True shin pain that is not a referred pain from the lumbar spine or knee normally falls in to one of two categories. The first is a condition named shin splints or within the medical and physiotherapy field medial tibial stress syndrome (MTSS). The second condition is named compartment syndrome.

Shin pain resulting from MTSS and shin pain resulting compartment syndrome may have very different rehabilitation exercises prescribed due to the different nature of the condition and underlying biomechanical causes.

In some cases of MTSS related shin pain there may be some underlying metabolic issue which may contribute to the tibial stress response. Similarly, if the symptoms are indicative of compartment syndrome, in rare cases there may be a structural problem to the facial soft tissue compartment housing the muscle groups. Circle Health are able to offer appointments with our expert sports and exercise medicine consultants and arrange further investigations as necessary under these circumstances.

The shin bone (tibia) is extremely good at withstanding vertical forces. However, it is thought that MTSS results when there is excessive rotational forces placed upon the tibia. Therefore, rehabilitation will not only involve a period of appropriate rest and gradual loading to the lower limb but will aim to address strengthening the muscles which resist rotation of the lower limb. Primarily these muscles are located around the hip and ankle and foot with the muscles around the knee primarily able to flex and extend the knee only.

Early stage hip rotational strengthening exercises around the hip may involve commonly used clam exercises involving rotating the top knee away from the floor in side lying. These may be progressed to performing this rotational movement against resistance band. Further progressions may include pelvic bridging, squatting or lunging exercises with resistance band around one or both knees.

The main force to stabilise the ankle and foot against excessive rotation (over pronation) is the tibialis posterior muscle and tendon. A variety of strengthening exercises exist but early stage exercises will often involve inverting the foot inwards into a ball or against resistance band. These exercises may be progressed to heel raising exercises squeezing a ball between to the heels.

Compartment syndrome occurs when a particular muscle group suffers from an inability to be able to get the appropriate blood supply in to (due to oxygen requirements) and out from (metabolic product removal) the muscle tissue. As the name suggests this is due to the fascial soft tissue compartment the muscle is housed in being too restrictive.

It is a condition which is a medical emergency if it occurs acutely after a trauma to a large muscle group such as the quadriceps. However, non-traumatic compartment syndrome can also occur in the muscles to the outside of the shin bone (anterior crural compartment). These muscles work to pull the foot and toes up and decelerate the foot  to the ground after we heel strike. They are used heavily during sports involving acceleration/ deceleration and kicking.

As a result, it can be seen at the start of the football and other sports related seasons when the muscles of the anterior shin may have weakened with disuse and need to rapidly gain size and strength.

Rehabilitation exercises for compartment syndrome related shin pain will be focused on a gradually introducing more difficult strengthening exercises to the shin muscles. Early in the rehabilitation process this may involve lifting the foot and toes against a resistance band. This may be progressed to lifting the foot and toes against gravity while sitting and more advanced level exercises may involve foot and toe lift in standing or heel walking to build endurance.

Throughout the rehabilitation process our physiotherapists may also work on releasing tight areas of the compartment with soft tissue techniques during appointments as well as advise self applied soft tissue release exercises as part of a home exercise routine. This may involve using a massage ball or foam roller over the shin muscles.

To ensure steady progress, clients suffering with compartment syndrome related shin pain may be monitored with strength and endurance tests by our expert physiotherapists.

Once our physiotherapists are happy that their clients with shin pain have built significant strength and stability in the rotational stability muscles of the lower limb and flexibility has improved as needed, they will introduce further challenges to the program. These balance related exercises are also referred to as proprioceptive exercises and rather than target direct strength they place the joints and muscles of the lower limb in to a correct alignment and work on functional movements that challenge the balance of the stabilizing muscles.

Common examples may be to place the client in a single leg stance position on a balance board or cushion and produce single leg squat movements or striding movements maintaining pelvic stability. In later stages of the shin pain rehabilitation process these may be progressed to lumping and landing on stable and progressed to unstable surfaces focusing on the alignment of the hip, knee and ankle.

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Circle Health, 32 Welbeck St, Marylebone, London W1G 8EU