Shin Splints

About shin splints

If your child or teen has developed shin splints, it will comfort you to know that the Boston Children’s Hospital Orthopedic Center has a tremendous amount of experience treating this injury, developing therapies for healing and conducting research that leads to better care.

What are shin splints?

With more and more kids playing organized sports, there’s been a rise in the number of overuse injuries among children and adolescents. The Orthopedic Center is known for our clinical innovations, research and leadership. Regularly ranked among the top in orthopedics by U.S. News & World Report. we provide the most advanced diagnostics and treatments, several of which were pioneered and developed by Children’s researchers and clinicians — including platelet-rich plasma (PRP) treatment for tendon repair and physeal-sparing ACL procedures for children whose growth plates are still open.

As a common overuse injury, shin splints occur largely among runners — but sometimes among aerobics participants and athletes whose sports involve quick cutting and sideways motions. At Children’s, our patients with shin splints are usually teenagers or post-adolescents, since this is the age group that’s most likely to run and train competitively.

Shin splints and other overuse injuries are sports-related microtraumas (small injuries) that result from repetitively using the same parts of the body.
“Shin splints” is a catch-all term for tenderness and pain in the area of the shin bone (tibia). Pain can be:
- along or behind the inside edge of the tibia (posteromedial)
- along the tibia in the front/outside of the lower leg (anterolateral)

What are shin splints, and why do they occur?

Shin splints are an overuse injury caused by repetitive stress to the muscles, tendons and/or tissues associated with the shin bone (tibia) over a period of time, without enough rest to give the leg enough time to heal.

Muscles and tendons adapt to stress — that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. With an overuse injury like shin splints, the muscle or tendon receives the stress, but never gets a chance to rest.

Consult your child’s doctor if his lower leg is painful or inflamed. Tell the doctor if your child:

has been training very hard (usually running or aerobics)
has changed his exercise routine
has been running on hard surfaces
has been running with improper footwear

What factors can contribute to young people getting shin splints?

Shin splints can occur if a runner or athlete:

is experienced but is overtraining (often occurs late in the sports season)
resumes hard training after a lay-off
increases the duration or intensity of training too quickly
trains on hills
is a novice who begins training too hard before he’s conditioned
runs on surfaces that are too hard or uneven
runs in improper or outworn footwear
pronates (turns his feet outward) while running
has flat feet or fallen arches
has poor running mechanics
has tight muscles

What are the symptoms of shin splints?

Pain and/or inflammation at the side or front of the shin bone can be symptoms of shin splints. The pain tends to intensify in stages:

At first, the injury may hurt mildly when the child plays his sport.
As more trauma occurs, the child will experience constant pain when he’s playing.
At the end stage, the child has constant pain in his lower leg, even when he’s not playing. At that point, the affected area will have sustained a significant amount of damage.

How are shin splints diagnosed?

Your child’s doctor will do a physical examination, and may use diagnostic tests — including x-rays, an MRI (magnetic resonance imaging) and, rarely, a bone scan — to get detailed images of the injury and rule out a stress fracture.

What should I know about shin splints?

You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

You probably already have some ideas and questions on your mind, but it can be easy to forget the questions you wanted to ask when you’re talking to your child’s doctor. It’s often helpful to jot them down ahead of time to make sure that all your concerns have been addressed. You may also suggest to your child that she writes down questions to ask her health care provider, too. Some of the questions you may want to ask include:

What has happened to my child’s leg, and why?
Is this a serious injury? Will it do any permanent damage?
What tests will you perform to diagnose my child?
What actions might you take after you reach a diagnosis?
Will my child be OK if he has shin splints?
Will there be restrictions on my child’s activities? If so, for how long?
What should we do at home?
How can we help him understand that he needs to rest the injury?

Can my child return to sports after having shin splints?

If your child’s doctor has cleared him to go back to sports, the many benefits and life lessons he’ll gain from playing greatly outweigh the risks of injury. These benefits include:

physical fitness
teamwork, competitive prowess, accomplishment
improved body composition — less risk of obesity
reduced risk of heart disease and diabetes
stronger immune system
academic fitness — kids who play sports often academically outperform kids who don’t
emotional and psychological fitness — improved self-esteem, self-concept, self-confidence, empowerment and perception of competence

Who's at risk for shin splints?

runners and, less often, aerobics participants
run on surfaces that are too hard or uneven
have recently changed their training routine or started running hard up steep hills
are using outworn footwear
have had prior shin splints
are not conditioned, yet are suddenly training rigorously
have flat feet or rigid arches
tend to pronate (turn feet outward) when running
(to a lesser degree) aerobics participants
(to a lesser degree) athletes whose sports involve quick cutting and side-to-side motions, such as basketball

Complications

If an overuse injury like shin splints isn’t treated and the injury continues to worsen, a stress fracture can result. Complications after proper treatment for shin splints are uncommon, but can occur. These can include:

failure to respond to treatment
vulnerability of the area to re-injury

For teens

Many teens who have shin splints are not only high-performing, determined athletes, but also high-performing, determined students. If you approach your rest and healing period with that same spirit of determination, you should be back to sports and your active lifestyle within a few weeks or months, depending on how severe your injury was in the first place.

The most important thing you can do to get back into your sport is to give your leg a total rest. But even though you know the importance of rest and recovery, you still could find this to be a tough time. If you feel frustrated, depressed or angry during this important time, speak to your doctor, parent or counselor — they’re all on your team, and they all want to help.

For parents

If your teen is like many young athletes who have an overuse injury, he’s not only a high-performing, determined athlete — he’s also a high-performing, determined student. Encourage him to approach his rest and recovery period with the same spirit of determination that he applies to other areas of his life. With patience and perseverance, he’ll probably be back to sports and his active lifestyle within a few weeks or months.

Even though you and your teen know the importance of resting his leg, you both might experience his healing period as a difficult time. Parents who identify with their children’s success can feel frustrated or depressed along with their children, so speak to your doctor or counselor if you need help.

How can I prevent shin splints?

Our Sports Medicine specialists advise young athletes to:

warm up and stretch before practice
rest at least one day a week
cross-train/alternate sports: It’s usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend not to get as many overuse injuries as those who just specialize in one sport.
alternate exercises during practice: Not only are you less likely to experience an injury — studies have also shown that over the long term, muscle memory actually improves if you vary the drills.

Shin splints glossary

cast or walking boot: custom-made protections worn around the lower leg while shin splints heal
cartilage: a smooth, rubbery tissue that cushions the bones at the joint, and allows the joint to move easily without pain
diagnosis, diagnostics: identifying disease or injury through examination, testing and observation
ligament: elastic band of tissue connecting bone to bone
medial-tibial stress syndrome: the medical term for shin splints
microtrauma: a small injury to the body, such as microtears to muscle fibers, stress to the tendon, bruising of the bone; can occur to bone, muscle, tendon or ligament. If not allowed rest in order to heal, accumulated microtraumas can lead to overuse injuries, such as shin splints.
MRI (magnetic resonance imaging): produces detailed images of organs and structures within the body; shows the amount of damage from an injury
non-surgical (non-operative) treatments: alternatives to surgery; most treatments for overuse injury are non-surgical
orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
orthopedist/orthopedic surgeon: a physician concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
osteopenia: less bone mineral density than normal, a precursor to osteoporosis
osteoporosis: loss of bone density
overuse injuries: sports-related microtraumas that result from repetitively using the same parts of the body, usually by overtraining; can occur to muscle, tendon, ligament or bone
periosteum: the thin layer of tissue that covers a bone
physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
shin splints: pain and inflammation to muscles, tendons and tissue in the area of the shin bone (tibia)
tendon: a band of tough, inelastic fibrous tissue that connects a muscle with its bony attachment
tibia: shin bone

Shin Splints | Diagnosis & Treatments

How do we diagnose shin splints?

We know that the first step to treating your child is forming an accurate, timely diagnosis. To diagnose shin splints, your child’s orthopedic specialist will take a medical history and perform a physical exam on your child.

The doctor will also get x-rays to make sure there isn’t a true fracture. But because children can have stress fractures and damage to their growth plates that can’t be seen on x-rays, the clinician may use MRI (magnetic resonance imaging) and, rarely, a bone scan to get detailed images of the injury and verify that there is — or isn’t — a fracture.

How do we treat shin splints?

Boston Children's Hospital's Orthopedic Center provides patients with comprehensive care — including evaluation, diagnosis, consultation, non-surgical therapies, surgery, and follow-up care.

Initial first aid for shin splints usually involves “R.I.C.E.” (rest, ice, compression, and elevation), as well as medications to help control pain and swelling:

Rest: Make sure your child doesn't exert in any way that involves the injured area; he can use crutches or a cane, if it helps.
Ice: Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
Compression: Wrap a bandage or soft brace (from the drugstore) around his injury.
Elevation: The child should remain seated or reclining, with his leg elevated, as often as possible before seeing the doctor.

The primary therapy for most cases of shin splints is simply to rest the injured leg — restricting all activities that involve using the leg for a period of weeks or months. Your child's doctor may also recommend a cast or walking boot in order to:

relax the stress on the leg
protect the leg from further damage
force the athlete to rest

For an unusually severe overuse injury, treatment options may include:

temporary use of crutches or a wheelchair
physical therapy to stretch and strengthen the injured muscles and tendons
(very rarely) surgery or cauterization

Caring for your child as he heals

Your child's doctor will give you guidance regarding:

how long your child's leg should be rested in order for it to heal
tools for getting the injured leg back in shape, such as massage, stretching exercises, and strength training

Most kids with shin splints can return to sports and regular activities after several weeks or months of rest and healing time. But during the healing period, it's important for everybody in the family to support the young athlete's resolve to rest the healing area, since he may feel disappointed and even a bit depressed at not being able to run or play his sport.

How can parents and coaches help kids avoid shin splints and other overuse injuries?

Parents and coaches have a great deal of influence — for better or for worse. Parents and coaches should stress moderation in training and should restrain the zeal with which they push youth and teens.

Coaches themselves should learn and use proper training techniques, and should avoid too many repetitive drills, since these are the overwhelming reason for overuse injuries. Coaches should also teach proper running mechanics and other sport-specific motion techniques.

Physical education departments should make sure that the surfaces of a track or field are in good shape, and that proper equipment, footwear, and protective gear are used for each sport.

Our orthopedic specialists advise:

warming up and stretching before practice
resting at least one day a week
cross-training/alternating sports: It is usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to get fewer overuse injuries than those who specialize in just one sport.
alternating exercises during practice: Not only is the athlete less likely to experience an injury — studies have also shown that over the long term, muscle memory actually improves if one varies the drills.

Are there other guidelines and resources for injury prevention and safer training?

The American Academy of Orthopaedic Surgeons (AAOS) has issued comprehensive guidelines for helping to prevent sports injuries. Below is an excerpt from the AAOS recommendations:

use proper equipment
warm up
stretch
drink water

Drink enough water to prevent dehydration, heat exhaustion, and heat stroke.
Drink 16 ounces (one pint) of water 15 minutes before exercising and another 16 ounces after cool-down.
Drink water every 20 minutes or so while exercising.

cool down

Cool down for twice as long as warm-up.
Slow down motion and lessen intensity for at least 10 minutes before stopping completely.

rest

Schedule regular days off from exercise, and rest when tired.
Fatigue, soreness, and pain are good reasons to not exercise.

Coping and support

At Boston Children's Hospital, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's — and your own — hospital experience as pleasant as possible. The Hale Family Center for Families staff will give you all the information you need regarding:

In particular, we understand that you may have a lot of questions when your child is diagnosed with shin splints. Will this affect my child long term? When can he return to his sports and activities? We can connect you with extensive resources to help you and your family through this stressful time, including:

patient education: From the first doctor's appointment to treatment and recovery, our staff will be on hand to walk you through your child's treatment and help answer questions you may have — How long will his recovery take? Will he need home exercises and physical therapy? We'll help you coordinate and continue the care and support your child received while at Boston Children's.
parent-to-parent: Want to talk with someone whose child has been treated for shin splints? We can often put you in touch with other families who've been through the same process that you and your child are facing, and who will share with you their experience.
faith-based support: If you're in need of spiritual support, we'll connect you with the Boston Children's chaplaincy. Our program includes nearly a dozen clergy — representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian, and United Church of Christ traditions, among others — who will listen to you, pray with you, and help you observe your own faith practices during your experience.
social work: Our clinical social workers have helped many families in your situation. Your Boston Children's social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to dealing with a child's injury, changing family dynamics, and financial issues.

Shin Splints | Research & Clinical Trials

Research & Innovation

For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research—pioneering treatment approaches and major advances in the care and treatment of trauma to the joint, scoliosis, polio, TB, hip dysplasias and traumas to the hand and upper extremities.

Our advanced research helps answer the most pressing questions in pediatric orthopedics today—providing the children we treat with the most innovative care available.

Children’s research shows that too much high-impact training can lead to stress fractures in pre-teen and teen girls
Today’s kids are urged to participate in sports at younger and younger ages and at greater levels of intensity. While weight-bearing activity is generally thought to increase bone density, a Children's study found that for preadolescent and adolescent girls, too much high-impact activity can lead to stress fractures.

If stress fractures are detected too late in children and adolescent athletes, they pose a risk of true fracture, deformity or growth disturbance requiring surgical treatment, say the researchers, led by Alison Field, ScD, of Children's Division of Adolescent Medicine, and Mininder S. Kocher, MD, MPH, associate director of Sports Medicine at Children's.

Their study, published online on April 4, 2011, by the Archives of Pediatric and Adolescent Medicine, followed 6,831 girls aged 9 to 15 participating in the large national Growing Up Today study, co-founded by Field. During the seven years after enrollment, 4 percent of the girls developed a stress fracture. The most significant predictors were high-impact activities—particularly running, basketball, cheerleading and gymnastics.

"This is the first study to look prospectively at causes of stress fracture among a general sample of adolescent girls," says Field, who is also affiliated with Brigham and Women's Hospital. "Most research has been on specialized groups, such as army recruits or college athletes, making it difficult to figure out if the results apply to average adolescents. Our study was large enough to look at the risk associated not only with hours per week of activity, but also hours per week in a variety of activities."

When researchers adjusted for other risk factors (age, later onset of menstruation and family history of osteoporosis and low bone density), the association between high-impact sports and fractures only strengthened. Girls engaging in eight or more hours of high-impact activity per week were twice as likely to have a stress fracture as those engaged in such activity for four hours or fewer.

"We are seeing stress fractures more frequently in our pediatric and adolescent athletes," says Kocher, senior author on the report. "This likely reflects increased intensity and volume of youth sports. Kids are often playing on multiple teams, including town and travel teams, and participating in high-intensity showcases and tournaments. It's not uncommon to see young athletes participating in more than 20 hours of sports per week."

Each hour of high-impact activity per week increased fracture risk by about 8 percent. Basketball, cheerleading/gymnastics and running were independent predictors.

"The youth athlete is specializing in a single sport at a younger age," says Kocher. "This does not allow for cross-training or relative rest, as the athlete is constantly doing the same pattern of movement and impact. Small injuries are being made in the bone with greater cumulative frequency than the body can handle."

The key to the treatment of stress fractures is early recognition, Kocher adds. If recognized early, most stress fractures will heal fully with activity restriction. "Kids should not play through pain," he says. "'No pain-No gain' is not an appropriate adage for the young athlete."

The study was supported by the Orthopedic Center at Boston Children's Hospital and the National Institutes of Health (NIH).

Sports Medicine Research Laboratory

Children’s Sports Medicine Research Laboratory, led by principal investigator Martha M. Murray, MD, focuses on sports medicine injuries, including those of the ACL (anterior cruciate ligament), knee meniscus and articular cartilage.

In conjunction with our collaborators, we are studying these problems on multiple levels: gene, protein, cell, tissue and organism.

The lab’s research includes projects in:

molecular orthopedics
platelet optimization and characterization
tissue engineering
joint imaging
biomechanics of injury repair
histology and immunohistochemistry
device design and development
injury prevention
outcomes research

The Orthopedic Center conducts research into:

the mechanisms of sports injuries
the techniques of rehabilitation and treatment
the physiology of exercise and conditioning

Ongoing research includes the study of:

knee injuries
running injuries
injuries to pre-adolescent children
the psychological impact of sports and sports injuries
the treatment and prevention of injuries to dancers

Division of Sports Medicine director Lyle J. Micheli, MD, is one of the world's leading authorities on sports care. Micheli has treated world-renowned dancers and professional athletes, and is the author of hundreds of published clinical studies and scholarly review articles and books.

Innovations for tendon and ligament treatment

Platelet-rich plasma. For tendon repair, as with tennis elbow, the Orthopedic Center is now incorporating the latest in tendon regeneration—the application of platelet-rich plasma (PRP). This treatment has been popular in Europe—and now in the United States—for stimulating tissue regeneration in difficult-to-heal areas such as tendons (including Achilles, elbow and patella) that don’t respond to physical therapy or to limits on activity.

There are normally many healing growth factors in our platelets. The process involves isolating these growth factors in the patient’s blood platelets, and then injecting them into the affected areas under ultrasound guidance. This special procedure is performed by Children’s Pierre d'Hemecourt, MD.

Physeal sparing. A series of innovative, age-specific reconstruction techniques for treating the ACL injuries of growing children has been developed by Children’s orthopedic surgeon and director of the Division of Sports Medicine Lyle Micheli, MD. These are classified as physeal sparing procedures—that is, they spare the child’s growth plates (physes) from disruption that would occur in traditional ACL reconstructive surgery.

These physeal sparing treatment techniques are customized to the growing child’s age: pre-pubescent, adolescent or older adolescent. Originally developed as a temporary procedure until a child reached skeletal maturity, follow-up studies have found that five years after their surgeries, 95 percent of children who’d had physeal sparing procedures were doing so well that they didn’t need ACL reconstructive surgery, after all.

Children speak about what it’s like to be a medical research subject
View a video of a day in the life of Children’s Clinical and Translational Study Unit, through the eyes of children who are “giving back” to science.