What should I do for pain in my left foot that radiates up my shin?

Pain in Left Foot Radiating Up Shin

Start with plain radiographs of the foot and ankle as your initial imaging study, then proceed to clinical examination focused on distinguishing between medial tibial stress syndrome (shin splints), stress fracture, or lumbar radiculopathy based on pain location and neurologic symptoms. 1, 2

Initial Diagnostic Approach

First-Line Imaging

• Obtain weight-bearing radiographs of the foot and ankle immediately (anteroposterior, lateral, and mortise views) as this is the most appropriate initial imaging study for chronic foot pain and can identify fractures, stress injuries, or osseous abnormalities. 1, 3
• Radiographs have 80-100% sensitivity for detecting many foot pathologies but only 12-56% sensitivity for stress fractures, so negative films do not rule out significant pathology. 3

Critical Physical Examination Findings

• Palpate for point tenderness at the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and along the posteromedial tibial border. 2, 3
• Perform calcaneal squeeze test (medial-to-lateral compression of the heel) to evaluate for calcaneal stress fracture. 2, 3
• Assess for neurologic symptoms including burning, tingling, numbness, or specific dermatomal radiation patterns that suggest L5-S1 nerve root compression. 2
• Conduct straight leg raise test and check for lower extremity neurologic deficits to evaluate for lumbar radiculopathy. 2

Differential Diagnosis Based on Pain Pattern

If Pain is Along Posteromedial Tibial Border

• Medial tibial stress syndrome (shin splints) presents as diffuse tenderness along the posterior medial tibial border at the origin of the posterior tibialis muscle, typically from repetitive stress. 4, 5, 6
• Pain occurs during activity and may worsen with continued exercise. 5, 7
• This is a clinical diagnosis when there is diffuse tibial tenderness without focal bone pain. 7, 6

If Pain is Focal and Severe

• Tibial stress fracture causes localized, sharp pain that worsens progressively and may present with nocturnal discomfort. 8, 7
• Patients often report increased walking or running activity before symptom onset. 3
• Initial radiographs may be negative, requiring advanced imaging. 3, 7

If Pain Radiates from Heel Proximally Through Posterior Leg

• Lumbar radiculopathy (L5-S1 nerve root compression) can cause pain radiating from the heel through the posterior leg and up to the hip. 2
• This pattern demands immediate neurologic evaluation—do not assume isolated plantar fasciitis or shin splints when pain radiates proximally beyond the heel. 2

Advanced Imaging Algorithm

When Radiographs are Normal but Suspicion Remains High

For suspected stress fracture or medial tibial stress syndrome:

• Order MRI foot/ankle without IV contrast as the next study if pain persists >1 week after negative radiographs. 1, 3, 7
• MRI demonstrated 95% sensitivity compared to bone scan in one prospective study of acute shin splints. 7
• Alternatively, triple-phase bone scan can be used, though MRI is preferred to avoid radiation exposure. 3, 7

For suspected lumbar radiculopathy:

• Order MRI of the lumbar spine if examination findings suggest nerve root compression. 2
• Obtain electromyography and nerve conduction studies for confirmed neurologic involvement requiring subspecialist referral. 2

For suspected calcaneal stress fracture with negative radiographs:

• Technetium bone scanning or MRI should be obtained. 2, 3

Treatment Considerations

Conservative Management for Medial Tibial Stress Syndrome

• Rest from aggravating activities, ice, and anti-inflammatory medications are first-line. 8, 5
• Early physical therapy with muscle strengthening and balance training prevents progression. 9, 5
• Proper footwear assessment is essential. 3

When to Escalate Care

• Immediate subspecialist referral is required if neurologic heel pain with proximal radiation is suspected, as this indicates possible nerve root compression requiring urgent evaluation. 2
• Progressive worsening despite conservative treatment warrants advanced imaging within 1-2 weeks. 3, 7

Critical Pitfalls to Avoid

• Never diagnose based on imaging alone—combine symptoms, clinical signs, and imaging findings, as bone scan and MRI can show abnormalities in asymptomatic individuals. 1, 7
• Do not assume isolated shin splints when pain radiates proximally—this pattern requires neurologic evaluation for radiculopathy. 2
• Reexamine 3-5 days post-onset if initial examination is limited by swelling and pain, as excessive early swelling can obscure findings. 3
• Consider systemic causes (arthritides, infections, tumors, vascular compromise) when symptoms are bilateral, involve other joints, or are unexplained by mechanical causes. 2, 3