EVIDENCE-BASED ANSWER
Encourage patients who are concerned about shin splints to decrease the intensity of their running; suggest rest and ice and foot orthoses, to treat the condition. Reducing running intensity probably reduces lower extremity soft tissue injuries (strength of recommendation [SOR]: B, low-quality randomized controlled trials [RCTs]), although doing stretching exercises doesn’t. Rest and ice alone promote faster recovery than rest and ice combined with nonsteroidal anti-inflammatory drugs (NSAIDs), a walking cast, or heel-cord stretching. (SOR: B, low-quality RCT). Although foot orthoses or insoles don’t prevent lower limb injuries (SOR: A, systematic review), they do significantly relieve symptoms and promote return to running (SOR: C, poor-quality cohort studies). Lower limb fasciotomy can reduce symptoms caused by shin splints in athletes, but the rate of return to previous level of sports activity is modest at best (SOR: C, case series).
Clinical commentary
Review, rest, follow-up
Doug Aukerman, MD
Pennsylvania State University, State College
Shin splints are an early indicator of abnormal stresses that cause periostitis along the tibia. Medial tibial stress syndrome (MTSS) is best thought of as part of a continuum, with shin splints at the mild end and tibial stress fracture at the severe extreme. I find that reviewing biomechanical forces and training schedules often helps prevent and treat injury. Aging footwear and training errors, including a rapid increase in training volume, are common culprits when biomechanics are normal. Adequate rest to allow the body to respond to the stresses of training can help prevent stress-related injuries.
My treatment regimen for shin splints includes a period of relative rest that allows the runner to remain active but reduces the stresses placed on the tibia and musculature of the lower leg. Relative rest may comprise either reducing running distance and intensity or changing the mode of exercise to deep water running or cycling. Consider follow-up examination to ensure that the tibial pain doesn’t become more localized, indicating a possible stress fracture.
Evidence summary
MTSS, or shin splints, is the most common cause of exertional leg pain in athletes. MTSS is an overuse injury characterized by pain along the posteromedial aspect of the distal two-thirds of the tibia.
Reduced running time, frequency, and distance may prevent injury
A systematic review of 12 trials of 8806 mostly young male military recruits, evaluated nonsurgical interventions to prevent lower limb soft tissue running injuries, including MTSS.1 Five trials investigating stretching and 4 trials of shoe insoles showed no benefit. Three studies showed that reducing the duration of running (to between 15 and 30 minutes), frequency (to 1 or 3 days a week), or distance (to 16.5 fewer kilometers over 12 weeks) reduced the risk of all injuries. Methods and outcome measures of the studies were heterogeneous, limiting the generalizability of these results.
A prospective RCT of custom semi-rigid shoe orthoses in the boots of Danish army recruits found a significantly lower prevalence of MTSS at 3-month follow-up in the intervention group (13% compared with 24%, P=.005; NNT=5).2 However, a systematic review of methods to prevent MTSS in sports found no high-quality studies in nonmilitary populations.3 No difference in the incidence of MTSS was noted with shoe inserts, different combat boots, or stretching routines.
To treat shin splints, consider orthotics, rest, and ice
Two studies retrospectively surveyed runners about their response to orthotics to treat MTSS.4,5 In one study, 16 of 41 collegiate cross-country runners were prescribed orthotics; 14 (88%) reported relief or improvement in their symptoms and return to running within 4 weeks.4 The other survey, of long-distance runners, found that 70% who had used or were using orthotics for a presumed diagnosis of MTSS reported complete relief or great improvement.5