Shin Splints

Anatomy, foot posture and orthotics

By Nelson Rodriguez De Leon, PT
Master Of Manipulative Physiotherapy by Coursework
ID 125479

Introduction
In the medical literature pain presenting along the middle to distal medial border of
the tibia, that starts at the beginning of walking or running (jogging), resolves during
the activity and presents again after it has been named shin splints, medial periostitis
and medial tibial stress syndrome and no agreement has been reached to put an end to
this long list of names. Different aetiologies have been proposed, among them the
presence of a pronated foot and an abnormal and excessive eccentric contraction of
the tibialis posterior muscle. However, none of them have provided a definite answer
to the problem and the answer remains elusive.
The aim of this essay will be:

To describe the anatomy and biomechanics of the subtalar joint and posterior
compartment of the leg and its implication on the development of shin splints.

To determine if foot posture has an influence in the gait and running patterns and
the development of shin splints.

To determine if foot posture can be modified through the use of orthotics devices
and how these devices alter the firing of some of the muscles that control the
subtalar joint during running (jogging).

Anatomy and Biomechanics of the Subtalar Joint

First of all we will start defining the movements of inversion eversion and supination
and pronation regarding the subtalar joint and the ankle. Eversion/inversion are the
movements taking place in the frontal plane on an AP axis and moves the calcaneus
laterally and medially. Supination is the combination of adduction, inversion and
plantarflexion and pronation is the combination of abduction, dorsiflexion and
eversion (Norkin and Levangie 2000) (Fig.1).

Fig 1. The movements of pronation and supination. From www.orthogate.com

The subtalar joint complex presents two distinct articulations which are oblique to
each other, posteriorly the calcaneus joint surface is convex and the talus concave and
anteriorly this disposition is reversed (Perry 1983). Perry (1983), Czernecki (1988)
and Sarrafian (1993) give different degrees of tilt and inclination for the subtalar joint
quoting the work of Inman and Manter (Table 1) (Fig. 2). The subtalar joint functions
as a mittered hinge converting the torque of the foot into external and internal rotation
of the tibia when the foot is fixed and viceversa.

Fig 2. The angulation and tilt of the subtalar joint. From www.orthogate.com

Generally speaking, in normal gait the entire lower limb rotates medially during the
swing phase and laterally during the stance phase. Prior to heel strike the tibia is
internally rotated and transmits the medial rotation to the talus. At heel strike the
calcaneus contacts the ground laterally creating a pronatory movement on the
subtalar joint (Rodgers 1988). As the talus is rotated medially the calcaneus is forced
into pronation.
Author

Upward Tilt

Medial Angulation

Inman
(1976)
Manter
(1941)

42 9 degrees

23 11 degrees

42 degrees
16 degrees
(range 29-47
(range 8-24 degrees)
degrees)
Table 1. Degrees of tilt and angulation of the subtalar joint

Generally speaking, in normal gait the entire lower limb rotates medially during the
swing phase and laterally during the stance phase. Prior to heel strike the tibia is
internally rotated and transmits the medial rotation to the talus. At heel strike the
calcaneus contacts the ground laterally creating a pronatory movement on the
subtalar joint (Rodgers 1988). As the talus is rotated medially the calcaneus is forced
into pronation.
Eversion of the calcaneus is initiated at foot strike. At this stage the calcaneus contacts
the ground with its lateral aspect thus lateral to the axis of the subtalar joint and
because body weight is transmitted to the talus at heelstrike a valgus force is created
on the subtalar joint (Perry 1983). The net resultant of this action is eversion of the

calcaneus. This eversion is determined by an inferolateral movement of the anterior

facet which, in turn, is going to cause internal rotation of the talus and subsequently of
the tibia by the mittered hinge effect (Czernecky 1988, Perry 1983).
The main difference in gait and running (jogging and sprinting) patterns is that during
running there is a phase where both feet are off the ground (airborne phase) (Brown
and Yavorsky 1987). This has two main implications one being an increase in the
ground reaction forces from 70-80% of bodyweight to 275-300% and the second
being a shortening of the stance phase from 0.6 sec to 0.2 (Brown and Yavorsky
1987).
Some authors (Donatelli, 1994) implicate tightness of the Achilles tendon as a
possible mechanism that can cause abnormal pronation of the foot. They hypothesise
that in an overpronated foot a tight gastronecmius has an increased muscle pull that
positions the calcaneus into more eversion due to its insertion point being changed
from medial to lateral thus changing the line of pull. They also add that limited
dorsiflexion impedes the tibia to translate anteriorly to the talus during the stance
phase of gait and this is compensated by subtalar joint pronation.
Influence of Foot Posture on Shin Splints
In a study to investigate the correlation between foot posture and the medial tibial
stress syndrome (Sommer and Vallentyne, 1995) 25 subjects were recruited, 10 had
been diagnosed with MTSS and 15 hadnt. Of the 10 subjects of the affected group 4
had bilateral MTSS leaving the group with 14 limbs to study against 36 of the control
group because the unaffected leg of the control group was included in the control
group. Methods to evaluate foot posture were qualitative in nature including forefoot
and rearfoot valgus and varus measures and quantitative (standing foot angle). The
measurements were studied on its interrater reliability and it found to be good. There
was a tendency toward forefoot and rearfoot varus in the cases without MTSS and a
combined varus tendency toward hindfoot and forefoot varus was more common in
the MTSS group. The SFA was found to be statistically significant showing a
tendency toward a lower SFA in the MTSS group. Part of the control subjects used for
this study was the non-affected limbs. This could have biased the study due to the fact
that they are assuming that the pes planus can be the cause of shin splints and
clinically we more often than not we see that the individuals have the same arch
characteristics in both feet. It would have been much better to use a control group
composed of normal non-injured subjects or non-injured runners. Also even though
the interrater reliability was studied and found to be good the intrarater reliability was
not and this has been found to be poor for physiotherapist measuring subtalar joint
mobility (Elveru, Rothstein and Lamb, 1988).
To determine the relation between selected biomechanical and anthropometric
variables and shin splints (Messier and Piatalla 1988) a group of 17 runners diagnosed
as having shin splints and a control group consisting of 19 non-injured runners were
evaluated. Anthropometric variables included dorsiflexion range of motion and
biomechanical variables included total rearfoot movement, maximum pronation and
maximum pronation velocity measured in a gait analysis laboratory. They found a
trend that was not statistically significant towards a decrease in range of motion in the
shin splints group and a significant correlation between maximum pronation and

maximum pronation velocity in the shin splint group. No evidence of reliability or

validity is given for the anthropometric measures used in the study. The
biomechanical assessment was performed using video analysis. However, no details
are given regarding to the position of the camera or the placement of the markers. The
type of shoes used by the subjects was not standardised. Shoes have been shown to
alter foot and ankle biomechanics and this can have an influence biasing the results of
the movement analysis (Nigg and Segesser, 1992).
Three groups of athletes were studied in terms of their foot and ankle and lower leg
posture and dynamic and static kinematics (Vitassallo and Kvist 1983). Subjects were
allocated into three groups a control group (n=13) consisting of subjects without
history or present symptoms of shin splints and two experimental groups: a bad shin
splints group (n=13) which had frequent and long lasting pain in the shin and a
slight shin splint group (n=22) which had occasional shin pain lasting between 2
and 4 weeks. They measured the subtalar passive joint mobility and the position of the
subtalar joint. They found that both groups of athletes with shin splints had an
increased range of motion, which was statistically significant. The standing foot
posture values were greater in the shin splint group although not statistically
significant. The shin splint group also showed increased pronation during treadmill
running just before touch down and during full contact than the control group, which
was statistically significant. The subtalar joint mobility was assessed using a method
that is not reliable (Elveru et al., 1988). The position of the subtalar joint in normal
standing also was measured from angles obtained by photographs but no further detail
is given on the use of this method. Its is not stated if the video analysis used was 2D
or 3-D which can have significant differences in the results (Engsberg and Andrews,
1987). The groups were not homogeneus particularly regarding the sample size.
To correlate foot structure and kinematics of the rearfoot (Nawoczenski, Saltzman and
Cook 1998) 20 recreational runners that had sought consultation for a diversity of
musculoskeletal injuries in the lower limb were studied. They divided the subjects
into two groups classified as high and low rearfoot following radiographic criteria
consisting in the measurement of standard lateral and AP radiographs which has been
proven to have high reliability to classify foot by its structure according to the
authors. Motion analysis was carried out while the subjects ran in a treadmill for a
period of two minutes after a 5 minute warm-up period and consisted in the
measurement of calcaneal inversion and eversion and the tibial medial and lateral
rotation during the stance phase of running. They found that the high rearfoot group
had greater magnitudes of tibial lateral and medial rotation and the low rearfoot group
had greater magnitude of calcaneal inversion and eversion. However, in the period
from heel contact to maximum pronation both groups showed similar calcaneal
inversion and eversion magnitudes questioning the clinical notion that subjects with
high arches have hipomobile feet and and subjects with low arches have hipermobile
feet. They concluded that an imbalance between tibial rotation and calcaneal
movement maybe the culprit for the diverse pathologies seen in runners. It must be
noted that all the subjects in the study wore sandals, which make the heel to be free of
any restrictions. Results could have been biased by the use of this method. This
method was justified to make the placement of skin markers easier. However a
method similar to that of Genova and Gross (Genova and Gross, 2000) could have
been used.

Even though all the studies reviewed above have several threats to internal and
external validity and the methods vary in a significant way there seem to be a
consensus in that the presence of pronated foot and lack of dorsal flexion are
consistent factors in the development of shin splints (Table 2). A possible explanation
could be that in the presence of a pronated foot the tibialis posterior has to contract
more eccentrically to decelerate the foot to avoid collapse of the medial structures.
This deceleration maybe accompanied by an increased pulling of the tibialis posterior
tendon on the medial border of the tibia creating a constant microtrauma on the point
of insertion that ends developing an overuse injury. Another possible explanation is
that a shortening of the soleus muscle increases the valgus vector over an everted
calcaneum maintaining the abnormal position of the foot on the gait cycle and
diminishing the shock absorption capabilities of the lower limb. None of the studies
reviewed took in consideration the tibial rotations and its coupling mechanics with the
calcaneum. However, further research is needed to implicate this mechanism in the
development of shin splints.
Author
Sommer and
Vallentine (1995)

Vitassallo and
Kvist (1983)

Pathology
MTSS

Shin Splints

Nawocszenski,
Saltzman and
Cook (1998)
Messier and Piatalla
(1988)

Lower limb
Musculoskelet
al Injuries
(Non-Specific)
Shin splints

Measurement Method
Rear and Forefoot Varus
and
Valgus
(Goniometry)
Standing Foot Angle
(SFA)
(Radiographic)

Results
SFA was greater in MTSS

Subtalar Passive ROM

(Goniometric)
Video Analysis
(Not Specified 2D or
3D)

Shin splints subjects had

increase subtalar ROM

Lateral and AP Views

For planus and cavus
foot (Radiographic)
3-D Video Analysis
Anthropometric
measures
Video Analysis

MTSS had a tendency

toward rear and forefoot
Varus (not statistically
significant)

Shin splints subjects had

increase pronation in early
stance
Increase calcaneal
inversion and eversion in
low rearfoot group (pes
planus)
Subjects with shin splints
Had decrease dorsiflexion
And lower pronation
velocities

Table 2. Summary of postural findings and Shin Splints

Anatomy of the posterior compartment of the leg

In a dissection study of ten cadaveric legs using an incision running just posterior to
the medial border of the tibia the distance were the tibialis posterior muscle crosses
the flexor digitorum longus muscle starting from the medial malleolus was measured
(Saxena, OBrien and Bunce, 1990). A second measurement was then done to note the
most distal attachment of the tibialis posterior. They found that the mean distance of
insertion of the most distal point of the tibialis posterior muscle was 7.77 cm. and the
distance were it crossed the flexor digitorum muscle was 8.16 cm. They concluded
that the insertion point of the tibialis posterior muscle runs more distally than what
previous studies stated, thus possibly implicating the tibialis posterior muscle

insertion as a possible cause of shin splints. They didnt find any attachments of the
soleus muscle on the lower third of the leg (Fig. 3).

Fig 3 Proximal insertion of the TP, FDL and FHL. From www.vesalius.com

In a study to determine the origin site of the soleus, flexor digitorum longus, tibialis
posterior muscles and deep crural fascia (Beck and Osternig 1994) the legs of 50
cadaveric specimens were dissected (Beck and Osternig, 1994). To quantify the site of
attachments they divided the tibia bone on six equal parts along the longitudinal axis
of the tibia. They found that the soleus and the flexor digitorum longus were the only
muscles that possessed attachments to the medial border of the tibia specifically at 35
and 48% from the medial malleolus, respectively. The crural fascia had attachments
along the medial border of the tibia in all specimens. No insertion of the tibialis
posterior muscle was found in the medial border of the tibia. Regarding the study by
Saxena et al. (see above) the authors state: There is a disparity between the findings
of the present study and those of Saxena et al. who concluded that the tibialis
posterior consistently arises from the distal third of the tibia. An explanation for this
disparity may be that the measurement of the inferiormost attaching fibers of the
tibialis posterior can be complicated by the configuration of the muscle itself.
Sometimes a proportion of the inferior fibers of the tibialis posterior arise from a very
lateral position on the tibia In other words, the inferior fibers of the tibialis
posterior muscle often attach in the distal half of the leg; however the attachment site
of the fibbers is normally the interosseus membrane not the tibia (Fig 2).

Fig. 4 Proximal and distal insertions of the soleus. From www.vesalius.com

There is a tendency in the literature to implicate foot posture, particularly pronation,

in the development of shin splints. Clinically, it can be assumed that in the pronated

foot the invertor muscles of the ankle specially the tibialis posterior have to
excessively eccentrically contract to decelerate pronation to avoid a collapse of the
structures of the foot. This causes an increased pull on the superior insertion of the
tibialis posterior on the tibia that can lead to periosteal inflammation. Perry (1983)
states that the soleus muscle has twice the torque of the tibialis posterior for inversion.
However extrapolating this fact to Donatellis hypothesis of the change in the line of
pull of the Achilles tendon in the pronated foot it can be assumed that the tibialis
posterior must contract in excess to decelerate the eversion movement created for the
subtalar joint. However, the study by Beck and Osternig denies this fact stating that
the tibialis muscle does not insert along the medial border of the tibia.
The study by Beck and and Osternig however, can partially support the hypothesis
proposed by Donatelli mentioned above. The gastronecmius and soleus muscles
attatch to the calcaneus by a common tendon. If the gastronecmius causes an
increased pull to take the subtalar joint into eversion one can expect that by having the
same line of pull the soleus would also be responsible for this over pronation.
Foot posture, orthotics and running biomechanics
Different studies have proved that foot orthotics have an effect on calcaneal eversion
during the different phases of gait and running. However, very little has been done on
how the muscle recruitment changes because of the use of orthotics (Eng and
Pierynowski 1994; Genova and Gross 2000; Nawocszenski et al 1995).
Twelve recreational runners were study to determine the effects of foot orthoses in the
electromyographic activity of selected muscle groups on the stance phase of running
in a treadmill (Nawoczenski and Ludewig, 1999). All subjects had a history of lower
limb injuries. The results indicate an increase in EMG activity for the tibialis anterior

Fig. 5 An everted calcaneus. Note the lateral position of the subtalar joint with respect to the ankle joint and
how the insertion of the Achilles tendon goes from medial to lateral. From www.vesalius.com

muscle (37.5%) and a decrease of EMG activity for the biceps femoris muscle
(-11.1%) that were statistically significant. A decrease in the medial gastronecmius
was also noted although it was not statistically significant. The authors hypothesised
that an increase in tibialis anterior EMG could be due to the orthotics placing this
muscle in a mechanical advantage to resupinate the foot. The decrease in EMG
activity of the biceps femoris may be due to the diminished need for this muscle to
control the internal rotation of the tibia while wearing orthotics. This study supports

the hypothesis that in the pronated foot the gastronecmius muscle can be overactive
thus inducing more pronation (Fig. 5). When an orthotic is placed and the subtalar
joint position is normalised the outcome is a reduced activity in the gastronecmius
muscle. However, further study is needed in this area to generalise the results.
Conclusions
There is no definite agreement on the exact anatomical insertion sites of the muscles
of the posterior compartment of the leg. The studies reviewed contradict each other
adding little to the clear understanding of the anatomical facts regarding the
pathology. Further research is needed to clarify this question. There is tendency
towards implicating pronated or planovalgus feet type and lack of dorsiflexion range
of motion as aetiological factors in the development of shin splints and running
pathomechanics. However, all the studies reviewed present several threats to internal
and external validity, which can bias the results obtained. Specially, there is a lack of
reliability in the measurement of the subtalar joint motion, which can be an important
clinical tool for the design of foot orthotics. Furthermore there is a need for more
research involving 3-D analysis in running regarding subtalar joint motion. Recent
studies using this technique have shown results that contradict the common clinical
notion of subtalar joint pronation and its correlation with foot characteristics adding
new insight in the movement coupling between the tibia and the subtalar joint.
Orthotics devices seem to be an effective way of altering subtalar joint mechanics in
the pronated foot by reducing calcaneal eversion during the stance phase and tibial
internal rotation. However there is no agreement on how to construct such devices or
which postural parameters must be meet by the patient due to the lack of a gold
standard in the measurement of the subtalar joint position.
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