Common Running Injuries: Calf and Shin Pain

The bones, muscles, and other soft tissues in the lower leg take a pounding while running. Pain and injuries in the calf and shin are common. Recognizing and understanding painful symptoms can help runners prevent injuries from getting worse, so they can return to training safely. 

Calf and shin pain have several possible causes:

Medial Tibial Stress Syndrome (Shin Splints)

It is not clear what causes shin splints. It is most likely to develop in people who¹Reinking MF, Austin TM, Richter RR, Krieger MM. Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors. Sports Health. 2016;9(3):252-261. doi:10.1177/1941738116673299:

• Run long distances
• Were assigned female sex at birth
• Are overweight

This condition goes by many names, including shin splints, medial tibial stress syndrome, tibial stress syndrome, and soleus syndrome.¹Reinking MF, Austin TM, Richter RR, Krieger MM. Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors. Sports Health. 2016;9(3):252-261. doi:10.1177/1941738116673299

What it is: Most experts believe shin splints are caused by inflammation or other minor damage that develops in the calf muscles, tendons, or tibia bone. One theory is that damage occurs between the calf muscles and a thin layer of tissue that surrounds the tibia bone, called the periosteum.²Menéndez C, Batalla L, Prieto A, Rodríguez MÁ, Crespo I, Olmedillas H. Medial Tibial Stress Syndrome in Novice and Recreational Runners: A Systematic Review. Int J Environ Res Public Health. 2020;17(20):7457. doi:10.3390/ijerph17207457

How it feels: Shin splints cause pain and tenderness at the inside or front of the tibia bone. The pain is diffuse, meaning it can be felt along several centimeters of the shin. Pain is triggered or gets worse when running.¹Reinking MF, Austin TM, Richter RR, Krieger MM. Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors. Sports Health. 2016;9(3):252-261. doi:10.1177/1941738116673299^,2Menéndez C, Batalla L, Prieto A, Rodríguez MÁ, Crespo I, Olmedillas H. Medial Tibial Stress Syndrome in Novice and Recreational Runners: A Systematic Review. Int J Environ Res Public Health. 2020;17(20):7457. doi:10.3390/ijerph17207457 See Shin Splints Symptoms

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Tibia Stress Fracture

Nearly all stress fractures occur in athletes, including young runners with intense training schedules.³Vera AM, Patel KA. Stress Fractures of the Foot and Ankle. Operative Techniques in Sports Medicine. 2021;29(3):150852. doi:10.1016/j.otsm.2021.150852  About 1 in 4 stress fractures in runners occur in the tibia, commonly called the shin bone.⁴Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015;6:87-95. doi:10.2147/OAJSM.S39512

What it is: A tibia stress fracture is a crack in the tibia, or shinbone, caused by repeated stress. The damage to the bone happens little by little, with each run. The damage occurs faster than the bone canheal.  

How it feels: A tibial stress fracture causes deep pain in the shin. Initially, the pain is most noticeable while running. 

As the fracture gets worse, pain will occur even when walking or at rest. Pressing on the area over the stress fracture will trigger pain. Swelling may occur.⁴Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015;6:87-95. doi:10.2147/OAJSM.S39512

Some stress fractures are difficult to see on standard X-rays. A doctor who suspects a stress fracture may order an MRI or bone scan to confirm the diagnosis. However, this step is not always necessary before beginning nonsurgical treatment.⁴Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015;6:87-95. doi:10.2147/OAJSM.S39512

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Pulled Calf Muscle (Gastrocnemius Muscle)

The largest soft tissue structure in the lower leg, the calf’s gastrocnemius muscle is attached to the Achilles tendon. Runners tend to injure this muscle when ramping up a running routine without adequate training or during a sudden motion, such as making a quick turn. 

What it is: A muscle pull, or tear, refers to damage to the muscle’s fibers. Tears are often graded based on how much of the muscle is affected.⁵Hsu D, Chang KV. Gastrocnemius Strain. In: StatPearls. StatPearls Publishing; 2023. Accessed November 12, 2023. http://www.ncbi.nlm.nih.gov/books/NBK534766/ Grade 1 tears are mild, grade 2 tears are moderate, and grade 3 are the most severe, with half or more of a muscle’s fibers torn.

How it feels: Gastrocnemius tear symptoms vary depending on the severity. A mild gastrocnemius tear will cause calf stiffness and soreness that make walking and jogging uncomfortable. These symptoms usually appear several hours or even a day or two after a challenging run. 

In contrast, a partial or complete gastrocnemius tear can occur suddenly. It might feel like the calf has been hit by something and cause a popping or snapping sound. Bruising and swelling occur. Calf pain and weakness make it challenging to walk normally.⁵Hsu D, Chang KV. Gastrocnemius Strain. In: StatPearls. StatPearls Publishing; 2023. Accessed November 12, 2023. http://www.ncbi.nlm.nih.gov/books/NBK534766/

Chronic (Exertional) Compartment Syndrome

While this condition can occur anywhere in the body, 95% of cases affect the lower leg. Most people develop chronic compartment syndrome in the anterior compartment, located at the front of the lower leg. Anterior compartment symptoms are often confused with shin splints.⁶Nwakibu U, Schwarzman G, Zimmermann WO, Hutchinson MR. Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going? Curr Sports Med Rep. 2020;19(10):438-444. doi:10.1249/JSR.0000000000000762

It is important to note that chronic compartment syndrome is different than the acute version of this condition. Acute compartment syndrome causes intense pain and skin sensations. It is often preceded by a trauma and requires immediate medical attention.

What it is: Chronic compartment syndrome is caused by a build-up of pressure during exercise. The pressure develops in 1 of the 4 compartments in the lower leg. Each of these compartments contains muscles, nerves, and blood vessels, and is wrapped in a thin membrane of tissue called fascia. 

• Repetitive exercise, such as running, creates extra pressure within a compartment. 
• Because the fascia that surrounds the compartment does not stretch, the pressure builds up.
• Too much pressure limits blood flow to the compartment’s muscles and nerves.

How it feels: Chronic compartment syndrome can cause pain, weakness, or cramping in the lower leg, along with numbness or a burning sensation. The muscle might be seen bulging under the skin. Symptoms usually go away within 15 minutes of stopping exercise.⁶Nwakibu U, Schwarzman G, Zimmermann WO, Hutchinson MR. Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going? Curr Sports Med Rep. 2020;19(10):438-444. doi:10.1249/JSR.0000000000000762

Any calf injury should be treated and monitored so it does not lead to a secondary injury. For example, a strained calf muscle, while not considered a serious injury, can eventually lead to Achilles tendonitis.