Shin Splints or Stress Fracture? How to Tell the Difference
By APA Physiotherapist Ben Howie
If you're training for a running event, increasing your mileage, or returning to exercise after a break, you've probably heard the term shin splints. But what happens when that ache in your shin doesn't go away? Could it be something more serious, like a stress fracture?
Shin pain is one of the most common injuries seen in runners and active individuals. While Medial Tibial Stress Syndrome (MTSS) - commonly known as shin splints - and tibial stress fractures can cause similar symptoms, they require different management. Understanding the difference can help you make informed decisions about your training and know when it's time to seek professional advice.
What Are Shin Splints?
The term "shin splints" is commonly used to describe pain along the inside of the shin. In healthcare, this condition is more accurately known as Medial Tibial Stress Syndrome (MTSS). MTSS is an overuse injury caused by repetitive loading of the tibia (shin bone) and the surrounding muscles and connective tissues. It commonly develops when the demands placed on the leg exceed its current capacity to adapt.
Common contributing factors include:
• Sudden increases in running volume or intensity
• Hill running
• Returning to running after time off
• Inadequate recovery
• Changes in footwear or training surface
Unlike a muscle strain, MTSS usually develops gradually over days or weeks rather than after one specific incident.
What Is a Stress Fracture?
A stress fracture is a small crack in the bone that develops when repeated loading outpaces the bone's ability to repair itself. Rather than occurring after one traumatic event, stress fractures typically develop over time through repeated stress. They are considered part of the bone stress injury continuum, where increasing bone stress can progress from a stress reaction to a stress fracture if loading continues to exceed the bone's capacity to recover.
Although less common than MTSS, stress fractures require earlier recognition as continuing to run through symptoms may delay healing or increase the severity of the injury.
Why Do They Happen?
Both MTSS and stress fractures are considered overuse injuries and often share similar risk factors.
These include:
• Rapid increases in training load
• Running more frequently or further than usual
• Inadequate recovery between sessions
• Low energy availability or inadequate nutrition
• Previous bone stress injury
• Changes in footwear or running terrain
The good news is that many of these factors can be modified with appropriate training progression and rehabilitation.
How Can You Tell the Difference?
Although both conditions cause shin pain, there are some key differences.
Shin Splints (MTSS) Stress Fracture
• Pain is usually spread over a larger area of the shin
• Pain is often in one small, specific spot
• Pain may ease as you warm up during a run
• Pain often worsens as activity continues
• Tenderness extends over several centimetres • Tenderness is very localised
• Often settles with load modification
• Often requires stopping impact activities temporarily
• Usually no pain at rest • May become painful at rest or at night
While these differences can be helpful, it isn't always possible to distinguish between the two based on symptoms alone. A thorough assessment by a physiotherapist or sports medicine practitioner can help determine the most likely cause of your pain.
Can You Keep Running?
This depends on the underlying cause. Many people with MTSS can continue running with appropriate modifications to their training load, such as reducing mileage, avoiding hills, or temporarily decreasing intensity while beginning a rehabilitation program.
If a stress fracture is suspected, continuing high-impact activities may delay healing or worsen the injury. In these cases, early assessment is recommended to guide appropriate management.
When Should You Seek Professional Advice?
It is worth seeking assessment if you experience:
• Pain that becomes increasingly localised
• Pain that worsens during every run
• Pain while walking or at rest
• Night pain
• Swelling around the shin
• Symptoms that persist despite reducing your training
• Difficulty hopping on the affected leg
Early assessment can help identify whether you're dealing with a training-related overload injury or a more significant bone stress injury requiring further management.
How Are These Injuries Managed?
Management depends on the diagnosis, but both conditions benefit from addressing the factors that contributed to the injury.
Treatment may include:
• Modifying training load
• Gradually rebuilding running volume
• Strengthening the calf, hip and lower limb muscles
• Improving lower limb capacity and resilience
• Reviewing running mechanics where appropriate
• Addressing recovery, sleep and nutrition
If a stress fracture is diagnosed, a temporary period away from impact activities may be required before a gradual return-to-running program begins.
Key Takeaways
• Shin pain is common in runners and active individuals.
• Shin splints (MTSS) and stress fractures can feel similar but require different management.
• MTSS typically causes diffuse pain that may improve as you warm up, while stress fractures often cause localised pain that worsens with activity.
• Both conditions are usually related to training loads exceeding the body's ability to recover.
• If your pain is persistent, worsening, or becoming more localised, it's worth seeking assessment early.
Understanding the difference between shin splints and stress fractures can help you manage your symptoms appropriately and reduce the risk of a longer recovery. If you're unsure about your shin pain, an assessment with a physiotherapist can help identify the cause and guide your return to running safely.
References
Hamstra-Wright, KL, Bliven, KCH & Bay, C 2014, ‘Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis’, British Journal of Sports Medicine, vol. 49, no. 6, pp. 362–369.
Jasty, N, Dyrek, P, Kaur, J, Kathryn E. Ackerman, Kraus, E & Heyworth, B 2021, ‘Evidence-Based Treatment and Outcomes of Tibial Bone Stress Injuries’, Journal of the Pediatric Orthopaedic Society of North America, vol. 3, no. 4.
Lee, I, Jeon, HG, Ha, S, Jeong, H & Lee, SY 2024, ‘How Medial Tibial Stress Syndrome Is Affected by Alignment, Range of Motion, Strength, and Gait Biomechanics: A Systematic Review and Meta-Analysis’, Journal of sport rehabilitation, vol. 34, United States, no. 2, pp. 134–155.