Shin splints vs stress fracture: how to tell runner's shin pain apart

Shin splints is the everyday name for pain along the front or inner edge of the lower leg that comes from exercise such as running. The NHS says it is not serious and usually gets better within a few weeks. Clinicians call it medial tibial stress syndrome. A stress fracture is a small break in the bone from repeated overuse, and the shinbone (tibia) is one of the places it can occur.

The practical difference is the pattern of pain. In shin splints, pain and tenderness are spread along a stretch of the shin, and ease with relative rest. In a stress fracture, pain tends to sit in one very specific spot that is tender to touch, and the pain can be present at rest or at night. The two share causes, which is why they can be confused.

The following draws on the NHS shin splints page, the NHS Greater Glasgow and Clyde guidance on medial tibial stress syndrome, and a Gloucestershire Hospitals leaflet on stress fractures. It is a guide to the pattern and not a way to diagnose yourself.

NHS Greater Glasgow and Clyde acknowledges that tibial stress fracture can be hard to differentiate from medial tibial stress syndrome and may even be part of the same underlying problem. Its guidance sets out a rule of thumb. If exercise-induced pain is spread over more than 5cm along the inner edge of the shinbone, it fits shin splints. If tenderness is confined to less than 5cm, a bone stress injury should be suspected, and point tenderness should be treated as a stress fracture until ruled out.

Shared risk factors add to the confusion. The NHS says you are more likely to get shin splints if you have started exercising after a period of inactivity, run or jump on hard surfaces, or have poor running technique. Gloucestershire Hospitals lists people who take part in high impact sports, a sudden increase in activity, long walks on uneven surfaces, and menopausal women whose bones are often weaker as being most at risk of stress fracture. Both groups overlap in the person who suddenly doubles their mileage.

The same Glasgow guidance lists other conditions that can mimic both, including chronic exertional compartment syndrome (often both legs, relieved by rest, with tingling or cold skin), vascular problems and nerve problems, which is part of why persistent or unusual shin pain deserves a proper assessment rather than more of the same training.

The NHS says shin splints can usually be diagnosed by examining your leg and asking about your symptoms. NHS Greater Glasgow and Clyde adds that ultrasound is not recommended for this purpose because findings are common in people with no symptoms. A stress fracture, by contrast, may not be seen on an ordinary X-ray, according to Gloucestershire Hospitals, which is why further imaging such as MRI or CT may be arranged by orthopaedics if the diagnosis is unclear and symptoms continue, as the Glasgow guidance describes.

The guidance lists the reasons for orthopaedic referral: focal bone tenderness (less than 5cm), night pain, pain at rest, pain with a single-leg hop, a clear pattern of declining function despite reduced load, failure of conservative management over about 3 to 6 months, or recurrent episodes that limit function.

For shin splints the NHS recommends painkillers such as paracetamol or ibuprofen gel, an ice pack in a towel for up to 20 minutes every 2 to 3 hours, switching to gentle exercise such as yoga or swimming, exercising on soft ground when better, warming up and stretching, and shoes that support your feet. It says not to continue the exercise that caused it and not to rush back at your previous level. If it is getting worse or not improving, see a GP, and in many areas you can refer yourself to NHS community musculoskeletal services.

For a stress fracture, Gloucestershire Hospitals says to stop the activity that is causing pain, use ibuprofen if suitable, apply an ice pack, raise the foot or leg when lying down, and use protective footwear or a brace; a cast or splint is sometimes used, usually removed after 4 to 6 weeks. When you can walk without pain, activity is built up gradually over several days before low impact activity and then high impact exercise. If the pain returns, reduce what you are doing and allow it to settle.

See a GP if you have tried self-care for shin splints but the pain is getting worse or not getting better. Get help from NHS 111 if the pain is severe or you have injured your shin. Pain that wakes you at night, hurts when you are resting, or sits in one tender spot is a reason to be assessed rather than push through, because the standard advice for a stress fracture is to stop the activity that is causing the pain.