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BASICS

DESCRIPTION
Medial tibial stress syndrome (MTSS) is preferred over “shin splints.” It is an aching pain along the inner edge of the tibial shaft caused by irritation of musculature and/or periosteum from repetitive activity. It is part of a continuum of stress-related injuries to the lower leg and not related to ischemic pain (compartment syndrome) or stress fractures.
Related pathology includes tendonitis/periostitis of the medial soleus, anterior tibialis, posterior tibialis muscles.
Synonyms: tibial stress reaction, anterior muscle syndrome, tibial periostitis, perimyositis, soleus syndrome, shin splints.

EPIDEMIOLOGY

  • Common, accounting for 4-35% of running injuries, often bilateral.
  • May account for up to 31% of overuse injuries in high school athletes.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Multifactorial anatomic and biomechanical factors.
  • Microtrauma from repetitive motion causes periosteal inflammation.
  • Overpronation of subtalar joint, tight gastrocnemius/soleus complex, increased eccentric loading along medial shin.
  • Pathogenesis involves calf muscle traction on periosteum causing inadequate bone remodeling, possible microfissures without fracture.
  • Affected structures: flexor hallucis longus, tibialis anterior/posterior, soleus, crural fascia.

RISK FACTORS

Intrinsic:
- Hip internal/external rotation >65°, overpronation, muscle imbalance, female gender, lean calf, femoral neck anteversion, navicular drop, genu varum, previous MTSS.

External:
- Lack of fitness, inexperienced runners, rapid mileage increase, hard/inclined surfaces, prior injury, poor equipment.

Others:
- Elevated BMI, low bone mineral density, tobacco use.
- Common in runners, military recruits, gymnasts, soccer/basketball players, ballet dancers.

PREVENTION

  • Proper guided calf stretching and lower extremity strength training (though gastrocnemius/soleus stretching alone shows no significant risk reduction).
  • Gait analysis and retraining for overpronation.
  • Orthotic footwear inserts effective in naval recruits.

COMMONLY ASSOCIATED CONDITIONS

  • Pes planus (flat feet).

ALERT

  • Rule out stress fracture and compartment syndrome if pain persists at rest.

DIAGNOSIS

History:
- Dull, sharp, or deep pain along lower leg, worsened with activity, relieved with rest initially.
- Patients may continue running early on; severe pain may persist at rest.

Physical Exam:
- Tenderness along posteromedial border of middle-to-distal tibia.
- Pain with plantar flexion.
- Intact distal pulses, sensation, reflexes, muscle strength.

DIFFERENTIAL DIAGNOSIS

  • Bone: Tibial stress fractures (pain at rest, focal tenderness, hopping test positive).
  • Muscle/soft tissue: Strain, tear, tendinopathy, muscle hernia.
  • Fascial: Chronic exertional compartment syndrome (pain cramping/squeezing, worse with exertion, neuro symptoms).
  • Nerve: Spinal stenosis, radiculopathy, common peroneal nerve entrapment.
  • Vascular: DVT, popliteal artery entrapment.
  • Infection: Osteomyelitis.
  • Malignancy: Bone tumors.

DIAGNOSTIC TESTS & INTERPRETATION

  • Diagnosis primarily clinical history and exam.
  • Plain radiographs to exclude stress fractures if symptoms >2 weeks.
  • Bone scintigraphy: diffuse linear uptake in posterior tibial cortex (vs. focal uptake in stress fractures).
  • MRI: abnormal periosteal and bone marrow signals, useful early for stress fractures.
  • Intracompartmental pressure testing to exclude compartment syndrome if indicated.

TREATMENT

General Measures:
- Activity modification with gradual return based on symptom improvement.
- Run on flat, firm surfaces.
- Maintain fitness with low-impact activities (swimming, cycling).
- Continue modification until pain-free on ambulation.

Medications:
- Analgesics: acetaminophen or NSAIDs.
- Cryotherapy (ice massage) to relieve acute symptoms.

Additional Therapies:
- Orthotics may help.
- Calf/peroneal stretching, eccentric calf raises, TheraBand exercises improve strength and endurance.
- Compression stockings show mixed results.
- CAM boot for significant weight-bearing pain.

Surgery:
- Posterior medial fascial release for severe cases with failure of conservative therapy >6 months.
- Risks: infection, hematoma.
- Extracorporeal shock wave therapy (ESWT) may reduce recovery time.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Polyurethane orthoses may help chronic cases.
  • No evidence for benefit of special insoles, low-energy laser, PEMF, knee braces.
  • Other modalities (ultrasound, acupuncture, aquatic therapy, electrical stimulation, whirlpool, taping, steroid injection) may improve pain.
  • Physical therapy including Kinesio tape and osteopathic manipulative treatment may hasten return to activity.

ONGOING CARE

Follow-up:
- Gradual return to preinjury running pace once pain resolves.
- Maintain stretching/strengthening exercises.
- Correct training errors.
- Replace running shoes every 350-450 miles.

PROGNOSIS

  • Usually self-limiting, responds well to conservative management.

COMPLICATIONS

  • Untreated MTSS can progress to stress fractures or compartment syndrome, leading to fractures or tissue necrosis.

Clinical Pearls

  • MTSS is the preferred term for “shin splints.”
  • Diagnosis is clinical; imaging reserved for suspicion of stress fracture.
  • Pain localized to middle and distal third of posteromedial tibia, worsened by activity, relieved with rest (vs. stress fracture or compartment syndrome where pain persists at rest).
  • Treatment: ice, activity modification, analgesics, eccentric stretching, gait retraining, gradual return.
  • Recurrence common if return to activity is too rapid.