When you have chronic and painful shin splints and nothing helped

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

You are a runner or an athlete, most likely a soccer player, that requires stamina and the ability to run up and down the field or court. You have an on-again, off-again problem with pain in the shin area. Your initial research online was “what do I do about this?” You got pretty much the same tips about resting, taking anti-inflammatories, ice, compression sleeves, and exercises and stretching from the websites you visited. You also found out that a lot of runners have your problem.

Finally, you went to the health care provider with your complaints and he/she recommended that you have “shin splints,” “Periostitis,” an inflammation of the soft tissue that surrounds the tibia (the main shin bone), or you have “Medial Tibial Stress Syndrome.” For the most part, they all mean Shin Splints.

You got your diagnosis and perhaps a prescription for a strong anti-inflammatory. You were probably advised to rest more often, continue with icing if that was helping, and come back in a few weeks if this problem did not resolve.

A few weeks later, you went back to the health care practitioner to report little improvement

While some people do respond to rest, some people do not. This is probably you and why you are reading this article. You are now back at your practitioner’s office and you decide that you want to follow a more aggressive treatment plan. Physical therapy may be called for. The exploration of shoe inserts may be explored to distribute the impact of walking or running to different parts of your foot, ankle, and shin. At least you feel that more is now being done. But will more work?

Understanding that your problem is much more than painful shins. This can end your ability to run.

As your problems progressed and you spent more time online researching, you started to discover that your problem may be more than just painful shins. You start to realize that there are reasons you cannot run or get better. Understanding of the causes of shin splints goes beyond “overdoing it” for people like you whose situation has become long-term.

Many athletes look to alternative treatments like Prolotherapy as a long-term solution to dealing with shin splint pain. We use Prolotherapy to stimulate the body to repair the painful injured area(s) when the body’s natural healing process is not able to do the job on its own.

Shoe after shoe

Shin splints are a common reason why people go through shoe after shoe, trying to find relief. Shin splints is the catch-all term for lower leg pain that occurs below the knee either on the front outside part of the leg (anterior shin splints) or the inside of the leg (medial shin splints). They are the bane of many athletes, runners, tennis players and even dancers. The condition typically involves only one leg, and almost always the athlete’s dominant one. If the athlete is right-handed, he or she is usually right-footed as well. Thus, the right leg of this individual would be more susceptible to shin splints. Physical examination of the patient with shin splints reveals a diffuse area of tenderness over the posterior medial edge of the tibia. The pain is occasionally aggravated by contractions of the soleus, posterior tibialis, or flexor digitorum longus muscles. We find the most reliable sign, though, is to poke on the area with the thumb to reproduce the athlete’s exact pain.

There are several causes and theories for why shin splints occur. Tightness in the posterior muscles that propel the body forward places additional strain on the muscles in the front part of the lower leg, which works to lift the foot upward and also prepares the foot to strike the running surface. Hard surface running as well as worn or improper shoes increase the stress on the anterior leg muscles. The lower leg muscles suffer a tremendous amount of stress when a runner lands only on the balls of the feet (toe running), without normal heel contact. The muscles of the foot and leg overwork in an attempt to stabilize the pronated (rotated in and down) foot, and the repeated stress can cause the muscles to tear where they attach to the tibia. Another possible cause is ligament damage. Both the “spring,” or plantar calcaneonavicular ligament, and the posterior talofibular ligament may be weakened or injured during running, again leading to painful shin splints.

Shin splints often plague beginning runners who do not build their mileage gradually enough, as well as seasoned runners who abruptly change their workout regimen by suddenly adding too much mileage or switching from running on flat surfaces to hills, to cite just two examples.

Since shin splints are felt as intense pain in the leg, traditional treatment usually involves rest. This is after other measures, such as taping the arches, using heal cups in the athletic shoes and applying muscle pain-relieving topical gels and creams. The problem with this approach is that extended resting of the muscles and the periosteum, or the bone covering, will further weaken the already weak structures. It does not repair the weakened “spring,” or plantar calcaneonavicular ligament, or the posterior talofibular ligament, both of which take a considerable beating during running, the activity that is the most common cause of shin splints.

The United States Army has a problem with chronic shin splints.

If you are in the military you know that shin splints are a problem for new inductees as they go through basic training. Long runs and carrying heavy back is a powerful formula for shin splints. So Army doctors teamed up with Indiana State University researchers and published a paper in the Journal of Athletic Training (1) as to what factors put physically active individuals at risk for the development of medial tibial stress syndrome (Chronic shin splints).

Body mass index (BMI). Increased BMI means increased pressure on your legs and joints as you run, which could lead to shin splints
Navicular bone drop. The instep or arch of the middle of the foot drops out of place as the foot-arch complex becomes unstable due to excessive pronation (tilt).
Ankle instability can cause a hyper plantar-flexion range of motion (increased ability to point your toes down). Simultaneously, it can cause increased difficulty dorsiflexing the foot (pointing toes up), which causes the muscles that dorsiflex the foot (anterior shin muscles) to be overactive and increase stress on the shin.
Quadriceps angle. Commonly called the “Q angle”, this is the measurement of the angle between your quadriceps muscles and patellar tendon. This angle helps us determine the alignment of your knee. Increased Q angles, more common in women, can contribute to the development of shin splints.
Hip instability This can cause a hyper plantar-flexion range of motion, similar to that which can be found with ankle instability. In addition, instability of the hip can increase forces on the tibia during activity or alter the Q angle, both of which increase torque on the lower leg and lead to shin splints.

An October 2020 study in the International Journal of Environmental Research and Public Health, (2) reviewed eleven research papers seeking risk factors for Medial Tibial Stress Syndrome in new and recreational runners. are mainly intrinsic (the way someone’s body moves) and include higher pelvic tilt in the frontal plane (please see our article Treatments for adult spinal deformities, leg length discrepancy, and pelvic tilt), peak internal rotation of the hip, navicular drop, and foot pronation (evaluation of the medial longitudinal arch, among others. Please see our article Adult acquired flatfoot deformity – fallen arches and flat feet treatments).

Treatment options

Since shin splints are felt as intense pain in the leg, traditional treatment usually involves rest. This is after other measures, such as taping the arches, using heal cups in the athletic shoes, and applying topical creams to the sore muscles have failed to give relief. The problem with this approach is that resting the muscles and the periosteum, or the bone covering, will further weaken the already weak structures. It does not repair the weakened ligaments of the hip and ankle that may be contributing, nor does it repair or undo the stress done on the tibia and surrounding soft tissue.

Cortisone

There is not much evidence that cortisone helps shin splints.

Dutch doctors offered the cases of two patients in the Journal of Sport Rehabilitation (3) where the cortisone injections did not help but further caused side effects.

Here the case doctors presented 2 cases of women with Medial Tibial Stress Syndrome who showed atrophy and depigmentation of the skin after pretibial corticosteroid injections.

Case 1 is an 18-year-old woman with pain in her lower leg for a period of 12 months. No improvement was noticed after conservative treatment, so she received local injections with corticosteroids. Five months later physical examination showed tissue atrophy and depigmentation around the injection sites.
Case 2 is a 22-year-old woman who presented with pain in both lower legs for 24 months. Several conservative treatment options failed, so she received local injections with corticosteroids. Physical examination revealed tissue atrophy and depigmentation around the injection sites.

Prolotherapy treatments for shin splints

Shin splints or medial tibial stress syndrome (MTSS) is caused by injury to muscle attachments onto the medial tibia which can include the soleus, posterior tibialis, among others. While conservative care medicine treats shin splints with rest, ice, compression, and elevation (RICE), and NSAIDs, these can often make the structures weaker and is one of the reasons shin splints often come back.

Research

In a study published in the British Journal of Sports Medicine, titled: The effectiveness of Prolotherapy in the management of recalcitrant medial tibial stress syndrome: A pilot study (4) researchers examined seven patients who received dextrose Prolotherapy under ultrasound guidance to the painful area of the tibia. Using a visual analog scale (VAS) (10=highest pain, 0=no pain), all subjects reported a marked improvement in their symptoms after eighteen weeks post-injection.

The average visual analog scale pain score improvement per subject was 4/10, representing a return to the desired level of activity.

That research was from 2012, some of those same researchers have now published an April 2021 study. (5) Here their goal was to “evaluate whether ultrasound-guided injection of 15% dextrose (Prolotherapy) for treatment of recalcitrant medial tibial stress syndrome decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.”

Here the researchers followed eighteen patients: fifteen male and three female; (average age = 31.2 years) with recalcitrant medial tibial stress syndrome. Previously, these patients had failed all available conservative treatment.
The patients received an ultrasound-guided sub-periosteal injection of 15% dextrose Prolotherapy along the length of the symptomatic area.
The pain was assessed using the visual analog scale and assessed at short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up.
Patients reported a significant reduction in average visual analog scale pain at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10.
Patients rated their condition as ‘much improved’ at medium-term follow-up and the median return to sports score was ‘returned to desired but not pre-injury level’ at medium-term and long-term follow-up. No adverse events were reported. (Let’s note that this was a single treatment – we would suggest 3 – 6 treatments for this problem.)

Conclusions: “Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in medial tibial stress syndrome. This benefit may be maintained long-term. . . Clinical relevance: Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant medial tibial stress syndrome.

Shin Splints Treatment with Prolotherapy

Prolotherapy specialist Danielle R. Steilen-Matias, MMS, PA-C, describes and demonstrates the treatment.

We are treating this patient today for shin splints. The patient is a runner, he runs every day. The patient has tried many of the other recommended treatments like icing, new shoes, and other things that did not seem to work for him.

The injections begin at 0:27 of the video.

I inject along the tender areas of the shin where the muscles meet up with the bone.

What happens in shin splints is that you can get these microtears in the muscle and you put ice on it or you’re rested it and it does not get better you may need to find other options. In Prolotherapy we can treat those micro tears and help them heal so we can alleviate the pain from the shin splits while repairing the damage.

We recommend that you continue your training and activities while receiving Prolotherapy. Runners however may want to decrease mileage and avoid doing too much too soon. Using the elliptical or power walking on the treadmill set at an incline to keep the heart rate up can help you continue to exercise during treatments. Stretching the Achilles and calf muscles is very important as is strengthening the lower leg muscles. Listen to your body. While some muscle aches or discomforts are to be expected when you push yourself, pain is not. Pain is your body’s way of telling you that something is wrong. If you continue exercising through pain, you risk injury.

A case report:

A 21-year-old male with a history of shin splints came to our office as a new patient. For the past 4 years, he has been suffering from shin splints when running, which he attributed to running in worn-out shoes for several years. He reported that his shins were in intense pain and “clicked” when running. He had tried rest, ice, ultrasound, stim, and chiropractic care for several years without any long-term benefit.

On exam, no instability in his hips, knees, or ankles was noted. His shins were diffusely severely tender to touch along the tibia and surrounding musculature attachments. He underwent several dextrose Prolotherapy and Neural Prolotherapy treatments, all the meanwhile doing cross-training and walk/jog intervals as the tissue healed. After three treatments, he reported significant pain when running and his shins were no longer clicking. At that time, he started training for a half marathon. As his training increased, he came back for two more treatments to his shin and ended up running his half marathon in just over two hours.

Can Prolotherapy help shin splints?

We have found that shin splints respond very well to Prolotherapy. As the ligament and tendon attachments strengthen, the athlete can continue to get back to working out without dreaded shin splints.

Dr. Ross Hauser is the Medical Director of Caring Medical. He is a Physical Medicine and Rehabilitation physician who specializes in sports injuries and tough cases of chronic pain. In this video, Dr. Hauser discusses Prolotherapy treatment for shin splints or periostitis. At Caring Medical we treat many runners with injuries, including shin splints, runner’s knee, plantar fasciitis, and ankle sprains, among many other common sports injuries.

Questions about our treatments?

If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References:
1 Winkelmann ZK, Anderson D, Games KE, Eberman LE. Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. J Athl Train. 2016 Nov 1. Indiana State University. [Google Scholar]
2 Menéndez C, Batalla L, Prieto A, Rodríguez MÁ, Crespo I, Olmedillas H. Medial Tibial Stress Syndrome in Novice and Recreational Runners: A Systematic Review. International Journal of Environmental Research and Public Health. 2020 Jan;17(20):7457. [Google Scholar]
3 Loopik MF, Winters M, Moen MH. Atrophy and depigmentation after pretibial corticosteroid injection for medial tibial stress syndrome: two case reports. Journal of sport rehabilitation. 2016 Dec 1;25(4):380-1. [Google Scholar]
4 Curtin M, Crisp T, Malliaras P, Padhiar N. The effectiveness of prolotherapy in the management of recalcitrant medial tibial stress syndrome: a pilot study. British Journal of Sports Medicine. 2011 Feb 1;45(2):e1-. [Google Scholar]
5 Padhiar N, Curtin M, Aweid O, Awied B, Morrissey D, Chan O, Malliaras P, Crisp T. The Effectiveness of Prolotherapy for Recalcitrant Medial Tibial Stress Syndrome: a Prospective Consecutive Case Series. [Google Scholar]

This article was updated April 19, 2021