Medial tibial stress syndrome (MTSS), commonly called “shin splints,” is a condition in which pain occurs over the shin bone (the tibia) with running or other sports-related activity. It is usually due to overuse and occurs in athletes who participate in repetitive activities, especially running and jumping. The condition can also develop in athletes who have suddenly increased the duration or intensity of their training. It is quite common and occurs more often in females.
What causes Medial Tibial Stress Syndrome?
Medial tibial stress syndrome develops when there is irritation where the calf muscles attach to the shin bone. It can also occur when running on a slanted surface or downhill, or when someone participates in a sport with frequent starts and stops. Training errors, shoe wear, and changes in training intensity, duration, and surface can contribute to the development of medial tibial stress syndrome. Risk factors for developing medial tibial stress syndrome include abnormalities of ankle and foot alignment, lower extremity flexibility, and strength.
What are the symptoms of Medial Tibial Stress Syndrome?
Most people complain of pain along the shin bone. The pain can range from a dull ache to a sharp, intense pain. Commonly, the pain is located along the inside border of the shin bone, usually in the middle or lower third. Pain may be present with early activity and subside with continued exercise, but may also persist throughout the activity. Typically, the pain goes away when the athlete rests, though in very severe cases, the pain can occur throughout the day (without activity) and continue even during rest. These more severe symptoms can also occur with stress fractures, a more serious injury.
How is Medial Tibial Stress Syndrome diagnosed?
Medial tibial stress syndrome is diagnosed based on a review of the patient’s history and physical examination of the lower leg. X-rays appear normal in people with shin splints. If the doctor is unsure of the diagnosis, an x-ray, MRI, or bone scan may be used to rule out a more serious condition, such as a stress fracture.
How is Medial Tibial Stress Syndrome treated?
Treatment includes a period of rest and modification of activities to allow the inflammation and pain to resolve. Ice can also be helpful, as well as anti-inflammatory medication. Physical therapy may be prescribed, with the patient following a lower extremity strengthening and stretching program. Some people benefit from special shoe inserts (orthotics) that redistribute pressures during activity.
References
Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med. 2004;32(3):772-80.
Reshef N, Guelich DR. Medial tibial stress syndrome. Clin Sports Med. 2012;31(2):273-90.
Your physical therapist will perform a thorough examination that will include taking a full health history and observing you as you walk and perform the activity that causes your symptoms, such as running or jumping.
Your physical therapist will further perform a series of tests and measures of your musculoskeletal system that assess your strength, mobility, flexibility, and pain response. The most reliable symptom of MTSS is pain felt when pressure is applied to specific locations on the shin.
If the results of the examination suggest MTSS, your physical therapist will discuss with you the goals of treatment and develop a specialized rehabilitation program for you. If a more serious condition could be contributing to your pain, you may be referred to a physician for further tests.
Overview
The term “shin splints” refers to pain along the shin bone (tibia) — the large bone in the front of your lower leg. Shin splints are common in runners, dancers and military recruits.
Medically known as medial tibial stress syndrome, shin splints often occur in athletes who have recently intensified or changed their training routines. The increased activity overworks the muscles, tendons and bone tissue.
Most cases of shin splints can be treated with rest, ice and other self-care measures. Wearing proper footwear and modifying your exercise routine can help prevent shin splints from recurring.
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Symptoms
If you have shin splints, you might notice tenderness, soreness or pain along the inner side of your shinbone and mild swelling in your lower leg. At first, the pain might stop when you stop exercising. Eventually, however, the pain can be continuous and might progress to a stress reaction or stress fracture.
When to see a doctor
Consult your doctor if rest, ice and over-the-counter pain relievers don’t ease your shin pain.
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Causes
Shin splints are caused by repetitive stress on the shinbone and the connective tissues that attach your muscles to the bone.
Risk factors
You’re more at risk of shin splints if:
- You’re a runner, especially one beginning a running program
- You suddenly increase the duration, frequency or intensity of exercise
- You run on uneven terrain, such as hills, or hard surfaces, such as concrete
- You’re in military training
- You have flat feet or high arches
Prevention
To help prevent shin splints:
- Analyze your movement. A formal video analysis of your running technique can help to identify movement patterns that can contribute to shin splints. In many cases, a slight change in your running can help decrease your risk.
- Avoid overdoing. Too much running or other high-impact activity performed for too long at too high an intensity can overload the shins.
- Choose the right shoes. If you’re a runner, replace your shoes about every 350 to 500 miles (560 to 800 kilometers).
- Consider arch supports. Arch supports can help prevent the pain of shin splints, especially if you have flat arches.
- Consider shock-absorbing insoles. They might reduce shin splint symptoms and prevent recurrence.
- Lessen the impact. Cross-train with a sport that places less impact on your shins, such as swimming, walking or biking. Remember to start new activities slowly. Increase time and intensity gradually.
- Add strength training to your workout. Exercises to strengthen and stabilize your legs, ankles, hips and core can help prepare your legs to deal with high-impact sports.
Pain generally in the inner and lower 2/3rds of tibia.
Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers[1]. It presents as exercise-induced pain over the anterior tibia and is an early stress injury in the continuum of tibial stress fractures.[2].
It has the layman’s moniker of “shin splints.”[2]
Risk factor- quick increase in running volume
The incidence of MTSS ranges between 13.6% to 20% in runners and up to 35% in military recruits. In dancers it is present in 20% of the population and up to 35% of the new recruits of runners and dancers will develop it.[3]
Large increase in load, volume and high impact exercise can put at risk individuals to MTSS. Risk factors include being a female, previous history of MTSS, high BMI, navicular drop, reduced hip external rotation range of motion, muscle imbalance and inflexibility of the triceps surae), muscle weakness of the triceps surae (prone to muscle fatigue leading to altered running mechanics, and strain on the tibia), running on a hard or uneven surface and bad running shoes [2][4] [5]
Periosteum, vivid green
The pathophysiologic process resulting in MTSS is related to unrepaired microdamage accumulation in the cortical bone of the distal tibia, however this has not been definitively established. Two current theories are:
- The pain is secondary to inflammation of the periosteum as a result of excessive traction of the tibialis posterior or soleus, supported by bone scintigraphy findings of a broad linear band of increased uptake along the medial tibial periosteum. But a case-controlled ultrasound based study which compared periosteal and tendinous edema of athletes with and without medial tibial stress syndrome found no difference between the groups.
- Bony overload injury, with resultant microdamage and targeted remodeling. A study evaluating tibia biopsy specimens from the painful area of six athletes suffering from medial tibial stress syndrome gave only equivocal support for this theory. Linear microcracks were found in only three specimens and there was no associated repair reaction[6].
Clinical Presentation and Assessment
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KEY POINTS FOR ASSESSMENT MTSS[3]HISTORY
- Increasing pain during exercise related to the medial tibial border in the middle and lower third
- Pain persists for hours or days after cessation of activity
- Pain decreases with running (early stage)
- Differentiate from exertional compartment syndrome, for which pain increases with running
- Earlier onset of pain with more frequent training (later stages)
PHYSICAL EXAMINATION
- Intensive tenderness of the involved medial tibial border, more than 5 cm
- Pes planus
- Tight Achilles tendon
- A “one-leg hop test” is a functional test, that can be used to distinguish between medial tibial stress syndrome and a stress fracture: a patient with medial tibial stress syndrome can hop at least 10 times on the affected leg where a patient with a stress fracture cannot hop without severe pain. The sensitivity of the hop test for diagnosing medial tibial stress fracture when pain and tenderness were present was 100%, the specificity 45%, the positive predictive value 74%, and the negative predictive value 100%
- Provocative test: pain on resisted plantar flexion
IMAGINGMRI: Periosteal reaction and edemaTREATMENTSee later in page
[7][8][4][3][6]
Watch this video on MTSS.
Navicular drop test
Management of MTSS is conservative, focusing on rest and activity modification with less repetitive, load-bearing exercise. No specific recommendations on the duration of rest required for resolution of symptoms, and it is likely variable depending on the individual.
Other therapies available (with low-quality evidence) include iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking, and extracorporeal shockwave therapy. A recent study on naval recruits showed prefabricated Introduction to Orthotics reduced MTSS[2].
Complications: Recurrence common after resumption of heavy activity.[9]
Physical Therapy Management
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Patient education and a graded loading exposure program seem the most logical treatments.[7] Conservative therapy should initially aim to correct functional gait, and biomechanical overload factors.[3]Recently ‘running retraining’ has been advocated as a promising treatment strategy and graded running programme has been suggested as a gradual tissue-loading intervention.[3]
Prevention of MTSS was investigated in few studies and shock-absorbing insoles, pronation control insoles, and graduated running programs were advocated.[3]
Over-stress avoidance is the main preventive measure of MTSS or shin-splints. The main goals of shin-splints treatment are pain relieve and return to pain‑free activities.[10]
Acute phase
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2-6 weeks of rest combined with medication is recommended to improve the symptoms and for a quick and safe return after a period of rest. NSAIDs and Acetaminophen are often used for analgesia. Also cryotherapy with Ice-packs and eventually analgesic gels can be used after exercise for a period of 20 minutes.
- There are a number of physical therapy modalities to use in the acute phase but there is no proof that these therapies such as ultrasound, soft tissue mobilization, electrical stimulation[11] would be effective.[4] A corticoid injection is contraindicated because this can give a worse sense of health. Because the healthy tissue is also treated. A corticoid injection is given to reduce the pain, but only in connection with rest.[5]
- Prolonged rest is not ideal for an athlete.
Subacute phase
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The treatment should aim to modify training conditions and to address eventual biomechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency and intensity by 50%. It is advised to avoid hills and uneven surfaces.
- During the rehabilitation period the patient can do low impact and cross-training exercises (like running on a hydro-gym machine). After a few weeks athletes may slowly increase training intensity and duration and add sport-specific activities, and hill running to their rehabilitation program as long as they remain pain-free.
- A stretching and strengthening (eccentric) calf exercise program can be introduced to prevent muscle fatigue. [12][13][14] Patients may also benefit from strengthening core hip muscles. Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. [14]
- Proprioceptive balance training is crucial in neuromuscular education. This can be done with a one-legged stand or balance board. Improved proprioception will increase the efficiency of joint and postural-stabilizing muscles and help the body react to running surface incongruities, also key in preventing re-injury.[14]
- Choosing good shoes with good shock absorption can help to prevent a new or re-injury. Therefore it is important to change the athlete’s shoes every 250-500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities.
In case of biomechanical problems of the foot, individuals may benefit from Introduction to Orthotics. An over-the-counter orthosis (flexible or semi-rigid) can help with excessive foot pronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.[4] - Manual therapy can be used to control several biomechanical abnormalities of the spine, sacro-illiacal joint and various muscle imbalances. They are often used to prevent relapsing to the old injury.
- There is also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but their efficiency is not yet proved.
Differential Diagnosis
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ConditionCharacteristicsTissue originAnterior tibial stress syndromeVague, diffuse pain along anterolateral tibia, worse at beginning of exercise that decreases during trainingPeriosteumMedial tibial stress syndromeVague, diffuse pain along middle-distal tibia, worse at beginning of exercise, that decreases during trainingTibial/fibular stress fracturePain with running, point tenderness over fracture site, “dreaded black line” on lateral x-rayBoneExertional compartment syndromeSymptoms begin 10min into exercise andresolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressuresMuscle and fasciaLeg TendinopathyMay be Achilles tendon, peroneal tendon, or tibialis posteriorTendonSural or SPN entrapmentDermatomal distribution of symptomsNerveLumbar radiculopathyWorse with lumbar tension position (sitting)Popliteal artery entrapmentDiagnosed with vascular studiesBlood vessel
[9]
Clinical Bottom Line
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‘Shin splints’ is a vague term that implicates pain and discomfort in the lower leg, caused by repetitive loading stress. There can be all sorts of causes to this pathology according to different researches. Therefore, a good knowledge of the anatomy is always important, but it’s also important you know the other disorders of the lower leg to rule out other possibilities, which makes it easier to understand what’s going wrong. Also a detailed screening of known’s risk factors, intrinsic as well as extrinsic, to recognize factors that could add to the cause of the condition and address these problems.
