Adolescent Shin Pain
1. Introduction
Adolescent shin pain can be defined as pain in the large bone on the inside of the lower leg (tibia) felt during activities such as walking, running and jumping. This condition tends to affect 12–18-year-olds who are very physically active. Physical activity places strain on the bones and muscles of the lower leg, having to absorb force as we put weight through the leg, but the bones also provide the anchor for muscles to pull against to produce movement. Therefore, symptoms are often felt during the activity, with almost 1 in 5 active 12–18-year-olds experiencing at least one bout of shin pain.
During our adolescent years, our muscles and bones go through significant changes as we develop from a child to an adult. Adolescence is a period where we go through accelerated periods of change where our bones are not only growing in length but also changing in structure from soft cartilage style bone to the hard adult bone. Add to this peak height velocity over a 12 to 18 month period, where we can gain up to 10% of adult height, and this mixture of growth and physical activity can leave our shin bone susceptible to injury.
Adolescent shin pain can represent a spectrum of injuries from mild irritation where the muscle inserts onto the bone, through to stress fracture of the bone and full fracture. If pain is present for a period of 3 weeks or more on activity and the symptoms are getting worse, you should seek further advice.
Frequently Asked Questions
- Shin pain is a common complaint in adolescent athletes. The term “shin splints” has historically been applied to these people, but there are in fact a number of similar conditions that can bring about pain in this area.
- Adolescent shin pain is very common in the active adolescent population.
- Stress fractures of the shin are the most common, accounting for around 48% of all lower limb fractures (1).
- Up to 19% of the athletic population suffer with adolescent shin pain (4).
- No.
- 99% of adolescent shin pain is treated with activity modification, strengthening and a gradual return to activity (2,5).
- Whilst most stress fractures of the shin heal well with appropriate management, there is a small risk of progression to full fracture and for this reason they should be assessed by a health professional (2).
- Adolescents between the ages of 12-18.
- Females are twice as likely to have this condition.
- Delayed age of menarche (first occurrence of menstruation).
- Family history of osteoporosis.
- It is more common in people with ethnicities from native America and Sami backgrounds.
- Someone who has had recent changes to a training programme or increased training volume (2, 4, 5).
- Pain at the front and upper half of the shin, or pain on the inside lower half of the shin (2).
- Pain that is made worse by activity but eased by rest (2, 4).
- Limping on the affected leg (1, 2).
- Worsening shin pain over time (2, 3).
- Review with your GP/physio to get a full diagnosis which may include blood tests for bone health or imaging (2).
- Activity modification – initially this may mean total rest or using crutches, depending on the severity (3).
- Physiotherapy – after the initial period of rest, exercises can help to strengthen the muscles around the shin (2).
- Medications can help relieve pain and reduce swelling (3).
- This will depend upon a number of factors including, but not limited to, the severity of the injury, diet and bone density (2).
- Most adolescent shin pain cases will take between 4-8 weeks to heal (2).
- More severe cases can take 3-6 months to heal and return to sport (6).
- In rare cases, adolescent shin pain can become a full fracture and surgery is required. Return to sport after this can take 6-9 months (5).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
Adolescent shin pain can present with a variety of signs and symptoms:
- Pain can present at any point on the inside of the shin (near the calf at the back) or the outside of the shin (front and centre).
- The most common presentations are inside and lower half of the shin towards the ankle and outer and upper half of the shin towards the knee.
- Pain that is worse when active (walking, running, playing sports).
- Pain that is generally alleviated by rest.
- Calf pain.
- Limp at any point in the day or after activity, even if only for a short period.
- A gradual onset without trauma that progressively worsens and starts to cause symptoms earlier into activity.
- Sudden worsening of symptoms after activity.
- Recent increase in training volume or return from a break.
3. Causes
A number of reasons have been suggested as to why people develop adolescent shin pain. These reasons include hormonal changes associated with maturation, but also body image concerns and disordered eating meaning the availability of vitamins and minerals used to build bone and muscle may be reduced. Recent changes to a training programme or increased training volume are also linked to the development of the condition.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing adolescent shin pain. It does not mean everyone with these risk factors will develop symptoms.
- Females are twice as likely to suffer this condition as males.
- Up to 1 in 5 who engage in high-impact sports, e.g. sprinters, distance runners, basketball players, soccer players, and dancers are at risk.
- Adolescents experiencing accelerated growth between 12-18 are more susceptible.
- Those with low levels of vitamin D or poor diet.
- Girls who have a delayed start to menstruation.
- Those with a family history of osteoporosis and engage in high-impact sports are at the greatest risk.
5. Prevalence
Adolescent shin pain is present in up to 20% of the athletic population of 12–18-year-olds, with females twice as likely to develop adolescent shin pain than their male counterparts.
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.
Further investigations or imaging may include:
- Vitamin D levels – this is a blood test that will give an indication of bone health; for most adolescents, it should be between 75 and 95. Vitamin D helps the body to absorb calcium, along with phosphorous which is vital for bone growth and maintenance. If you are below these levels the doctor may discuss supplementation unique to your injury needs.
- Imaging – if your symptoms have not resolved within 3-4 weeks the doctor may decide to send you for an X-ray or MRI to get a definitive diagnosis of the problem and help to decide the best treatment options. If you have had previous stress fractures and another one is suspected, you may be sent for a DEXA (dual-energy X-ray absorptiometry) scan that will give an indication of your overall bone health.
7. Self-Management
If you develop a bout of aches or pains around the shin in response to an activity which settles within 2 days and does not recur, this is not likely to represent adolescent shin pain and you should continue with your normal activities.
If pain continues to be present on activity for more than 2 weeks, the initial self-management is to stop all aggravating activities for a period of 3 weeks (2). During this time, you can do things to help manage symptoms such as icing or heating the area. You can then gradually reintroduce activity, building back up to your normal activities over 3-4 weeks. If pain returns during this period of build-up, you should then seek further assessment with a musculoskeletal physiotherapist (3).
8. Rehabilitation
This will depend entirely on your symptoms and the outcome of any imaging that may be requested. For those with mild symptoms, they may be able to continue to do impact activities alongside a strengthening programme provided symptoms do not worsen (2).
For moderate symptoms, you may be asked to stop all aggravating activities and switch to non-impact activities such as cycling, swimming or aqua jogging. Once symptoms have settled you will be asked to start a programme of strengthening for the legs and trunk (2,3).
For severe symptoms, including limping during or after activity, or a diagnosed stress fracture, you may be asked to take part in a period of non-weight-bearing on crutches and wearing a walking boot. You will then be reviewed and tested and when you are able to walk again pain-free the boot can be removed and you can stop using the crutches (2,3).
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing adolescent shin pain. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Adolescent Shin Pain
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on some early strengthening exercises that are safe to perform to ensure that deconditioning (decline in physical function) is limited. Pain should not exceed 4/10 on your perceived pain scale whilst completing this exercise programme.
- 0
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- 910
At this stage the emphasis moves towards trying to strengthen around the area to reduce the risk of the problem occurring in the future. Pain should not exceed 4/10 whilst completing this exercise programme.
- 0
- 1
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- 4
- 5
- 6
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- 910
At this stage we move towards more loaded and whole-body exercises to help ensure a return to normal movement and a safe and effective return to activity. Pain should not exceed 4/10 whilst completing this exercise programme.
- 0
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- 4
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- 910
10. Return to Sport / Normal life
Returning to sport after adolescent shin pain is a gradual process of slowly increasing the difficulty of strengthening exercises and reintroduction to preferred sporting activities (2, 3).
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence (3).
Unfortunately, a small percentage of patients with this condition do suffer a reoccurrence of their pain and in this instance, they should seek further medical advice before continuing their rehabilitation (1, 2).
11. Other Treatment Options
For those who do not recover with activity modification, exercises and other comprehensive treatments, the next option is often surgical (7, 8, 9) such as:
- Anterior tension band plating – a long thin cut is made just to the side of the fracture site and muscle lifted away from the front of the shin. Some drilling around the fracture site is done to stimulate bone healing and bone marrow from the other side hip is inserted into the fracture site. A small metal plate is applied to the site and tensioned to bring the fracture site closer together. This is then held in place by screws (8).
- Intramedullary nail – the surgeon makes a cut at the bottom end of the thigh and passes a metal nail all the way through the shin bone centre. This gives support to the healing bone by offloading some of the weight-bearing. These can stay in long-term or be removed at a later date.
References
- Niemeyer P. et al, (2006) Stress Fractures in the Juvenile Skeletal System. International Journal of Sports Medicine, 27, 242-249.
- Korsh J. Matijakovich D. & Gatt C. (2017) Adolescent Shin Pain. Pediatric Annals, 46, 29-32.
- Field A. et al, (2011) Prospective study of physical activity and risk of developing a stress fracture among preadolescent and adolescent girls. Archives Pediatric Adolescent Medicine 165, 723-728-73.
- Winters M. et al (2018) Medial tibial stress syndrome can be diagnosed reliably using history and physical examination. British Journal of Sports Medicine 52, 1267-1272.
- Changstrom B. et al (2015) Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012- 2013. American Journal of Sports Medicine 43, 26-33.
- Nattiv A. et al (2013) Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. American Journal of Sports Medicine 41, 1930-1941.
- Varner K. et al (2005) Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing. American Journal of Sports Medicine 33, 1071-1076.
- Borens O. et al (2006) Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases. Journal of Orthopaedic Trauma 20, 425-430.
- Tsakotos et al (2018) Tension band plating of an anterior tibial stress fracture non-union in an elite athlete, initially treated with intramedullary nailing: a case report Journal of Medical Case Reports 12, 183-187.
Other Conditions in
Lower Legs
Tibialis Posterior Tendinopathy
A condition involving injury to the tendon found around the bone at the inner side of the ankle leading to pain and weakness.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.