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Lower Leg and Calf Injuries


Shin Splints

What is it?

“Shin Splints” is a widely used term to describe a number of different conditions that cause pain in the lower leg region.

It most commonly refers to a condition known as Medial Tibial Stress Syndrome (MTSS). Other conditions it can refer to are; compartment syndrome and stress fractures.

MTSS is chronic stress on the regions of the shin bone where the muscles attach, causing microtrauma and subsequent inflammation on the inside aspect of the shin bone.

What do I look for?

  • The most common site of pain will be at the inner part of the shin bone and often only felt with activity
  • Pain may also be in the outer side of the shin bone, in the shin and/or calf muscles
  • Numbness in the foot region with activity
  • Gradual onset over a period of time


What causes it?

  • Poor foot mechanics or change of footwear
  • Muscle tightness in the calf muscles
  • Poor lower limb mechanics and pelvic stability
  • Rapid changes in training routines or surface


When do you see someone for help?

Your Physiotherapy4u Practitioner will be able to provide an accurate diagnosis and an appropriate management plan.

Often this problem can require a Sports Medicine Doctor, Physiotherapist, and/or Podiatrist to assist.

For more information contact us.


Medial Tibial Stress Syndrome

What Are Shin Splints?

The term shin splints has been widely used as a catch-all term referring to a collection of different conditions that cause lower leg pain. The term Medial Tibial Stress Syndrome (MTSS) better defines the injury and separates it from injuries such as stress fractures or compartment syndrome.

MTSS is caused by chronic strain, overuse, and microtrauma of the soleus (calf) muscle at its origin on the inside of the shinbone (posteromedial tibia), or deep inflammation of the periosteum, which is the connective tissue that covers the bone, of the tibia beneath the posterior tibialis muscle.

MTSS usually occurs in unconditioned people who begin a new running or jumping activity or conditioned runners who change or increase their speed or distance or change their type of shoe or running terrain. MTSS also affects individuals who have flat feet because the mechanics of the foot increase stress on the soleus muscle.

Differential Diagnosis – MTSS vs Compartment Syndrome vs Stress Fracture

MTSS – Medial Tibial Stress Syndrome is the most common presentation of lower leg pain, with pain localized to the inner portion of the tibia in the middle/lower thirds of the lower leg and in the surrounding soft tissue. With MTSS, pain usually disappears once the activity that causes the pain is reduced or stopped. An X-Ray sometimes shows chronic cases of MTSS, where there is a mild thickening of the tissue surrounding the tibia (periostium) or an uneven edge at the end of the tibia in the back. Despite being the most common of lower leg complaints, MTSS is often a common misdiagnosis for similar conditions such as stress fractures and compartment syndrome.

Stress Fracture – Stress fractures are hairline cracks in the bone. This often follows as a result of shin-splints that have not been managed correctly or when patient tries to “run-through” the problem. A patient with a stress fracture usually experiences severe pain that does not always go away with rest. The pain often persists with walking and increases when walking up steps or during similar moderate activity. A patient with a stress fracture feels pain around the upper outside portion of the tibia. The patient commonly complains of pain at night. X-rays are often required to rule out a stress fracture. However, X-rays may not show a fracture line or a healing stress fracture until several weeks after injury, so a bone scan, CT scan or MRI may be used instead.

Compartment Syndrome – There are four divisions of muscles in the lower leg (anterior, lateral, posterior – superficial/deep). Each of these are surrounded by a thick tissue called fascia that surrounds the muscles completely. During exercise muscle volume generally increases by 20% increasing pressure within each compartment. Excessive pressure can affect supply to blood vessels and nerves in the leg.

Compartment syndrome is a painful condition that results when pressure within the muscles of the lower leg builds to dangerous levels, preventing nourishment from reaching nerve and muscle cells. This diffuse widespread lower leg pain typically comes on 5–10 minutes after beginning a bout of exercise, and rapidly builds to such a severity exercise needs to be ceased.

Pain usually settles rapidly on stopping exercise. The increased severity of pain reflects the fact that it is caused by restriction of oxygen and blood to the involved muscle compartment.

Causes of Medial Tibial Stress Syndrome

Excessive pronation of the feet. Pronation is a normal movement of the foot that allows the arch to flatten which helps the body to absorb shock and adapt to different surfaces. If the arch flattens more than normal is it called excessive pronation.

This places increased pressure on the arch and upon repetitive movement such as running will greatly increase the stress placed on the lower leg.

Tightness in the posterior muscles, which propel the body forward, places additional strain on the muscles in the front part of the lower leg, which work to lift the foot upward and also prepare the foot to strike the running surface.

Insufficient shock absorption. Hard surface running, or worn or improper shoes increases the stress on the anterior leg muscles. Softer surfaces and shoe cushioning materials absorb more shock and less is transferred to the shins.

Poor lower limb biomechanics/improper foot positioning. The lower leg muscles suffer a tremendous amount of stress when a runner lands only on the balls of the feet (toe running), without the normal heel contact.

The muscles of the foot and leg overwork in an attempt to stabilize the over-pronated foot and the repeated stress can cause the muscles to tear where they attach to the tibia. Rapid increase of speed or distance

Signs and Symptoms of Medial Tibial Stress Syndrome

  • Aching along the front of the shin with activity.
  • The pain may begin as a dull aching sensation after running.
  • The aching may become more intense, even during walking, if ignored.
  • Pain along the inside (medial) part of the lower leg.
  • Generally, develops gradually over weeks/months
  • May have swelling in lower leg
  • Tender areas are often felt as one or more small bumps along either side of the shin bone.



MTSS is an inflammatory disorder, that can be best managed initially with rest, ice and anti-inflammatories (ie nurofen, voltaren).

Physiotherapy at this stage will involve ultrasound, light massage, and education with guidelines into exercise intensity and frequency.

This aims to settle and relieve the inflammatory process thereby relieving symptoms. More intense physiotherapy can then be commenced. It usually involves, deep tissue massage, Myofascial releases, muscle frictions, structure rehab programs to increase flexibility, strength and endurance and gradual recommencement to normal activities.

Throughout rehabilitation your physiotherapist will advise you on continuing aerobic fitness activity, however it will likely be modified to reduce lower limb impact (ie swimming, orbital training, beach walking/running)


MTSS can be painful but is usually easily resolved. If you experience pain in your shin, thoroughly stretch before exercising, reduce your activity level, and check your footwear. If you run on a hard surface, find some softer ground to train on.

Avoid training errors (‘start low and go slow’). Introduce gradual changes in intensity, activity, and terrain. Maintain adequate calf and anterior tibial flexibility, strength, and endurance.

When do you see someone for help?

Your Physiotherapy4u Practitioner will be able to provide an accurate diagnosis and an appropriate management plan.

Often this problem can require a Sports Medicine Doctor, Physiotherapist, and/or Podiatrist to assist.

For more information contact us.

Anterior (Tibial) Compartment Syndrome

The anterior (tibial) compartment syndrome, also called anterior or lateral shin splints, usually occurs when a runner changes from a flatfooted to a toe-running style, begins interval training on a track or hill, or runs in a shoe with a sole that is too flexible. All of these activities overload the anterior compartment muscles, producing pain in the antero-lateral area of the leg along the extensor tendons of the ankle and foot (see diagram).

Anterior compartment syndrome caused by a segmental artery spasm or by ischaemia of the muscles and nerves from increased tension in the fascial compartment is rare in runners.


Successful treatment may include proper training technique (wearing good shoes, running on a level surface, no excessive hill or speed work), stretching exercises and strengthening exercises for the anterior compartment musculature, physiotherapy treatment including a range of modalities and ice treatment at home.

A runner with a chronic or long standing injury may require fasciotomy (which will allow more room for muscle swelling in the anterior compartment).

If the symptoms do not respond to therapy, a tibial or fibular stress fracture should be suspected. Conditions that simulate shin splints and the compartment syndromes (e.g. thrombophlebitis, osteomyelitis, cellulitis, tumours and intermittent claudication) are rarely seen in runners but should be considered.

Cross-section through anterior and lateral compartments of leg

For more information contact us.

Achilles Tendinosis

Tendons are the body tissues that connect muscle bellies to our bones. The achilles tendon is the rope-like structure running from the calf muscle in the back of your leg down to the heel bone.

A healthy achilles tendon may be nearly as strong as a steel cable, coping with tremendous forces from the action of your calf muscle. Our calf muscle is made up of three muscle bellies (medial and lateral gastrocnemius and soleus). All three muscle bellies connect to the Achilles tendon.

What is Achilles tendinosis?

It seems most pain arising from the achilles tendon is due to degenerative changes, or “wear and tear”, within the tendon itself. There may be some inflammation present but not as much as we used to think (when the condition was called achilles tendonitis).

 How do you get achilles tendinosis?

Usually the cause is overuse over a period of time. Overuse means there has been too much force repetitively going through the tendon but doesn’t necessarily mean you have be overtraining or on your feet too much. For example, there may have been too much force going through part of your Achilles tendon because you have flat feet or have developed a stiff ankle. There again, it may be from trying to walk or run too far without an adequately graduated build up.

How do you overcome achilles tendinosis?

This can be a very frustrating injury as tendons don’t receive as much blood as some of our other body tissues and are therefore slower to heal.

Rest will probably allow the pain to settle but once you increase your activity level again the symptoms are likely to return. The balance between maintaining exercise but not reaggravating the condition is the key to your rehabilitation.

The best results are gained by acting quickly to sort out the underlying cause of the problem. e.g. overtraining/flat feet/stiffness/inappropriate shoes, etc. Your biomechanics (the way your body parts move) need to be carefully assessed.

Treatment may consist of specific stretches and very specific “eccentric” strengthening programmes that are closely supervised by your Physiotherapist.

 When do you see someone for help?

Your Physiotherapy4u Practitioner will be able to provide an accurate diagnosis and an appropriate management plan.

Often this problem can require a Sports Medicine Doctor, Physiotherapist, and/or Podiatrist to assist.

For more information contact us.