Shin Splints & Other Types of Lower Leg Pain. How to differentiate, manage & treat.
- Ben Elliot
- Sep 10
- 11 min read

In November 2013, I wrote a 'how-to' article for The Acupuncturist magazine on the topic of shin splints. Twelve years on, with more knowledge and experience, I feel it's a good time to give an updated account of shin splints, what other lower leg pain issues can be treated with acupuncture & massage - plus treatment protocols for anyone interested in how I treat these issues.
What Are Shin Splints?
Shin splints is a common term for anterior or medial tibial stress syndrome (ATSS/MTSS). It's a condition that causes pain around the shinbone (tibia). It's often caused by the muscles, connective tissue, tendons, and bone tissue becoming inflamed due to overuse or repetitive stress.
How to tell the difference between ATSS & MTSS Shin Splits.
The simple way to define which type of shin splints someone is suffering from is by the location of the pain, which is dictated by which tissues are inflamed.

Anterior tibial stress syndrome presents as a dull aching pain on the outside of the lower leg. Along with the tissue surrounding the tibia bone, the anterior tibialis muscle, and connective tissue containing it can become irritated, painful, and tender to touch.

Medial tibial stress syndrome also presents as a dull aching pain, but on the inside of the lower leg, and most commonly of the lower two-thirds of the inner aspect. MTSS involves irritation around the tibia bone and the posterior tibialis muscle, which runs behind the tibia bone.
Whether anterior or posterior, the pain can vary from quite mild to very severe and will often prevent people from carrying out activities and exercise. Generally, you would expect the pain to be worse when exercising, though some sources I've come across state that the pain can improve while exercising and return at rest, or be painful when starting exercise but gradually improve throughout the exercise session. From my experience, as with most things, the symptoms vary from one person to another and advice and treatment needs to be developed on an individual basis. That said, I will discuss other issues that present similar symptoms and how to recognise them later in this post.
Causes of Shin Splints
Shin Splints are caused when the muscles, bones, tendons and connective tissues that wrap around all these structures become irritated and inflamed by continued stress on the area, most commonly from persistent impact. I most commonly see long-distance runners for treatment of shin splints; however, any activity that puts a lot of load through the legs can be a cause. For example, dancers, any ball sports where there is a lot of running, with stopping and starting, military personnel, and people with flat feet. If you have flat feet, it's less about the activity and more about the fact that your feet lack the shock absorption from the arches, and a podiatrist is likely to be key to your recovery, alongside manual treatment.
Factors that increase the likelihood of developing shin splints:
Sudden increase in activity or exercise.
Activity or exercise on hard surfaces, such as road running or indoor sports.
Activity or exercise on uneven ground.
Flat feet, unsupported arches.
Long periods on feet, running, walking or standing.
Inadequate footwear can reduce support and shock absorption
Body weight - The heavier we are, the more stress goes through our lower legs
Differential Diagnosis of Lower Leg Pain
We've discussed how the location of the pain will differentiate between the anterior and medial tibial stress shin splints, but there are a few other conditions that share similar symptoms, are worse during exercise, and would require different treatment or referral to a different practitioner.
Posterior/Medial Tibial Stress Syndrome (PTSS/MTSS):
I've struggled to differentiate PTSS from MTSS, they may be different terms for the same issue. Although some sources say the two conditions are not the same, none have given a rationale for why they differ. From my research, they share pretty much identical symptoms, and advice for recovery is the same. The only discernible difference I have seen is that MTSS causes pain in the lower two-thirds of the lower leg, whereas PTSS is only in the lower one-third. Comments welcome!
Tibial Stress Fracture:
Stress fractures are where a small crack develops in a bone. You more or less retain the integrity of the bone, so it is not debilitating in the way other fractures would be for day-to-day activities - however, you would be more susceptible to a full break if not rested.
The symptoms are very much the same as shin splints - pain around the shin bone, possible swelling, tenderness and worse with exercise or activity. The differentiating factors would be that the symptom would likely be more severe than commonly found with shin splints. Stress fractures are caused by the same impact and stress-inducing activities as shin splints, and shin splints are often a precursor to a stress fracture, making it even more difficult to differentiate.
Diagnosis can be made using an X-Ray; however, practitioners may use a 'hopping test' to guide their diagnosis. With shin splints, a patient should be able to hop ten times on the affected leg. It would likely be uncomfortable, but they would be able to complete the task. With a stress fracture, the pain would likely prevent them from hopping ten times. I wouldn't often use this test myself as hopping could cause an enlargement of the stress fracture, yet the fact it is a way to differentiate remains true.
Compartment Syndrome
Compartment Syndrome is when damage to a muscle can cause inflammation and internal swelling or bleeding. If the connective tissue that wraps around the muscles is overly restricted and does not allow the muscle to expand, it can cause compression and pressure build-up within the muscle. This pressure build-up prevents oxygen and nutrients from reaching the muscle tissue, causing pain, and in severe and untreated cases, permanent damage can occur. Most often, manual treatment will release the connective tissue, and healing can then begin; however, surgery is sometimes needed for extreme cases.
There are two types of compartment syndrome:
Acute compartment syndrome is caused by fractures or a severe injury to the muscle, where it is crushed or bruised heavily, and is severely painful. It can also be caused by the use of steroids or overuse of support or compression bandages. Surgery is often needed to release the pressure and prevent tissue necrosis.
Chronic or exersional compartment syndrome is less severe and more treatable. It's caused by similar impact-based activities as shin splints, such as running or jumping. It usually gets better by stopping the activity and with manual treatment.
It's a bit easier to recognise compartment syndrome as the pain in the lower leg is often accompanied by a tightness and numbness in the area, and a lack of range of movement in the ankle.
Lower Leg Tendinopathy
Other issues that can affect the lower leg are lower leg tendinopathy, where tendons in the lower leg tear or degrade due to repetitive stress in the area. This leads to pain, inflammation and lack of range of movement in the tendon area. Most commonly, this affects the Achilles tendon at the rear of the lower leg, or the Peraneal tendons at the outside of the ankle.
Sciatica
Sciatica traditionally causes pain down the back of the whole leg, though it can present at the front of the lower leg. The pain can be shooting or burning and can be accompanied by tingling or numbness. I've covered sciatica in detail in a previous post, so best to have a read of Sciatica: causes, symptoms & treatment if you want to find out more.
Treatment For Shin Splints & Lower Leg Pain
I'll break the treatment options down into the general benefits of acupuncture for lower leg pain; things you can do at home to help recovery, and then a more detailed account of which methods I use to treat these kinds of issues.
Generalised Benefits of Acupuncture for Lower Leg Pain
The generalised benefits of acupuncture for painful conditions are summarised below by Dr. AI. The mechanisms that deal with muscle relaxation, circulation and inflammation are crucial to aiding recovery in any soft tissue condition.
Acupuncture is believed to help lower leg pain through several mechanisms, including:
Pain relief: It stimulates the release of endorphins, the body's natural painkillers, and affects nerve pathways to reduce pain signals.
Reduced inflammation: Acupuncture can decrease inflammation and swelling around the tibia (shin bone).
Improved blood flow: Targeting specific acupuncture points can increase blood circulation to the affected area, delivering oxygen and nutrients crucial for healing and recovery.
Muscle relaxation and improved function: Acupuncture can help release muscle tightness and improve the function of muscles like the tibialis anterior and posterior, which are often involved in shin splints.
Enhanced healing: It may help modulate the body's immune response, potentially accelerating tissue regeneration and reducing the risk of chronic pain.
Self-help tips for recovering from Shin Splints & other types of leg pain
Sometimes these tips are enough to recover from shin splints or other lower leg issues without having to seek treatment - I tend to see people who've already tried these things, but the issue is stubborn to the extent that they need a little extra help.
Looking at footwear is perhaps the best place to start when recovering. Old or heavily worn shoes or trainers will contribute to a mechanical imbalance of feet, legs, hips and even the back. If you have any issues with your feet, even the most expensive footwear may not be appropriate for you. Podiatrists can develop insoles and supports that give the right support to your feet, whereas specialist sports stores can analyse your feet and gait to suggest the best footwear for you individually.
Rest and reduce or stop any high-impact activities that aggravate the issue, while the soft tissue recovers.
If the issue presents with swelling, elevate the leg and use compression.
Conditioning your muscles can help provide support to the area, though this can sometimes cause more irritation to the issue, so starting small is key here. Conditioning involves both strengthening and stretching a muscle. Common areas to work on for the issues discussed are the calf muscles and the tibialis anterior muscle.
As there is an inflammatory aspect to many of these issues, using an ice pack rather than heat on the area is likely to provide some relief.
Acupuncture & Massage Treatment Methods
Each of the issues discussed in this post will need an individualised approach, which will be determined by diagnosis and location, amongst other factors.
Shin Splints
The purpose of the treatment is to locally reduce muscle tension and inflammation, whilst simultaneously manually stretching and manipulating the restricted fascia. Additionally, there are options to include methods to reduce pain using channel and balance theory alongside TCM theory.
Massage:
Effleurage and petrissage across the tibialis anterior and gastrocnemius muscle is helpful in broadly reducing muscle and fascial tension. Working on both the front and rear aspects of the leg ensures all surrounding tissue is released.
Effleurage of the foot and ankle, followed by frictions and mobilisations of the ankle joint, is helpful to free up any adhesive tissue in the area, which may be hindering movement of the ankle and the sliding surfaces of the lower leg. It also gives an opportunity to feel for any issues with ankle alignment or arch issues that may be contributing the the stresses on the lower leg and perhaps prompt a referral to a podiatrist, or sports footwear specialist.
Acupuncture:
The following is the original 2012 treatment plan, with present-day additions and updates in italics.
• Determine the area of pain: it may be quite broad, or very specific, and tends to run roughly along one or more of the Stomach, Gallbladder or Liver channels. I would also include Spleen and Kidney channels, basically any channel that has some or all of its location on the anterior of the lower leg. Most important is that when dealing with soft tissue issues, it is crucial to be led by feedback of the location of the pain, and by restriction felt under palpation. Channel identification is important for integrating channel, balance and distal acupuncture, but we can afford to deviate from the very specific pathways of the TCM channels when working locally, if our observations lead us to do so.
• Insert four to five needles in series between the knee and ankle, at a depth of around half a cun: if the pain area is quite broad, repeat at lateral/medial intervals.
• To stretch the tissue, gently rotate each needle until you feel a resistance, caused by the fascia wrapping around the needle shaft to the point of tension. Conventionally, you would avoid getting the connective tissue caught up with the needle, but in this case, it is an important part of the treatment. By wrapping the fascia around the needle, you are causing the length between each needle to become stretched and taut.
• Rotate each successive needle in the opposite direction to the last: this ensures an even stretch of the tissue between needles and reduces the likelihood of the most proximal or distal point taking the bulk of the strain - and the discomfort! Having used this method dozens of times over the years, I've concluded that the direction of rotation is not critical in creating an even stretch. Sometimes you have to try both clockwise and anticlockwise to find the binding point of the fascia, and this doesn't seem to depend on which direction the previous needle was rotated.
• The muscle fibres and connective tissue will now be taut, potentially recreating the pain experienced while exercising: as the tissue begins to relax and lengthen, the pain should lessen, and while the needles are being retained, any discomfort should ease.
• After 20 minutes, rotate each needle in the opposite direction, so it will withdraw smoothly without tugging on any tissue. Keeping note of which direction each needle was rotated is key here, especially if you are not following an alternating rotation pattern. Using a cotton bud to hold and stabilise the skin adjacent to the needled area can help to remove the needle cleanly and painlessly if any fascial fibres have remained caught.
To help clear stagnation, I also like to treat the meridians. The area of pain relates best to the yang ming region of the lower leg, and I use a combination of methods: Using the channels can also be a good option for anyone who has acute pain when touched in the area. Occasionally, the area is too tender to treat locally, which is when the following methods can be helpful.
• If not already needled, St 36 zu san li is the obvious choice.
• Dr Tan’s mirroring technique: needle the significant point of the coupled channel on the opposite side of the body to the pain, in this case LI4 hegu. I understand Dr Tan's balance method somewhat better these days. There are countless options using mirroring and flip-mirroring, and numerous different system options. Personally, if the pain pathway is along the Stomach channel, I would start by palpating the Large Intestine channel between LI5 and LI10, needling any areas of restriction and pain on palpation. If there is nothing notable along this pathway, I would explore different systems.
• LI10 shou san li, as the arm equivalent to St 36.
• Depending on the exact location of the pain, distal channel points including St 44 nei ting, Liv3 tai chong or GB41 zu lin qi can be used. The primary goal here is to draw the 'stagnation' or pain down the channel. There are many options for distal point depending on the channel or channels determined.
Tibial Stress Fracture:
Compartment Syndrome:
If acute, a trip to the hospital is likely to be in order; however, if chronic, acupuncture and massage can be very helpful. As compartment syndrome and shin splints share the traits of inflammation, swelling and connective tissue restriction, following the shin splints treatment using both the massage and acupuncture methods will be appropriate for chronic compartment syndrome.
Lower Leg Tendinopathy:
Generalised massage across the lower leg will help to reduce tension in the muscles, taking potential strain off the impaired tendons, allowing recovery and healing where possible. From an acupuncture standpoint, working locally to reduce muscle tension, congestion and adhesions will be appropriate. Additionally, local acupuncture will help to reduce inflammation and promote a rich blood supply to the area, again aiding the healing process.
Useful Acupuncture points:
Ashi points that match areas of damage or pain
Kid 3
BL60
Kid6
BL62
BL57
Sciatica:
I've written about sciatica treatment in detail in a previous post. Follow the link below and scroll to the end to get all the sciatica treatment info.
If you want any more information on treatment for these issues, you can contact me at benelliot.co.uk/contact