> Table of Contents > Medial Tibial Stress Syndrome (MTSS)/Shin Splints
Medial Tibial Stress Syndrome (MTSS)/Shin Splints
Michael Y. Yang, MD
Marc W. McKenna, MD
image BASICS
DESCRIPTION
  • Medial tibial stress syndrome (MTSS) is preferred nosologically to “shin splints.” Aching pain along the inner edge of the tibial shaft develops when the musculature and/or periosteum in the (lower) leg become irritated by repetitive activity. The condition is part of a continuum of stress-related injuries to the lower leg. MTSS does not encompass pain from ischemia (compartment syndrome) or stress fractures.
  • Tendonitis/periostitis of the medial soleus muscles, anterior tibialis, and posterior tibialis muscles
  • Synonyms: tibial stress reaction; anterior muscle syndrome; periostitis; perimyositis; shin splints
EPIDEMIOLOGY
Incidence
Common, can account for between 5% and 35% of novice-running injuries. Frequently occurs bilaterally (1).
Pediatric Considerations
MTSS may account for up to 31% of all overuse injuries in high school athletes (2).
ETIOLOGY AND PATHOPHYSIOLOGY
  • Multifactorial anatomic and biomechanical factors
    • Overuse injuries causing or limited by
      • Microtrauma from repetitive motion leading to periosteal inflammation
      • Overpronation of the subtalar joint and tight gastrocnemius/soleus complex with increased eccentric loading of musculature inserting along the medial shin
      • Interosseous membrane pain
      • Periostitis
      • Tears of collagen fibers
      • Enthesopathy
    • Anatomic structures affected include the following:
      • Flexor hallucis longus
      • Tibialis anterior
      • Tibialis posterior
      • Soleus
      • Crural fascia
  • Pathogenesis: theorized to be due to persistent repetitive loading, which leads to inadequate bone remodeling and possible microfissures causing pain without evidence of fracture or ischemia
RISK FACTORS
  • Intrinsic or personal risk factors:
    • Greater internal and external ranges (>65 degrees) of hip motion
    • Significant overpronation at the ankle
    • Imbalance of inverters and everter musculature of the ankle and foot
    • Female gender
    • Leaner calf girth
    • Femoral neck anteversion
    • Navicular drop
    • Genu varum
  • External or environmental factors
    • Lack of physical fitness
    • Inexperienced runners—particularly those with rapid increases in mileage and inadequate prior conditioning
    • Excessive overuse or distance running, particularly on hard or inclined (crowned) surfaces
    • Prior injury
    • Equipment (shoe) failure
  • Other risk factors
    • Elevated BMI
    • Lower bone mineral density
    • Tobacco use
  • Those typically affected include the following:
    • Runners
    • Military personnel—common in recruit/boot camp
    • Gymnasts, soccer, and basketball players
    • Ballet dancers
GENERAL PREVENTION
  • Proper technique for guided calf stretching and lower extremity strength training
  • Rehabilitation for prior injuries
  • Other suggested recommendations
    • Gait analysis and retraining, particularly for overpronation
    • Orthotic footwear inserts
COMMONLY ASSOCIATED CONDITIONS
  • Rule out stress fracture and compartment syndrome.
  • Pes planus (flat feet)
image DIAGNOSIS
PHYSICAL EXAM
  • Tenderness to palpation is typically elicited along the posteromedial border of the middle-to-distal third of the tibia.
  • Pain with plantar flexion
  • Ensure neurovascular integrity of the lower extremity, examining distal pulses, sensation, reflexes, and muscular strength.
DIFFERENTIAL DIAGNOSIS
  • Bone
    • Tibial stress fractures
      • Typically, pain persists at rest or with weight-bearing activities.
      • Focal tenderness over the anterior tibia
  • Muscle/soft tissue injury
    • Strain, tear, tendinopathy
    • Muscle hernia
  • Fascial
    • Chronic exertional compartment syndrome (3)[C]
      • Pain without direct tenderness on exam
      • Pain increases with exertion and resolves at rest.
      • Pain is described as cramping or squeezing.
      • Pain with possible weakness or paresthesias on exam
    • Interosseous membrane tear
  • Nerve
    • Spinal stenosis
    • Lumbar radiculopathy
    • Common peroneal nerve entrapment
  • Vascular
    • DVT
    • Popliteal arterial entrapment (4)[B]
      • Rare but limb-threatening disease
      • History of intermittent unilateral claudication
      • MRI reveals compression of the artery by the medial head of the gastrocnemius muscle.
  • Infection
    • Osteomyelitis
  • Malignancy
    • Bone tumors
DIAGNOSTIC TESTS & INTERPRETATION
  • Plain radiographs help rule out stress fractures if >2 weeks of symptoms (5).
  • Bone scintigraphy
    • Diffuse linear vertical uptake in the posterior tibial cortex on the lateral view.
    • Stress fractures demonstrate a focal ovoid uptake.
  • High-resolution MRI reveals abnormal periosteal and bone marrow signals, which are useful for early discrimination of tibial stress fractures.
  • Increased pain and localized tenderness warrants further imaging with MRI due to concern for tibial stress fracture.
  • Exclude compartment syndrome using intracompartmental pressure testing.
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image TREATMENT
GENERAL MEASURES
  • Activity modification with a gradual return to training based on improvement of symptoms
  • Patients should maintain fitness with low-impact activities such as swimming and cycling.
  • Continue activity modification until patients are pain-free on ambulation.
  • Good supportive footwear is recommended.
MEDICATION
  • Analgesia with acetaminophen or other oral nonsteroidal anti-inflammatory agent
  • Cryotherapy (ice massage) is also advised to relieve acute-phase symptoms (6)[C].
ADDITIONAL THERAPIES
  • Stretching of the gastrocnemius, soleus, and peroneal muscles are treatment mainstays (6)[C].
  • Calf stretch, peroneal stretch, TheraBand exercises, and eccentric calf raises may improve endurance and strength.
  • Compression stockings have been used to treat MTSS with mixed results.
  • Structured running programs with warm up exercises have not been demonstrated to reduce pain in young athletes (7)[B].
SURGERY/OTHER PROCEDURES
  • Surgical intervention includes a posterior medial fascial release in individuals with both
    • Severe limitation of physical activity and
    • Failure of 6 months of conservative treatment
      • Patient should be counseled that complete return of activity to sport may not be always achieved postoperatively. Surgical risks include infection and hematoma formation.
  • Extracorporeal shock wave therapy (ESWT) may decrease recovery time when added to a running program (8)[B].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Individualized polyurethane orthoses may help chronic running injuries (9)[A].
  • Special insoles, shock-absorbing running shoes, and knee braces have not been shown to decrease the incidence of MTSS (6)[C].
  • Ultrasound, acupuncture, aquatic therapy, electrical stimulation, whirlpool baths, cast immobilization, taping, and steroid injection may help improve pain.
  • Physical therapy approaches including Kinesio tape and fascial distortion massage may yield quicker return to activity (10)[B].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Patients should avoid prematurely resuming preinjury running pace.
  • Stretching and strengthening exercises should be added.
  • Preinjury training errors should be identified and corrected with a gradual return to activity dictated by symptoms (pain).
PROGNOSIS
The condition is usually self-limiting, and most patients respond well with rest and nonsurgical intervention.
REFERENCES
1. Fullem BW. Overuse lower extremity injuries in sports. Clin Podiatr Med Surg. 2014;32(2):239-251.
2. Cuff S, Loud K, O'Riordan MA. Overuse injuries in high school athletes. Clin Pediatr (Phila). 2010;49(8):731-736.
3. Hutchinson M. Chronic exertional compartment syndrome. Br J Sports Med. 2011;45(12):952-953.
4. Politano AD, Bhamidipati CM, Tracci MC, et al. Anatomic popliteal entrapment syndrome is often a difficult diagnosis. Vasc Endovascular Surg. 2012;46(7):542-545.
5. Chang GH, Paz DA, Dwek JR, et al. Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment. Clin Imaging. 2013;37(5):836-846.
6. Fields KB, Sykes JC, Walker KM, et al. Prevention of running injuries. Curr Sports Med Rep. 2010;9(3):176-182.
7. Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:12.
8. Moen MH, Rayer S, Schipper M, et al. Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. Br J Sports Med. 2012;46(4):253-257.
9. Hirschmüller A, Baur H, Müller S, et al. Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. Br J Sports Med. 2011;45(12):959-965.
10. Schulze C, Finze S, Bader R, et al. Treatment of medial tibial stress syndrome according to the fascial distortion model: a prospective case control study. ScientificWorldJournal. 2014;2014:790626.
Additional Reading
&NA;
  • Abelson B. The Tibialis Anterior Stretch-Kinetic Health. https://www.youtube.com/watch?v=6Z6XM63x2TM. June 19, 2014.
  • Cosca DD, Navazio F. Common problems in endurance athletes. Am Fam Physician. 2007;76(2):237-244.
  • Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analyasis. Br J Sports Med. 2015;49(6):362-369.
Codes
&NA;
ICD10
  • S86.899A Other injury of other muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter
  • S86.891A Other injury of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
  • S86.892A Other injury of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
Clinical Pearls
&NA;
  • MTSS is the preferred term for “shin splints.”
  • Diagnosis is based on the history of repetitive overuse accompanied by characteristic shin pain.
  • Pain that is worsened with activity and relieved with rest is commonly described along the middle and distal third of the posteromedial tibial surface.
  • Treatment includes ice, activity modification, analgesics, eccentric stretching, gait retraining, and a gradual return to activity.