What is the recommended treatment for shin splints?

Shin Splints Treatment

Start with a 2-week period of relative rest combined with ice massage, NSAIDs for pain control, and stretching exercises, followed by a progressive return to activity with emphasis on correcting training errors and biomechanical abnormalities. 1, 2

Initial Conservative Management (First 2-4 Weeks)

Activity Modification

• Reduce or temporarily cease the aggravating activity rather than complete immobilization, as rest alone without addressing underlying causes leads to recurrence 1, 2
• Substitute high-impact activities with low-impact alternatives (swimming, cycling, water running) to maintain cardiovascular fitness 1
• Avoid complete rest beyond what is necessary for pain control, as prolonged immobilization leads to deconditioning 1

Pain and Inflammation Control

• Apply ice massage directly to the painful area for 15-20 minutes, 3-4 times daily to reduce pain and inflammation 2
• Use NSAIDs for short-term pain relief (typically 7-14 days) to control symptoms and allow participation in rehabilitation 3, 2
• NSAIDs are effective without significantly increasing adverse events compared to placebo 3

Stretching Program

• Stretch the triceps surae (gastrocnemius and soleus) muscles as tightness in these muscles is a contributing factor 1, 4
• Perform stretching exercises multiple times daily, holding each stretch for 30 seconds 2

Progressive Rehabilitation Phase (Weeks 3-8)

Strengthening Exercises

• Begin eccentric strengthening of the tibialis posterior and tibialis anterior muscles once acute pain subsides 1, 5
• Progress to plyometric exercises emphasizing gradual eccentric stress loading to the deep posterior and anterior compartments 5
• Plyometric training can be safely introduced during the functional phase of recovery to augment rehabilitation 5

Biomechanical Correction

• Address muscular imbalances at the ankle and thoracolumbar complex as these contribute to recurrence 4
• Evaluate and correct foot biomechanics, particularly excessive pronation 1, 4
• Consider orthotic devices if significant biomechanical abnormalities are present 1

Training Error Correction

• Gradually increase training intensity and duration using the 10% rule (no more than 10% increase per week) 1, 4
• Ensure proper footwear with adequate cushioning and support 4
• Modify running surfaces when possible, avoiding hard or uneven terrain 1

Return to Activity Protocol

Graded Return

• Begin with pain-free walking, then progress to jogging only when there is no tenderness along the posteromedial tibial border 1, 4
• Increase distance before increasing speed or intensity 1
• If pain recurs, reduce activity level and reassess biomechanical factors 2

Monitoring

• Pain should be assessed during activity, immediately after, and the following day 4
• Diffuse palpable tenderness along the middle to distal third of the posteromedial tibial border indicates inadequate healing 4

Alternative Therapies for Refractory Cases

Acupuncture

• Interosseous membrane acupuncture may provide clinically significant pain relief in cases not responding to conservative therapy 6
• Technique involves deep needle placement through the interosseous membrane, with needles placed 1 cun distal and lateral to the tibial tuberosity 6
• This can produce immediate pain reduction lasting up to 4 weeks 6

Common Pitfalls to Avoid

• Do not rely solely on rest without addressing underlying biomechanical and training factors, as this leads to recurrence when activity resumes 1, 2
• Avoid returning to full activity too quickly based solely on pain resolution, as tissue healing lags behind symptom improvement 1
• Do not ignore body mass index above 30 as a contributing factor requiring weight management 4
• Avoid prolonged NSAID use beyond 2 weeks as inflammation is necessary for tissue healing 3

When Conservative Treatment Fails

• If symptoms persist beyond 4-6 weeks of appropriate conservative management, additional diagnostic workup is needed to rule out stress fractures or compartment syndrome 2
• More restrictive activity guidelines may be necessary for patients not responding to initial treatment 2
• Consider referral to sports medicine specialist for evaluation of alternative diagnoses 1, 2