Shin pain can arise from a number of structures here. First the main bone...
Our shin bone or Tibia is the weight bearing member in our leg, and is sometimes the site of a stress fracture³. A fracture line is a relatively straight line, and goes right across a bone - so the tenderness should be likewise.
A thin fracture line may not show in X-rays taken from all directions - oblique views as well as A-P and lateral, may be needed.
A nuclear medicine bone scan is the best test for fracture. It shows up new bone being laid down in the healing process.
The Tibialis anterior muscle shown on the left, is the main muscle stopping our foot from slapping down as we land on our heel, when walking or running.
If we start training vigorously, or switch onto a hard surface for running, the stress on tibialis anterior increases dramatically.
Years ago, I had to get a special Nikeᴿ running shoe with a hard backwards protruding ledge on the heel, which softened my landing and fixed my shin splints.
The musculo-tendinous junction of tibialis anterior, where the red ends on the picture, is a common site which complains, and can become so inflamed that it creaks.
Even if muscles don't get sore immediately after vigorous exercise, the muscles swell immediately, for an hour. They swell again a day later, and MRI changes are seen immediately and again at 12 hours¹.
The muscle damage can be shown by rises in blood levels of creatinine kinase (CK,) myoglobin and myosin heavy chain proteins.
Muscles are enclosed in strong fibrous envelopes called fascia. They have only a limited space to swell in, and can get too tight.
This can result in cuffing constriction of veins² leaving the muscle, and a vicious cycle of swelling and venous obstruction can ensue.
The diagrams show a vein within a muscle, leaving the muscle through a hole in the fascia.
If the pressure within the muscle increases, it is applied uniformly along the length A to B of the vein, with no increased pressure difference to drive blood from A to B.
The veins within the muscle are therefor not affected by the swelling. You can't squash blood flat.
It is a very different matter where veins leave the muscle. Here there is increased pressure on the vein at point B, but not at point C. This pressure transmitted to the blood in the vein at point B, results in a pressure difference which drives blood from B to C.
The vein collapses at point B, obstructing the flow of blood from the muscle.
This process can progress to the point where a fasciotomy is urgently needed to prevent the muscle dying - the fascial envelope is slit open to relieve the pressure.
Surgical emergency shin pain!
It is usually a milder, recurrent condition which results in shin pain and slapping gait (foot drop) when running.
This causes pain on the other (big toe) side of your shin bone. The bone will be very tender along this edge.
This is jarring shin pain when your heel lands on the ground, at the start of a run. If it gets worse it will be after the run as well, then eventually right through the run, and even that night ( if a medial tibial stress fracture occurs.)
A detailed discussion of this condition can be found at podiatry today.com, and I would like to emphasize the need to match your nutrition with what you are expecting of your body.
A good resource is Henry Osiecki's book "Food of the gods : hypernutrition for sport", from Bio Concepts Publishing.
Shin pain is usually a mechanical problem, but the tissues need to be extra strong if the mechanical forces are to be extreme.
1. Hideyuki Takahashi et al European Journal of Applied Physiology Volume 69, Number 5 / September, 1994 pp408-413
2. Lecture notes Professor Roy Douglas (Pansy) Wright
AK, MB (1929), MS, DSc (A.N.U. & Melb), Hon. LLD (Melb. & A.N.U.), FRACP.
After two years (1936–1938) research work in Oxford under the direction of Sir Howard Florey, he returned to Melbourne and was appointed Professor of Physiology (1939–1971)
I once only had the temerity to ask a question in a lecture, and was answered in a fashion which ensured I never did it again. We all held him in awe. Not so all the 1955 graduates, whose entertaining "reminiscences and opinions" talk about him on p 5 at http://medicine150.mdhs.unimelb.edu.au/sites/anniversary/files/the55ers.pdf
His one line instruction has stuck in my memory...
"Treasure your inconsistencies."
Prof. Wright lobbied hard both to establish and develop medical research institutions, ensuring they were well funded and prestigious enough to attract, foster and retain Australia’s best research scientists.
His legacy is seen in the world class institutions of the Peter MacCallum Clinic, the Howard Florey Institute of Experimental Physiology & Medicine and the John Curtin School of Medical Research.
From 1980 to 1989 he was Chancellor of the University of Melbourne.
3. Stress fractures cause impact pain, immediately or shortly after starting out. The pain settles soon with rest, rarely troubling one at night. Plain X-ray is usually normal in the first 4 weeks.
Stress fractures of the anterior tibia, neck of femur, navicular bone of foot and pars interarticularis of lumbar vertebrae, are slow healing.
This could be a golden staph infection but it isn't. There is no head with thick pus, and the person has had it twice before, years ago.
It has followed a recent flu-like illness this time, and sore throats before. A blood test before showed recent group A beta-haemolytic Streptococcus infection.
It is called erythema nodosum (a red bump.) It is not a local infection but a sign of our body's immune response to infection somewhere else.
This is a fairy uncommon condition, but a good example of the value of x-ray for pain experienced at night. It occurs particularly in young men.
Half of these little bone tumors are found in the femur and tibia. They are benign and can go away without treatment, but cause the same nasty persistent pain as cancer of bone.
Three years on NSAIDs used to be needed, but now radiofrequency ablation mostly does the job in one treatment.
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