What are the treatment options and medications for a patient with shin splints?

Shin Splints (Medial Tibial Stress Syndrome) Treatment

Initial Management: Rest and Activity Modification

The cornerstone of shin splint treatment is rest from the aggravating activity, combined with ice massage, NSAIDs for pain control, and stretching exercises. 1, 2, 3

Immediate Conservative Measures

• Stop or significantly reduce the aggravating activity until pain resolves, as continued stress will prevent healing and may lead to stress fractures 1, 2, 3

• Apply ice massage directly to the painful area for 15-20 minutes, 3-4 times daily to reduce inflammation and pain 1, 2

• Begin gentle stretching of the triceps surae muscles (calf muscles) as tight or weak calf muscles are a contributing factor 4, 2

• Avoid weight-bearing activities that reproduce the pain, particularly running, jumping, or prolonged standing 2, 3

Pharmacologic Treatment

NSAIDs are the primary medication for shin splints, used to control pain and reduce inflammation during the acute phase.

NSAID Recommendations

• Use oral NSAIDs such as naproxen (375-500 mg twice daily), ibuprofen, or celecoxib for short-term pain and swelling control (typically less than 14 days) 5, 1, 2

• Naproxen has been demonstrated effective for musculoskeletal pain with onset of pain relief beginning within 1 hour and lasting up to 12 hours 5

• Limit NSAID use to the shortest duration necessary (generally under 2 weeks) due to gastrointestinal and cardiovascular risks with prolonged use 5

• For patients over age 75, consider topical NSAIDs instead of oral formulations to minimize systemic side effects, though this recommendation comes from osteoarthritis guidelines 6

• Avoid NSAIDs in patients with history of GI ulcers, cardiovascular disease, or immediately before/after surgery 5

Important NSAID Safety Considerations

• NSAIDs increase risk of serious cardiovascular events, MI, and stroke, which can be fatal and may occur early in treatment 5

• GI bleeding and ulceration can occur without warning and may be fatal; risk increases with longer use, older age, smoking, alcohol use, and concurrent corticosteroid or anticoagulant use 5

• Use the lowest effective dose for the shortest duration needed 5

Activity Modification and Return to Activity

Gradual return to activity is essential once pain resolves at rest.

• Wait until the patient has no pain with daily activities before resuming the aggravating exercise 2, 3

• When resuming activity, reduce intensity and duration by 50% initially, then gradually increase by no more than 10% per week 2

• Correct training errors including excessive mileage, inadequate rest days, running on hard surfaces, and worn-out footwear 1, 4, 2

• Address biomechanical factors such as overpronation with appropriate footwear or orthotics 4, 2

Additional Treatment Considerations

Supportive Measures

• Maintain cardiovascular fitness through non-impact activities such as swimming, cycling, or pool running during the recovery period 2

• Address muscular imbalances at the ankle and strengthen the tibialis anterior and posterior muscles 4, 2

• Ensure BMI is below 30, as obesity is a risk factor for developing shin splints 4

Alternative Therapies

• Acupuncture targeting the interosseous membrane may provide significant pain relief in refractory cases, with one case series showing clinically significant improvement lasting 4 weeks 7

Common Pitfalls to Avoid

• Do not continue running or high-impact activities through the pain, as this can progress to stress fractures or chronic exertional compartment syndrome 1, 2, 3

• Do not rely solely on NSAIDs without addressing the underlying biomechanical and training factors, as this leads to recurrence 1, 2

• Do not use prolonged immobilization or complete rest from all activity, as maintaining cardiovascular fitness through alternative exercises is important 2

• Do not ignore persistent pain beyond 4-6 weeks of conservative treatment, as this warrants additional diagnostic workup including X-rays and MRI to rule out stress fractures, compartment syndrome, or other pathology 1, 3

When Conservative Treatment Fails

• If pain persists despite 4-6 weeks of appropriate conservative management, obtain imaging including X-rays to rule out stress fractures and consider MRI if diagnosis remains unclear 1, 3

• Consider referral to sports medicine or orthopedics for evaluation of chronic exertional compartment syndrome or other structural abnormalities 2, 3

• Bone tumors or lipomas can mimic shin splint pain and should be considered in atypical presentations 3