises help heal shin splints?

Key exercises target the calf and foot muscles. Progression should be gradual and guided by pain. Never exceed a pain level of 3/10 during or after exercises.

Calf strengthening program

• Standing on a step, heels hanging off
• Slowly rise onto your tiptoes (2 seconds)
• Lower even more slowly (4 seconds)
• 3 sets of 15 repetitions
• Progression: single leg, then with added weight

• Rise onto the balls of both feet
• Slowly lower on one leg (5 seconds)
• 3 sets of 10 repetitions per leg
• This exercise is particularly effective for strengthening the tendon

Strengthening intrinsic foot muscles

• Seated with an elastic band around the foot
• Turn the foot inward and downward against resistance
• Hold for 3 seconds at maximum position
• 3 sets of 15 repetitions

• Seated or standing, feet flat
• Activate the arch of the foot by bringing the forefoot closer to the heel
• Hold for 5 seconds without curling your toes
• 3 sets of 10 repetitions

• Grab a towel with your toes
• Separate and spread your toes
• These exercises strengthen the flexor muscles that attach to the shin bone.

Stability and control exercises

• Hold for 30-60 seconds with eyes open
• Progress to eyes closed
• Add perturbations (throw and catch a ball)

• Standing on a step
• Slowly lower yourself, ensuring your knee stays aligned.
• Do not let the knee fall inward
• 3 sets of 10 repetitions

• Lower to 45-60 degrees of flexion.
• Maintain knee alignment.
• 3 sets of 10 repetitions

Hip strengthening

Strengthening your hip muscles is crucial for controlling leg alignment:

• Lift your top leg towards the ceiling.
• 3 sets of 15 repetitions

• Bridge position, lift one leg.
• Hold for 20-30 seconds.
• 3 repetitions per side.

These exercises help prevent dynamic knee valgus, which increases stress on the shin bone.

Cross-training activities

Maintain your cardiovascular fitness with low-impact activities such as cycling, swimming, elliptical training, or light hiking. Aqua jogging (running in deep water with a flotation belt) is especially helpful as it allows you to mimic running without impact.

If you have other lower limb pains, such as plantar fasciitis or foot pain, these cross-training activities allow you to maintain physical fitness while protecting injured structures.

How long does recovery take?

Healing from shin splints (tibial periostitis) takes 2 to 6 weeks with appropriate treatment. The return to running should be gradual, over 4 to 8 weeks.

Return to Running Protocol

A gradual return to running is essential to prevent recurrence:

• Pain-free walking for 20-30 minutes daily
• Daily strengthening exercises
• Cross-training activities (cycling, swimming) 3-4 times per week
• Ice after activities if needed

• Alternate walking/jogging (e.g., 1 min jogging, 2 min walking)
• Total of 15-20 minutes, 3 times per week
• Continue strengthening exercises
• Monitor pain (maximum 3/10)

• Gradually increase jogging intervals
• Decrease walking periods
• Total of 20-30 minutes, 3-4 times per week
• Vary training surfaces

• Continuous running for 20-30 minutes
• Gradually increase volume (maximum 10% per week)
• Gradual integration of light intervals

• Gradual return to usual training volume
• Maintain strengthening exercises 2-3 times per week
• Continuous monitoring of symptoms

Golden rules for returning to running

Pain should not exceed 3/10 during or after running. If pain increases, return to the previous step of the program for an additional 3-5 days. More than 90% of cases heal completely with conservative treatment.¹

Never increase both volume AND intensity at the same time. First, increase the volume (total distance), and only after 2-3 weeks can you add intervals or speed work.

How to prevent recurrence?

Prevention involves gradual training progression, regular strengthening, and attention to running technique. The 10% weekly increase rule is a good basic guideline.

Effective prevention strategies

• Follow the 10% weekly increase rule
• Never increase volume and intensity simultaneously
• Plan recovery weeks (20-30% decrease in volume) every 3-4 weeks
• Vary training types (continuous running, intervals, fartlek)

• Vary surfaces (concrete, dirt, trail, track)
• Replace your shoes every 500-800 km of use
• Alternate between two pairs of shoes
• Avoid excessively hard or sloped surfaces for prolonged periods

• Continue strengthening exercises 2-3 times per week even after recovery
• Include stability and motor control exercises
• Strengthen hip muscles
• Maintain flexibility in your calves and hamstrings

• Aim for a cadence of 170-180 steps per minute
• Favor a mid-foot strike over a heel strike
• Maintain a stable torso and a horizontal pelvis
• Avoid over-extension upon ground contact

Listen to your body's signals

Mild pain (1-2/10) is a sign to temporarily modify your training: reduce volume by 20-30%, avoid hard surfaces, add a rest day. If the pain worsens or persists despite these changes, consult a professional.

Runners with shin splints are also at higher risk of developing other overuse injuries such as patellar tendinopathy or iliotibial band syndrome. Therefore, a comprehensive preventive approach including strengthening and controlled progression is essential.

Long-term monitoring

Even after full recovery, continue to monitor these indicators:

• Sudden increase in morning stiffness
• Pain that reappears after long runs
• Tenderness to touch along the shin bone
• Excessive muscle fatigue

These signs may indicate that you are approaching your tolerance threshold and that a temporary modification is necessary.

When to consult a physiotherapist?

Consult a physiotherapist if the pain persists after a few days of rest, if it limits your activities, or if you want to safely return to running. You do not need to see a doctor before consulting a physiotherapist.

Signs that warrant a consultation

• Pain that persists for more than 3 to 5 days despite relative rest
• Pain that prevents you from running normally
• Pain present when walking or at rest
• Night pain that disrupts sleep (to rule out a stress fracture)
• Frequent recurrences despite your prevention efforts
• Desire to optimize your running technique
• Preparation for a specific sporting event (marathon, triathlon)

What the assessment includes

A typical assessment lasts 45 to 60 minutes. Your physiotherapist will examine your strength, mobility, and biomechanics. If relevant, a video analysis of your running can be performed to identify contributing technical factors.

The assessment also includes:

• Ankle mobility tests (dorsiflexion)
• Calf and foot strength assessment
• Motor control and stability tests
• Leg alignment analysis
• Discussion of your training program

In Quebec, you have direct access to physiotherapy. No medical referral is necessary. If your condition requires further investigation (imaging, medical consultation), your physiotherapist will direct you to the appropriate professional.

Available treatment options

Our clinics offer several services to treat shin splints:

• Manual therapy to improve mobility
• Personalized therapeutic exercises
• Biomechanical analysis and technique correction
• Gradual return to activity program

Most shin splints are treated in 6 to 12 physiotherapy sessions spread over 6 to 8 weeks.

Frequently Asked Questions

Can I continue running with shin splints?

You can generally continue running if the pain remains below 3/10 during and after the activity. Reduce volume and intensity by 30-50% and avoid hard surfaces. If the pain increases, stop running and opt for non-impact activities.

Do compression socks help?

Compression socks can help some people by reducing muscle vibrations and improving venous return. The effect varies among individuals. Try them for 2-3 weeks to see if you notice a difference.

Should I apply ice or heat?

In the acute phase (first few days), ice is preferable to control inflammation. Apply for 15-20 minutes, 3-4 times a day. After a few days, heat can help relax your calf muscles before exercises.

Can taping help?

Taping can offer temporary support and reduce tension on the periosteum. Your physiotherapist can show you appropriate taping techniques. However, it is only a complementary tool and does not replace strengthening and correcting the underlying causes.

How long before I can participate in a race?

Plan for at least 8 to 12 weeks between the onset of symptoms and an important race. For a marathon, allow 12 to 16 weeks. Consult your physiotherapist to establish a return plan tailored to your goals.

References

• Galbraith RM, Lavallee ME. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009;2(3):127-133.

• McClure CJ, Oh R. Medial Tibial Stress Syndrome. StatPearls. 2019.

• Heiderscheit BC, Chumanov ES, Michalski MP, et al. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc. 2011;43(2):296-302.

• Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reactions in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472-481.