Shin Pain That Will Not Settle: How to Tell Stress Reaction from Compartment Syndrome or a Nerve Trap

Most runners, hikers, soldiers in training, and weekend athletes who feel a knife-edge ache along the front or inner shin get told, “It is just shin splints.” Sometimes that is right—medial tibial stress syndrome is common and usually improves with smart load management. But when pain lingers, sharpens, or behaves “off script,” you may be dealing with a tibial stress reaction or stress fracture, a compartment syndrome (chronic with exertion or, rarely, an acute emergency), or a nerve entrapment that mimics muscle or bone pain. Each cause has its own fingerprint—and missing the dangerous ones can cost you months or even muscle function.

This research-based guide explains how to spot the differences, which tests really matter, and what helps each condition.

Seek urgent care now if you notice any of the following in a painful lower leg:

• Severe, escalating pain, especially pain with passive stretching of the muscles, a tense or “wood-like” compartment, or pain that feels wildly out of proportion to the injury (possible acute compartment syndrome, a surgical emergency).^[1]
• Numbness, weakness, foot drop, or loss of pulses (late signs in compartment syndrome; do not wait for them).^[1]
• Inability to bear weight after trauma (possible fracture) or fever and swelling (possible infection).

If none of those are present, read on and map your pain pattern.

Medial tibial stress syndrome is an overuse bone stress injury along the posteromedial tibial border. It typically causes diffuse tenderness over more than five centimeters of the lower inner shin, with pain during or after activity that eases with rest. It is on the same continuum as stress fractures but sits at the stress reaction end; radiographs are often normal, and magnetic resonance imaging shows periosteal and sometimes bone-marrow edema.^[2]

• Diffuse tenderness (not a single pinpoint) over the inner shin.
• Pain settles with rest instead of lingering all day.
• No focal swelling, neurologic symptoms, or “bursting” tightness with exertion.^[2]

When your story deviates—pain that persists at rest, pinpoint bony tenderness, numbness or burning, or cramping tightness that forces you to stop—think beyond shin splints.

• Magnetic resonance imaging best identifies early stress injury and stages its severity; bone scans are alternatives but less specific.^[3]
• Clinical clues help: point tenderness and pain that does not fully settle with rest lean toward stress fracture rather than shin splints.^[3]

• Aching, cramping, or bursting tightness begins at a predictable time or distance into a run or march.
• Symptoms build during effort and ease minutes after you stop.
• Numbness or tingling over the dorsum of the foot (superficial peroneal nerve) or between the first and second toes (deep peroneal nerve) can appear when the anterior or lateral compartments are involved; calf-based pain and tenderness suggests deep posterior involvement.^[6]

• The current reference standard is dynamic intracompartment pressure testing before and after a provocative run. The commonly used Pedowitz thresholds are: ≥15 mmHg at rest, ≥30 mmHg at 1 minute, or ≥20 mmHg at 5 minutes after exercise. Some newer studies suggest higher post-exercise cutoffs may improve accuracy, but the Pedowitz criteria remain the best-known starting point.^[7]
• Imaging (radiographs, ultrasound, magnetic resonance imaging) mainly excludes other causes; research is exploring less invasive diagnostics, but pressure testing is still standard.^[8]

• Start with load modification, gait and strength work, and footwear or orthoses in selected cases. If symptoms remain disabling and testing confirms the diagnosis, fasciotomy of the involved compartment(s) is the definitive treatment with good outcomes in many athletes.^[6]

Severe pain out of proportion, a tense compartment, pain with passive stretch, and progressive neurologic changes can appear within hours of an injury (often a tibial fracture but not always). Compartment pressures ≥30 mmHg, or within 10–30 mmHg of diastolic blood pressure, support the diagnosis in unclear cases. This is an emergency—delays risk muscle and nerve death.^[1]

Not all “shin pain” is bone or muscle. The common peroneal nerve (around the fibular head), superficial peroneal nerve (in the lateral compartment and as it exits the fascia), and the saphenous nerve (medial leg) can be compressed by tight fascia, scar, bony surfaces, or habitual postures—especially in endurance athletes. The result is burning, tingling, numb patches, or electric shocks that worsen with certain positions or repetitive inversion-eversion, and sometimes foot drop if motor fibers are involved.^[5]

• Diffuse inner-shin ache during or after running that eases with rest, tenderness over more than five centimeters, normal x-ray → more like medial tibial stress syndrome (early bone stress). Consider magnetic resonance imaging if you are not improving or if pain localizes.^[2]
• Point tenderness, pain that lingers at rest, and impact pain (running, hopping) → think tibial stress reaction or stress fracture; magnetic resonance imaging confirms and grades severity to guide return.^[3]
• Predictable time-into-run tightness that forces you to stop, eases within minutes, sometimes with dorsum-foot tingling → think chronic exertional compartment syndrome; consider compartment pressure testing.^[6]
• Burning, tingling, numb patches, sensitivity to tapping at the fibular head or along the lateral leg, or medial-shin burning near the knee → think nerve entrapment (common peroneal, superficial peroneal, or saphenous).^[5]
• Severe pain with a tense leg after trauma, pain with passive stretch, progressive numbness or weakness → treat as acute compartment syndrome and seek emergency care.^[1]

1. History and focused exam. Your clinician will map location, timing, triggers, and quality—then palpate for diffuse vs. focal tenderness, screen for nerve symptoms, and check compartments for tension and pain with passive stretch where indicated. This first pass often distinguishes bone stress, compartment-type, and nerve-type pain. ^[3]
2. Imaging when appropriate.
   • Medial tibial stress syndrome vs. stress fracture: start with radiographs, but be aware early films can be normal. Magnetic resonance imaging is preferred to confirm and grade tibial bone stress injuries (for example, the Fredericson system). ^[3]
   • Compartment syndromes: imaging is mainly to rule out other causes; dynamic pressure testing remains the diagnostic reference for chronic exertional disease. ^[8]
   • Nerve entrapment: ultrasound can visualize nerve caliber changes or fascial exits; electrodiagnostics may help but can be falsely normal in entrapment. ^[5]
3. Testing for compartments. If your story fits chronic exertional compartment syndrome, expect pre- and post-exercise pressure measurements; the widely used Pedowitz cutoffs (≥15 mmHg rest, ≥30 mmHg at 1 minute, ≥20 mmHg at 5 minutes) are often applied, though newer research explores alternative thresholds. ^[7]

• Reduce impact load temporarily (swap a run for cycling or deep-water intervals).
• Progressive return with careful weekly volume increases; avoid big spikes.
• Consider prefabricated orthoses in pronated feet and address vitamin D and calcium if low; gait retraining may help in stubborn cases.^[3]

• Relative rest and, for higher-grade injuries, a period of protected weight-bearing until pain settles.
• A graded, structured return-to-run based on magnetic resonance imaging grade and symptoms.
• Address risk multipliers (training errors, low energy availability, footwear, surface).^[3]

• Begin with conservative steps: deloading, gait mechanics, strength and mobility work, and footwear changes.
• If pressure testing is positive and symptoms remain limiting, fasciotomy is the most reliable fix, especially for anterior and deep posterior compartments.^[6]

• Emergency fasciotomy to decompress all involved compartments; delays risk permanent damage. Do not “wait to see” if severe pain settles.^[1]

• Unload and desensitize: avoid habitual compressions (tight sleeves, leg-crossing), adjust braces or shoes, and change aggravating training tasks.
• Neural-friendly mobility and strength: work the hip abductors and rotators and foot intrinsics to improve mechanics and reduce traction.
• Targeted injections (diagnostic local anesthetic, selective corticosteroid) are used in some cases to localize and calm an entrapment.
• Surgical decompression is a good option for well-documented entrapments that do not respond to focused conservative care; outcomes are favorable in selected athletes.^[5]

• Shift two runs to low-impact sessions; keep daily steps but avoid hills and hard surfaces.
• If pain is diffuse inner shin, begin short bouts of calf raises and easy posterior-chain strength while you deload impact.
• If pain is predictable tightness that forces stops, log the time-to-symptoms—this detail helps your clinician decide on compartment testing.
• If you have burning or numb patches, note positions that trigger them (leg-crossing, crouching, ankle inversion-eversion).

• Reintroduce impact in small chunks (for example, 3 x 3 minutes easy run separated by 2 minutes walk), increasing weekly only if the next-day feel is acceptable.
• Add single-leg strength (hip abduction and rotation control, step-downs, calf capacity work) to support the tibia and reduce compartment strain.
• If pain persists at rest, is pinpoint, or returns earlier and earlier in a session, arrange evaluation; this speeds the right test (magnetic resonance imaging or pressure testing) and avoids months of circular rest.

No. Medial tibial stress syndrome and stress fracture are on a continuum, but many cases of medial tibial stress syndrome resolve with load management, footwear and surface tweaks, and—when needed—orthoses or gait work. Imaging helps when the story turns focal or persists despite treatment.^[2]

The gold-standard remains dynamic intracompartment pressure measurement around a provocative run. Non-invasive ideas exist, but they are not yet replacements.^[8]

Nerve pain often includes burning, tingling, or numb areas, sometimes worsened by specific positions (leg-crossing, crouch, ankle inversion-eversion) and tapping a focal spot (for example, over the fibular head) may reproduce symptoms. Bone stress pain is mechanical and impact-driven, with point tenderness over the tibia.^[5]

They are less common but can mimic exertional leg pain with claudication-type symptoms; clinicians consider them especially when pulses change with ankle position or when bone, muscle, and nerve workups are negative.^[1]

• Not all shin pain is “shin splints.” Diffuse inner-shin pain that eases with rest fits medial tibial stress syndrome; point tenderness and persistent pain point to stress reaction or fracture best confirmed and graded by magnetic resonance imaging.^[3]
• Tight, bursting pain that starts at a predictable time-into-run and fades after stopping suggests chronic exertional compartment syndrome; diagnosis relies on pressure testing, and fasciotomy is the definitive fix when conservative care fails.^[6]
• Burning, tingling, or numb patches—and sensitivity at the fibular head or medial knee—signal nerve entrapment (common peroneal, superficial peroneal, or saphenous). These respond to unloading, mechanics work, and, when needed, decompression.^[5]
• Never miss acute compartment syndrome. Severe pain with a tense leg and pain on passive stretch after an injury is an emergency.^[1]

Get the pattern right, and you will get the plan right—so your legs carry you farther, sooner, and safer.

References:

Educational information only; not a substitute for personal medical care.