Exercise Related Leg Pain aka Shin Splints

Athletes frequently seek out medical assistance and physicians often send referrals to physical therapy for “shin splints”.  Shin splints however is a junk term that is tells little of the actually pathology other than that the pain is in the lower leg.  What is typically referred to as shin splints can be one of a variety of different conditions affecting the lower extremities while exercising.

Medial Tibial Stress Syndrome

Patients with medial tibial stress syndrome have pain along the lower tibia.  Pain occurs with exercise and is relieved with rest.  Nerurological symptoms are not seen with MTSS.  The posterior tibialis, soleus and its’ fascia, and the FDL are thought to be the origin of MTSS pain.

Chronic Exertional Compartment Syndrome (CECS)

Compartment syndrome can be the result of macrotraumatic or micrtraumatic injury.  In both types of compartment syndrome, increased pressure within one of the compartments of the lower leg can decrease blood flow and nerve signaling.  Macrotraumatic injuries to a limb may lead to excessive bleeding within a lower leg compartment and is a medical emergency.  Microtraumatic causes are the result of overuse and increased compartmental muscle volume during a bout of exercise (CECS).

With CECS, patients typically complain of pain at a consistent point after they have begun an exercise bout.  They will typically have burning or cramping sensations in addition to numbness.  Muscles within the affected compartment may be weak after the onset of symptoms.

Chronic exertional compartment syndrome is diagnosed by measuring increased intracompartmental pressure after exercise.

Stress Fracture

Stress fractures are the result of inadequate adaptation to many repetitive, small loads to a bone.  Initially, pain occurs with exercise but with increased severity, pain may progress to impacting ADLs.

Fractured Metatarsus 1

Females are at a greater risk for developing stress fractures than males.  Stress fractures often occur following large changes in training volume, such as the adjustment between high school and collegiate athletics.  The tibia and metatarsals are common sites of stress fractures.

The gold standard test for stress fractures is a bone scan.

Tendinopathy

Tendinopathies are overuse injuries frequently involving the Achilles tendon and posterior tibialis tendon.  Pain typically begins after exercise but may progress to pain with ADLs.  Pain typically occurs along the tendon of the involved muscle, frequently at bony prominences.  Pain occurs with contraction of the involved muscle.

Nerve Entrapment

Nerve entrapment of the nerves of the lower leg is rare but presents in three stages.  In stage I nerve entrapment, pain and paresthesias may be experienced at night.  Parasthesia during the day with possible muscle weakness is seen in stage II.  Stage III involves loss of sensory and motor function with continuous pain.

Vascular Pathology

Popliteal and anterior tibial artery vascular pathologies are very rare but have symptoms much like those seen with chronic exertional compartment syndrome.  Compartmental pressure testing is needed to distinguish between these two conditions.  With vascular pathologies, distal pulses will be reduced.

Risk Factors

The Achilles' tendon. PD image from Gray's Ana...

Extreinsic risk factors include: high exercise volume, poor footwear, and sports involving excessive running and jumping.  Intrinsic risk factors involve overpronation, inflexibility (especially of the gastrocnemius: see 1 and 2), female sex, age, BMI, bodyfat, fitness level, injury history, bone mineral density, and excessive supination.

References

Reinking, M. (2007). Exercise Related Leg Pain (ERLP): A Review of the Literature.  North American Journal of Sports Physical Therapy, 2(3).

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