Shin pain: shin splints, stress fractures and the difference

Shin pain is one of the most common complaints in runners, particularly new ones and those who have recently increased their training. Most of it is medial tibial stress syndrome, “shin splints”, and a minority is a tibial stress fracture.

Telling those two apart is the whole point of an assessment, because one can be trained around and the other cannot.

Medial tibial stress syndrome

Pain along the inner border of the shin, usually across a stretch of several centimetres rather than one spot. Typically worst at the start of a run, sometimes easing as you warm up, and sore afterwards.

It is a bone stress reaction and an irritation of the tissue attaching to the bone along that border, caused by repeated loading beyond what the tissue has adapted to.

Tibial stress fracture

Pain that is focal. You can usually put one fingertip on it. It tends to get worse through a run rather than easing, and in a more advanced case it hurts walking, at rest, and at night.

A stress fracture is a genuine break in the bone that has developed under repeated load. Continuing to run on one risks it progressing to a complete fracture, which is a much longer problem.

How to tell them apart

That table is a guide, not a diagnosis. Focal pain, night pain or pain that hurts when you hop is worth being assessed for a stress fracture before you run again.

What causes both

The same things, at different doses:

• A sudden increase in load. The classic is going from nothing to a running programme, or adding distance faster than the ten-percent-a-week rule of thumb
• Surface changes, road to trail, treadmill to outdoors
• Footwear, worn out, or a sudden change in type
• Low bone density and low energy availability. Important and under-recognised: inadequate energy intake relative to training, disrupted menstrual cycles, and low vitamin D or calcium all increase stress fracture risk substantially. Repeated stress fractures warrant a medical workup rather than another gait analysis.
• Reduced calf and foot strength
• Biomechanics, foot posture, hip control and step rate all change how load is distributed

What treatment involves

For shin splints:

Load management first, reduce running to a level that does not aggravate it rather than stopping, and cross-train to hold fitness. Calf and foot strengthening, progressed properly. Increasing cadence slightly, which reduces the load per step. Footwear review. Hands-on treatment to the calf complex to reduce symptoms while capacity rebuilds.

Most cases improve over four to eight weeks with the load properly managed.

For a stress fracture:

Rest from impact, usually for six to eight weeks, sometimes in a walking boot depending on the site. Cross-training that does not load the bone, swimming, cycling, deep water running. A graded return to running once it is pain-free, starting far below where you left off. A look at why it happened, which for a first stress fracture means training load and for a repeat one means a medical workup including bone density and energy availability.

Some tibial stress fractures, particularly on the front of the shin, are higher risk and heal poorly. Those need specialist involvement.

Compartment syndrome

Worth naming because it is missed. Chronic exertional compartment syndrome produces tightness, aching and sometimes numbness or foot drop that comes on predictably at a certain point in a run and resolves within minutes of stopping.

That pattern, reliably brought on by exertion, reliably gone with rest, is different from both conditions above and needs a different assessment.

When to get it looked at

Any shin pain that is focal, wakes you at night, hurts when walking, or is not improving after a couple of weeks of reduced load. And any shin pain in someone with a history of stress fractures, disordered eating, or absent periods, where the threshold for investigating properly should be much lower.