The Red Kite Runners in Blaydon are a brilliant local running group who’ve asked me to professionally support their members.  Recently one of the ‘Kites’ contacted me about pain in their shin.

A lot of people might hear about a runner with shin pain (or indeed be a runner with shin pain) and immediately think that it’s been caused by a condition called Shin Splints.  That’s the first thing I thought of too.  But in my job, we have to do what’s called a differential diagnosis.  That means I have to think of every different possible cause of the pain and then ask questions and do tests to rule things out until we arrive at the most likely answer.

I thought you might like to join in and find out a bit more about shin pain.

My first, most important question is to make sure the pain is definitely on the shin.  What if the person has quite a bit of discomfort and the pain is actually localised further round the leg on the calf?  Now I have an immediate siren in my head labelled ‘potential deep vein thrombosis’.  It’s a loud, persistent siren and if I suspect this is what’s happening, then it’s straight off to the GP or walk-in centre to get checked out.

The next question I need to ask is whether this pain is related directly to the shin area, or whether it’s actually coming from somewhere else.  A good example of lower leg pain caused by a problem elsewhere would be sciatic nerve compression in the low back.  If you’d like to find out more about this there’s much more about it in the Osteo Detective article on low back pain on this blog.

For today we’re going to assume that the pain is directly related to the shin and it hasn’t been caused by a direct blow to the area.  So, what are the main things it could it be?

Shin splints

Stress fracture

Chronic compartment syndrome

(There can be additional unusual or rare possibilities in a differential diagnosis but we always look first at the most likely culprits). 

Shin Splints

You can get this on the inner side (medial) and outer side (lateral) of the shin. 

Medial shin splints are caused by one of the deep calf muscles pulling and inflaming around where it attaches to other tissue inside the leg.  The area it attaches to is called the interosseous membrane.  It’s really close to the very first layer of bone and can even show on an x-ray as inflammation known as Periostitis.

Medial shin splints are usually caused by overuse and also –

  • poorly fitting shoes
  • running on hard surfaces
  • running on cambered surfaces
  • hyper-pronation when running
  • change of running pattern – for example, from road running to running on a synthetic running track.

Lateral shin splints

These are caused by a temporary compartment syndrome due to swelling of the tibialis anterior muscle.  The muscle sometimes swells with exercise, and can end up cutting off its own blood supply!  This happens when there isn’t enough room in its tight compartment for it to expand.  Sometimes as well as pain on the shin you can get a numb big toe.

The most likely causes of lateral shin splints are –

  • long-distance running
  • hill running
  • over-flexible shoe.

Stress Fracture

How do I tell the difference between a stress fracture and shin splints?  Well to be absolutely sure it’s a stress fracture, you’d need an X Ray.  But what would make me suspect a fracture in the first place?

The main indicator is that the pain tends to be very localised, almost in a pinpoint position and there’s often a bit of swelling immediately over the position of the pain.  Also, pain from a stress fracture would hurt when you’re weight bearing, but would stop with rest.  Getting the details of when and why pain happens helps us with our diagnosis.  That’s why Osteopaths ask you so many questions!

Chronic Compartment Syndrome

Let’s talk a bit more about compartment syndrome.  It can cause shin splints in the lateral side of the leg.  But it’s also a separate condition in its own right. 

In my differential diagnosis of shin pain, what would I be looking for that would lead me towards chronic compartment syndrome?  Firstly, I think about who is most likely to suffer –

  • it’s most often seen around age 20-25
  • most at risk are those who exercise with repetitive motions or activity
  • particular risks include running, football, cycling, tennis and gymnastics
  • excessive training increases the risk.

Then I think about particular signs and symptoms

  • you feel severe pain and tightness in your leg, and I can feel the hardness of the compartment when I press on it
  • your pain is triggered by exercise and becomes worse as exercise continues, until it’s severe enough to force you to stop exercising.
  • the pain resolves with rest
  • You can feel muscle weakness, numbness or tingling, and it can affect the way you walk.

I hope this gives you an idea of the kind of things we have to think about when someone tells me they have shin pain.  Turns out it isn’t always shin splints!  And the ‘Kite’ who contacted me recently?  They had a stress fracture.

The next question of course is what treatment and advice I can give for these different conditions?  Look out for the blog article on ‘Management of Lower Leg Pain’ to find out.