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Medial Tibial Stress
Syndrome (Shin Splints)
Normal Anatomy
• Bone is constantly remodelling
• Remodelling is based on the force
and load placed through the bone
• Remodelling occurs quickly in
cancellous bone
• Remodelling occurs slowly in
cortical bone
• The tibia has a slight bow
• Soleus, Tibialis posterior and flexor
hallucis longus all attach onto the
tibia
Pathology
• Overuse injury resulting in stress
reaction of the tibia and
surrounding musculature
• Periostitis of the tibia most
commonly in acute phases
• Develops into bone remodelling
• MTSS can be considered on the
bone stress continuum with
stress fractures
Mechanism of Injury
• Insidious
• Change in training, change in
environment of activity or changes in
footwear all alter the stress through the
tibia
• Typically runners
• Soft Tissue Traction
• Soleus, flexor halluces longus and
potentially tibialis posterior tension
increases, causing strain on tibial fascia
and periosteum
• Tibial Bowing
• Calf muscles cause repeated bending or
bowing of the tibia at its narrowest point
• Causes a stress reaction and periosteal
reaction
Mechanism of Injury
• Insidious
• Change in training, change in
environment of activity or changes in
footwear all alter the stress through the
tibia
• Typically runners
• Soft Tissue Traction
• Soleus, flexor halluces longus and
potentially tibialis posterior tension
increases, causing strain on tibial fascia
and periosteum
• Tibial Bowing
• Calf muscles cause repeated bending or
bowing of the tibia at its narrowest point
• Causes a stress reaction and periosteal
reaction
Classification
• Grade 1
• Periosteal edema
• Grades 2 -3
• Progressive periosteal and bone
marrow edema
• Grade 4
• Cortical stress fracture
Subjective Examination
• Vague diffuse pain along the
posteromedial border of the
middle distal tibia with exertion
• Pain worse at the beginning of
exercise and then subsides
• As injury progresses pain can be
present throughout activity or even
rest
• Reports a change in
• Training methods (load, intensity,
pace, mileage, routine)
• Training environment (terrain)
• Training equipment (shoes)
Objective Examination
• Pain on hopping
• Tenderness on palpation of the medial ridge of the tibia (tibialis posterior
and soleus muscle origins)
• Nil neurological signs
• Increased pronation of the subtalar joint
• Kinetic chain abnormalities (tibial torsion, femoral anteversion, leg-length
discrepancy, knee varus/valgUS)
• Tightness triceps surae
• Weakness lower limb and proximal control
• Abnormal gait – forefoot running
• Uneven wearing on shoes
Further Investigation
• X- ray
• Bone Scans
• MRI
Management
• Multimodal
• Focus on controlling the load and stress that goes through the tibia
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Decrease running distance/time
Increase recovery time
Change running style
Change running footwear
Change biomechanics (orthotics, increasing ROM, increasing Strength)
Conservative
• Reduce pain and inflammation
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Massage
Ice
NSAID’s
Orthotics
Appropriate loading
Reduce stride length
• Restore Normal Range of Movement
• Ankle, Knee and Foot
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Soft tissue massage
Foam rolling
Stretching
Dry needling
Joint mobilisations
Joint manipulations
• Restore Normal Muscle Activation
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Tibialis Anterior
Flexor Hallucis Longus
Plantarflexors
Invertors
Hip External Rotators and abductors
• Restore Dynamic Stability
• Proprioceptive work
• Return to sport/activity specific
exercise
• Gait re-education
• Gradually increasing running
time/distance
• Reduce stride length
Plan B
• Extracorporeal shockwave
therapy
• Surgery rarely indicated
References
• Franklyn, M. and B. Oakes (2015). "Aetiology and mechanisms of injury in
medial tibial stress syndrome: Current and future developments." World J
Orthop 6(8): 577-589.
• Galbraith, R. M. and M. E. Lavallee (2009). "Medial Tibial Stress Syndrome:
Conservative Treatment Options." Curr Rev Musculoskelet Med 2.
• Hamstra-Wright, K. L., K. C. Huxel Bliven and C. Bay (2014). "Risk factors for
medial tibial stress syndrome in physically active individuals such as
runners and military personnel: a systematic review and meta-analysis."
British Journal of Sports Medicine.
• Reshef, N. and D. R. Guelich (2012). "Medial tibial stress syndrome." Clin
Sports Med 31(2): 273-290.
• Winters, M., M. Eskes, A. Weir, M. H. Moen, F. J. Backx and E. W. Bakker
(2013). "Treatment of medial tibial stress syndrome: a systematic review."
Sports Med 43(12): 1315-1333.