Dr Chris Milne, Sports Physician

1. What is it?

It is an overuse injury of the origin of the tibialis posterior muscles. There is micro-bleeding at the junction between the bone cover (periosteum) and muscle origin.

2. What causes it?

It is an overuse injury usually caused by excessive running in the presence of faulty alignment in the lower leg.

3. Symptoms – what you notice

• Pain – usually on the inside of the shin bone (tibia) extending over a length of 10-20cm. The pain is usually of gradual onset, and worst with running.
• If you have focal pain (i.e. all the pain is over a 1-2cm area) then it is possible you have a stress fracture, rather than periostitis.
• If your pain is concentrated in the muscles rather than the bone-muscle junction, then it is possible you have compartment syndrome.

4. Signs – what the doctor finds

• Tenderness – along a 10-20cm length of the inner border of the tibia if it is periostitis. Focal tenderness where the doctor can put one finger on the sore spot is suggestive of a stress fracture. Diffuse muscle tenderness is present in the case of compartment syndrome.
• Hopping on the injured leg is relatively pain free in the case of periostitis, but is very painful if a stress fracture is present.
• Over-pronating flat feet are commonly seen in those who complain of shin splint pain.

5. Investigations

Usually none are required. If a stress fracture is suspected, then an x-ray may confirm this if symptoms have been present for longer than a month. Otherwise, a bone scan is needed. Compartment pressure studies can help confirm a diagnosis of compartment syndrome.

6. Treatment

• First aid – an ice pack or ice massage can be helpful after painful activity.
• Mechanical correction of over-pronating feet is essential. A podiatry referral is recommended.
• Physiotherapy, including myofascial release and a muscle rehabilitation problem is useful.
• Surgery is only required for confirmed compartment syndrome or very severe cases of periostitis lasting many months.

7. Recovery time

Average recovery time is 2-4 weeks for periostitis, 6-8 weeks for stress fracture and several months for compartment syndrome.

8. Recovery sequence

• Step 1 Ice packs, pain relief, felt or orthotic footwear correction.
• Step 2 Myofascial release and muscle rehabilitation.
• Step 3 Continue swimming and cycling, and only restart running after at least two weeks when symptoms have settled. Start on grass initially.
• Step 4 Build up pace and add stop-start routines.
• Step 5 Run figure eights.
• Step 6 Perform cutting and turning exercises.
• Step 7 Team training and skill sessions.
• Step 8 Resume playing, half a game at first.