Many collegiate athletes, high school athletes and recreational runners have experienced shin pain during their athletic career. Whether this was after a challenging training session, following a hard race or during a significant hill work out, it is important to identify the source and extent of your shin pain.

For many years, shin pain associated with running or athletic activity has been called “shin splints” which is a non-specific term without any formal diagnostic description. It is essentially a term that means you have shin pain, but it doesn’t give you a reason why.  With the advent of MRI and a better understanding of running-related injuries, we are now able to make a true formal diagnosis and properly identify the source of pain.

The perpetuation of the term “shin splints” stems from a lack of understanding of the origin of the real problem and the relative lack of clinical appreciation by coaches or healthcare providers. When runners experience shin pain, it is a sign that the shin is irritated. Chronic pain IS probably linked to a true injury.

Overlooking shin pain has created some substantial problems for many runners who opt to dismiss the initial signs of formal injury to continue training. Ignoring the injury can create prolonged disability, negatively impact their performance, cause chronic pain, and for some athletes, progress to a complete fracture. In some cases, athletes have been forced to quit their sports because of chronic shin pain.

Causes of Shin Pain

Shin pain may be linked to a myriad of causes of bony stress injury that can include:

• Periostitis: irritation to the bone covering
• Fracture: a break in the bone
• Stress reaction: swelling on the inside or outside of the bone
• Compartment syndrome: compressing of neurovascular structures, which could be a medical emergency
• Tendinitis: irritation of a tendon
• Tenosynovitis: irritation of a tendon sheath
• Popliteal artery entrapment syndrome
• Bone tumor
• Infection

A term like shin splints, without distinction, should not be used to classify a medical issue that may have many distinctive causes. If runners consider addressing the factors associated with causing the shin pain in the first place, they might avoid significant injury and prolonged disability.

Shin Pain Research at UOA

At University Orthopaedic Associates (UOA) we have been formally studying shin pain among an adolescent (high school aged) athletic population to find answers for chronic shin pain. Through our research, we have come up with some significant findings.

In our most recent study, “Validation of the Shin Pain Scoring System” we evaluated the shins of 80 adolescent athletes who experienced more than one week of shin pain. Participants in the study completed a questionnaire, underwent a formal evaluation by one of our orthopaedic surgeons who assessed the location, extent of their pain and functional disability. Each had X-ray evaluation and a bilateral magnetic resonance imaging (MRI) scan of both shins during their evaluation.

The participants were then followed for six months and completed a follow-up questionnaire to track their recovery.

We studied 160 tibias (52 females, 28 males, average age 15.4) who participated in various sports, including:

• Running
• Soccer
• Basketball
• Lacrosse
• Softball
• Field hockey
• Wrestling

We found that 88 percent demonstrated evidence of some degree of bony stress injury on MRI.  In fact, 80 percent of those who had bony stress injury findings on MRI were at least grade II or greater (graded on a 4-point scale of severity) and involved actual inflammation and swelling within the bone.

Two-thirds of the participants in the study had evidence of bilateral injury on MRI. Some 27 percent demonstrated findings on X-ray that were indicative of a grade III/IV bony stress injury. A review of their follow up questionnaires revealed that 54 percent of the participants in the study still experienced significant shin pain more than six months after enrolling in the study, and 12 percent of these participants quit sports because of their chronic shin pain.

More Shin Pain Research

In a study of 222 athletes aged 13 to19 years old, published in the the Journal of Sports Medicine and Physical Fitness, the authors found that age is an important factor as bony stress injury spiked in the 15-16-year-old population they studied. They also found that those who were evaluated within the first three weeks of experiencing shin pain recovered significantly quicker than those who did not seek medical attention until more than 3 weeks. The delay in treatment only perpetuates the bony injury.

In another UOA study, “The National Stress Fracture Registry,” we created an online adolescent database of individuals who suffered a stress fracture while playing sports. Sixty athletic trainers from 11 states contributed information to the study and we collected information on 53 variables that were reportedly associated with stress fractures.

The National Stress Fracture Registry study collected one of the largest databases of adolescent stress fracture in the world. In total 365 stress fractures were reported to the registry.  The results of the injury collection yielded several interesting results:

• 65 percent of the stress fractures that were reported in track athletes occurred in the tibia
• 54 percent of the reported cases occurred to start/stop sports (soccer, basketball, lacrosse, etc)
• The tibia was 3 times more commonly involved than any other bone that was reported
• 19 percen t indicated they had a prior stress fracture
• 45 percent noted they had prior history of shin pain that persisted more than four weeks
• Those with a body mass index of more than 19 are more prone to injury
• 73 percent underwent some sort of change in their training

These finding highlight the importance of a formal evaluation by a physician sensitive to the causes and work up involved with a bony stress injury.

 When Should Your Shin Pain Be Evaluated by a Physician?

• You experience more than one week of shin pain either with activity or after.
• You rate your pain as a greater than 5 out of 10, with 0 being no pain and 10 being the worst pain you could ever imagine.
• Your pain impacts your performance
• When you hop on one leg 10 times and it causes shin pain

Be sure to check out our next article in Part 2 of our series: “Causes of shin pain”

Our extensive Sports Medicine experience and involvement in shin pain research has positioned UOA as one of the leaders in adolescent bony stress injury care. If you have shin pain, request an appointment with one of our fellowship trained sports medicine physicians.