Management of Shin Splints (Medial Tibial Stress Syndrome)
Stop all running and impact activities immediately until you are completely pain-free at rest and during daily activities. 1
Immediate Management Phase
Complete activity cessation is mandatory. The American College of Sports Medicine requires stopping all running, soccer, and impact activities until pain resolves completely at rest and during normal daily activities. 1 Avoid hills, hard surfaces, and any impact activities during this initial recovery phase. 1
Use NSAIDs for short-term pain relief during the acute phase to reduce inflammation, as recommended by the British Journal of Sports Medicine. 1 However, pain must guide all progression decisions—any activity causing pain greater than 3/10 should be stopped immediately. 1
Apply ice massage to the affected area as part of initial conservative treatment. 2
Assessment of Contributing Factors
Before progressing to rehabilitation, identify and address biomechanical risk factors:
- Screen for excessive hip adduction angle and increased rearfoot eversion during gait, as these are established risk factors for medial tibial stress syndrome per the American College of Sports Medicine. 1
- Assess ankle dorsiflexion range of motion—limited dorsiflexion is a modifiable risk factor that must be corrected. 1
- Evaluate for calf weakness, as this is directly linked to tibial stress injuries. 1
Rehabilitation Phase
Prioritize calf strengthening exercises as the highest priority intervention, since calf weakness is directly linked to tibial stress injuries according to the American College of Sports Medicine. 1
Include hip strengthening exercises focusing specifically on hip abductors and external rotators to reduce excessive hip adduction during running. 1
Perform daily calf stretching to address any dorsiflexion limitations, and include hamstring stretching as part of the comprehensive lower extremity flexibility program. 1
Return to Running Protocol
Do not return to running based on a timeline alone—progression must be guided by complete absence of pain, not by weeks elapsed. 1 This is critical because shin splints have one of the highest recurrence rates of all running injuries. 1
When pain-free at rest and during daily activities:
- Start on a treadmill or softer surface with walk-jog intervals at 30-50% of usual pace. 1
- Begin with 30-60 second running increments interspersed with 60 seconds of walking recovery on alternate days. 3
- Increase running duration by no more than 10% per week, with distance increased before speed. 1
- Do not progress speed until able to jog continuously for 30-45 minutes pain-free. 1
- Avoid hard surfaces, hills, and irregular terrain during the initial return to running phase. 1
- Limit training to a single terrain type initially; vary terrain only after returning to normal training volumes. 1
The scientific basis for this approach: bone cells become desensitized to prolonged mechanical stimulation, so short-duration running periods with adequate recovery prevent bone fatigue. 3 After 24 hours of rest, 98% of bone mechanosensitivity returns. 3
Sport-Specific Progression (If Applicable)
Progress from straight-line jogging to change-of-direction activities only after achieving 45 minutes of continuous pain-free running, as recommended by the British Journal of Sports Medicine. 1
Add sport-specific movements gradually while monitoring for any tibial pain. 1
Critical Pitfalls to Avoid
Avoid the temptation to progress too quickly when initial pain resolves—this is the most common cause of recurrence. 1 The pain often subsides with rest, but the underlying tissue healing requires more time. 4
Do not use prolonged immobilization or complete rest beyond what is necessary for pain control, as this leads to muscle deconditioning and does not address underlying causes per the British Journal of Sports Medicine. 1
Avoid activities that place excessive stress on the tibia during the initial weeks after returning to activity. 5
When to Consider Imaging
Consider imaging to rule out progression to tibial stress fracture if pain persists beyond 6-8 weeks despite appropriate conservative treatment, as recommended by the American College of Sports Medicine. 1 Be vigilant for signs of high-risk anterior tibial cortex involvement, which would require more aggressive management including possible prolonged non-weight bearing. 1
Prevention of Recurrence
Address all modifiable risk factors including proper footwear, muscular imbalances at the ankle, overtight or weak triceps surae muscles, and body mass index above 30. 6
Implement gradual training progression and avoid sudden increases in training volume or intensity. 7
Maintain proper biomechanics throughout the entire kinetic chain to optimize shock absorption. 8