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Shin Splints to Stress Fractures: A Continuum

June 18, 20237 min read

Shin splints are one of the most common running injuries... and there are multiple kinds.


Shin splints are typically an overuse injury in which the muscles of the lower leg are exerting too much pulling on the point where the muscles insert into the bone (the periosteum). Pain may be located at the inside or front of the shin depending on which muscle group is contributing to the problem. This issue is commonly seen in runners, basketball players, and other athletes.

You Get Shin Splints (Oprah)

1. General Causes

 Poor mechanics at the foot and ankle or poor stability and function at the hips and core can create excessive stress to the muscles of the lower leg. Training errors, such as increasing mileage too quickly (>10%/week), not allowing sufficient rest/recovery days, and using old or worn out shoes (>250-500 miles of use) are also common contributing factors for shin splints. 

2. Specific Causes

A) Anterior Pain (front of the shin): When the muscles at the front of the shin (anterior) are producing the pain, a heel strike with a quick foot slap creates excessive tension on the Tibialis Anterior muscle too quickly and too forcefully. This running style is also typically associated with running with an upright torso which decreases gluteal muscle activation and requires the Tibialis Anterior muscle to function as a braking mechanism for the foot more than running with the torso leaning slightly forward.

B) Medial Pain (inside of the shin): Oftentimes the pain on the inside of the shin (medial) is produced by the Tibialis Posterior and/or Soleus muscle(s). The Tibialis Posterior muscle supports the arch of the foot and it’s normal for the foot to pronate (collapsing of the arch of the foot) slightly in the landing/loading phase of running. Oftentimes when this motion is excessive and too quick this creates excessive pulling on the Tibialis Posterior muscle, increasing the pull on the periosteum, and creating edema and pain. Improving hip strength (specifically of the abductors and external rotators of the hip) can help control the pronation motion at the foot. 

Lower Leg AnatomyLower Leg Anatomy 2

3. Additional Causes

Abnormal stiffness or looseness of the joints at the foot and ankle can also create abnormal stress to the muscles at the foot and lower leg. Joint stiffness is something that can be assessed by your physical therapist.

With pain at both the front and inside of the shin, tightness in the respective muscles can create a pulling on the point where the muscles insert on the bone even when you’re not running. This is why some runners will take time off from running to rest, but then their pain returns very quickly once they start running again. This is because the muscle tightness was creating tension on the insertion point even at rest. Your therapist can help reduce muscle and fascial tightness with soft tissue techniques such as hands-on massage, cupping, or use of a massage gun. You can then use these techniques on yourself to address muscle and fascial tightness as part of your regular routine. Stretching can also be helpful to keep flexibility in the responsible muscles.

It’s important to address the muscle tightness contributing to the symptoms as well as the running or walking mechanics that originally created the muscle tightness.

4. The Role of Orthotics

Depending on the movement and mobility of the joints in your foot and ankle, your muscle strength, and mechanics with walking and running you may benefit from over-the-counter (OTC) or custom orthotics. There are some great OTC options such as Super Feet orthotics that provide different levels of arch support and stability without breaking the bank.

Orthotics can provide more support, height adjustments, or even a slight tilt to the arch, rearfoot (heel), and forefoot (ball of the foot). 

With 26 bones and many joints in between it’s helpful for a physical therapist to assess how your joints and muscles function at your foot while you’re moving and assess how you improve with physical therapy to determine if you’ll need any orthotic, an OTC orthotic, or something custom. While some people are able to make great gains in therapy and avoid needing a custom orthotic, others may benefit from having an orthotic to improve muscle activation that may desperately be needed to reach your goals.

Stress Fractures Of The Tibia:

The Continuum From Shin Splint to Stress Fracture

If the issues seen with shin splints are not addressed and the athlete continues to create a high tension load on the muscles at the foot and ankle, the excessive pull on the Tibia (the large bone of the lower leg) can create a stress reaction in the bone itself that may progress to a stress fracture. The figure below takes a look at the bone from the top down and ranges from normal (Grade 0), to the inflammation and edema seen with more advanced shin splints (Grade 1), to the more severe stress reactions and stress fractures (higher Grades).

Stress Fracture Classification Guidelines

The Impact of Nutrition On Bone Health

In the event of a stress fracture it’s also important to assess the athlete’s nutritional intake as a lack of calories can impact bone strength. For female athletes a lack of calorie intake versus expenditure can lead to the Female Athlete Triad which consists of decreased bone density (increasing the chance of fracturing a bone), irregular or absent menses, and abnormal fatigue. Similar consequences of decreased bone density and abnormal fatigue can also be seen in males experiencing a calorie deficit as well.

Female Athlete Triad Diagram

How To Identify A Stress Fracture

X-rays can be a good starting place to look at bone health if there are symptoms that are more aggressive than those present with shin splints. Stress fractures may be obvious or unidentifiable on X-ray depending on the intensity of the injury and the position of the leg when the X-ray is taken. See the figure below for two examples of X-rays of Tibial stress fractures. The images A & B on the left show a clearly seen stress fracture while it’s very difficult to see the stress fracture in the image on the right.

Stress fracture X-ray 1Stress Fracture X-ray 2

Ultrasound imaging can also be used to identify a stress fracture that shows a break in the outer layer of the bone (the cortex) and, in some cases, detect edema at the surface of the Tibia (Grade 1 on the Fredericson Classification System). Ultrasound imaging is somewhat superficial and may not be able to detect changes within the deeper layers of the bone (bone marrow and intracortical area). 

MRI imaging is another option to view the health of the bone and provides information about the health of all layers of the bone.

The figure below shows the ultrasound (left) and MRI (right) results from the patient whose stress fracture was unseen on X-ray (above right).

Stress Fracture UltrasoundStress Fracture MRI

What To Do If You Have A Stress Fracture

Oftentimes the advice you’ll get on how to heal a stress fracture is to simply rest. While decreasing the amount of intense weight bearing is helpful, there are still forms of exercise that can keep you strong while waiting for the stress fracture to heal. For example, if your stress fracture is on the smaller side you can do some light weight strength training with Blood Flow Restriction (BFR) and achieve strength gains as if you were pushing heavier weights. 

Depending on the location and causes of the stress fracture, cupping (away from the site of the fracture) but along the muscles that create tension on the fracture site can be helpful.

Get Help That's Specific To You

Even if you have the same type of shin splints as someone else, your mechanics, strength, etc may not be the same. To get advice that’s specific to you, visit our home page to schedule a free 15-minute phone consultation with one of our injury specialists.

Shin SplintsRunning injuriesLower leg painStress fractureShin PainBasketballSoccer
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Dr. Connie Hutchins

Dr. Connie is a Doctor of Physical Therapy and founder of Movement Solutions. She is passionate about staying active through running, yoga, and climbing and loves helping others do the same. She specializes in the treatment of orthopedic conditions and has been on faculty at the University of Southern California teaching clinical reasoning and manual therapy skills to the next generation of physical therapists.

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Where are you located?

We're located in Rancho Cucamonga near the intersection of Haven and Church (between the 10 and 210 freeways) at 10621 Church St #140, Rancho Cucamonga, CA 91730. You'll find us inside Studio 30. For information on where to park and enter check out this video.


Do I need a referral from my physician to see you?

No! You can get started right away.

In California you have Direct Access to physical therapy for 45 days before the law requires you to have your physician sign off on the plan or write a referral. We know it can take a long time to get an appointment with your physician and that's exactly why this Direct Access law was implemented in California, so that you don't have to wait to be seen by a physical therapist who can help you get better ASAP.

If your physical therapists identifies a condition at your first visit that requires the medical care of your physician or another medical professional your physical therapist will advise you of this at your visit.


How is this clinic different from other physical therapy?

After having interned and worked in a variety of typical physical therapy clinics Dr. Connie decided that she wanted more for her patients. With one-on-one care only with Doctors of Physical Therapy who care about our patients' results and who undergo extensive training beyond their Doctorate degree, we're able to get results so much faster and address the underlying issues causing pain so that it doesn't keep coming back.

This clinic was created with our patients and their awesome goals being the #1 priority. Don't be surprised when your therapist takes the time to really listen to you about why your goals are important and then designs an individualized program around those goals.


Do you think physical therapy will really help me?

We love this question! Many of our patients had already tried injections, pain medications, chiropractic care, and even physical therapy at another clinic and didn't find relief until they started physical therapy with us. We do things differently and it shows in the results we have with our patients. If you're wondering if physical therapy is right for you but are still unsure, fill out the Availability Inquiry Form or text the word "Call" to (909)414-3625 to set up a free, 15-minute, no-obligation phone consultation with one of our Doctors of Physical Therapy.

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