Shin Splints Encompass a Broad Range of Lower-Leg Ailments

TRAINING DOCTOR’S ORDERS

What’s in a name? Shin splints encompass a broad range of lower-leg ailments

By Dr. Jordan Metzl

llison is a 27- year-old scien- A tist and runner who comes to the office complaining of shin pain. “Doc, my shins hurt when I run,” she says. When asked, she describes a tightening pain in the soft, outside, muscular part of the shin. “Do your shins hurt more during exercise?” I ask. “Yes, once I get past 10 minutes or so, I get this tightening feeling in my shins. It has become so bad that I can’t run anymore. The weird thing is that 20 minutes after I stop running, the pain goes away, but it comes back the next time I try to run.” Jennifer, a 25-year-old physician’s-assistant student and triathlete, comes in also com- The treatment of ECS is initially manual plaining of shin pain. “I’ve been building my therapy, using a physical therapist or certified running mileage, and over the past few weeks, athletic trainer to manually loosen the fascia, my shins have been aching like crazy.” When or wrapping around the muscle, combined asked, she describes a pain on the bony part of with a good stretching program. Orthotics the shin, the tibia, which not only hurts dur- (arch supports) and motion-control running ing exercise but also hurts when she pushes shoes can be used to correct any existing bio- on her shin. “Ouch, that’s the spot”, she says, mechanical problems in the feet. In some cas- when I push on the inside of her tibia, the big- es, despite these measures, the pain with exer- ger bone in the lower leg (the smaller is the tion simply doesn’t go away. With these fibula). patients, the sports-medicine doctor will per- So what do these two stories tell us about form an exertional-compartment test, a test shin pain? Although both are characterized using a needle to measure the pressure inside as shin splints, pain in the shin from running, the leg before and after exercise, looking for the pathophysiology, meaning the biological a large pressure buildup, which confirms the cause of the pain, is quite different in each of diagnosis. When the pressure difference is these two stories. high, and when the other treatments don’t Allison, the first patient, is describing mus- work, a surgical procedure called a fasciotomy cular shin pain known as exertional compart- is performed to open the wrapping of the mus- ment syndrome (ECS). ECS can occur in the cle and give it room to expand. Patients can front, the side or the back of the lower leg and generally return to running within two months is characterized by a tightening in the shin of this operation. that worsens during exercise. Eighty percent Jennifer, the second patient, is describing of ECS cases happen in the front (anterior) bone-related shin pain. Bone-related shin pain part of the shin, as is the case with Allison. can cover a broad spectrum of ailments from When the region is palpated, there is no spe- a stress injury, irritation of the bone, to a stress cific location of pain, and the leg is pain free fracture, an actual crack inside the bone. Bone except during activity. pain in the shin is different from muscular

66 DECEMBER 2005 WWW.TRIATHLETEMAG.COM

John Segesta/wahoomedia.com pain in that it hurts during and, especially, the recommended amount) and a history of after exercise, and the tibia actually hurts when menstrual disorders (i.e., not getting a period it is touched or tapped in the affected region. for more than six months in a row causes low Bone-related shin pain is more common levels of circulating estrogen). than muscular shin pain and generally is the An MRI is often used to diagnose the sever- result of three variables: body mechanics, ity of the injury, since stress fractures don’t amount of activity and bone density. Body show up on x-rays unless they are very severe mechanics, how someone is built, encompass or are healing. However, catching stress frac- the largest set of variables. These include foot tures early, especially in the stress-injury phase, type, often corrected with orthotics or by is optimal. switching to a shoe type that limits prona- Once the diagnosis is made, fixing the prob- tion, as well as running style, which can be lem, and preventing the next one, is the pri- influenced by hip and core muscle strength. mary concern. This might mean correcting The volume or intensity of activity can be foot mechanics with a pair of orthotics, tweak- problematic if the athlete builds either too ing your training schedule or getting a bone- quickly. Follow the 10 percent rule: Do not density test called a DEXA, which scans for increase mileage by more than 10 percent per low bone density as a cause of the injury. week. Shin splints are more complicated than they Lastly, bone density is very important. Soft- might appear at first glance. Figuring out the er bones break more easily, so if you develop correct diagnosis, and then instituting the best a stress fracture that can’t be explained by treatment, can make all the difference. L poor mechanics or rapidly increased training, bone density might be the problem. Low Jordan D. Metzl, MD, is a nationally rec- bone density is called osteopenia, and very ognized sports-medicine specialist at Hospital low bone density is called osteoporosis. The for Special Surgery in New York City. In addi- causes of low bone density include genetics tion to his medical practice, Dr. Metzl is a 25- (it tends to run in families), poor dietary cal- time marathon runner and three-time Iron- cium intake (more than 1300 mg per day is man finisher.