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Medial tibial stress syndrome: causes, treatment and prevention

Medial tibial stress syndrome (MTSS) (‘shin splints’) is a generalised term for a condition which causes localised pain on the lower inner aspect of the shins. The condition can be seen to be on a continuum of pathology causing shin pain.

 Pain typically comes on gradually and is aggravated by exercise (Brukner & Khan, 2017). The loads on the inner shin bone (tibia) are too high and this causes micro-trauma to the bone. When bone is stressed, it breaks down and then adapts by remodeling itself. However, in MTSS, the stress to the bone is sustained over too long a time period so it does not have time to generate new bone. Therefore, painful micro-fissures can develop (Craig, 2009).


Shorter term conditions include a stress reaction within the tibia or inflammation of the sheath (periosteum) that surrounds the bone (periostitis), inflammation of the muscles, pain between the tibia and fibula and bone strains (Brukner & Khan, 2017). Longer term conditions include tibial stress fractures, tendon injury (tendinopathy) and tears of the fibres (collagen) which connect the muscle to bone (Thacker, Gilchrist, Stroup, & Kimsey, 2002). Other changes can be seen to take place at the tibia and its outer layer of tissue (periosteum) on scans. These include osteopenia (weakening of the bone), bone marrow swelling (oedema) and reduced bone mineral density (Moen, Tol, Weir, Stenebrink & Winter, 2009).




Some known factors in the literature which cause MTSS include: traction on the fascia, tight and/or fatigued calf muscles, tibial bending, lack of shock absorption, and excessive rolling in of the feet (pronation). Tight hips, tight ankles, previous injury, being overweight and the need to wear orthotics can be contributing factors (Winkelmann, Anderson, Games & Eberman, 2016).


Other factors that have been suggested (but with no strong evidence or agreement) include age, female gender, extremes in height and body fat, internal torsion of the neck of the thigh bone (femoral neck anteversion), anatomical variations such as genu valgus (‘knock-knees’) pes cavus (high arches) and decreased strength (Thacker, Gilchrist, Stroup, & Kimsey, 2002; Agresta & Brown, 2015).


Other contributing factors may include poor coordination, imbalance between thigh muscle strength, inadequate warm-up, incomplete stretching, increased running frequency, lesser skill, instability of running patterns, sudden increase in training volumes, inadequate weight training, fatigue, psychological factors, and smoking. Low bone mineral density, low calcium intake and hormonal imbalances are also possible causes of MTSS (Thacker, Gilchrist, Stroup, & Kimsey, 2002).


Environmental risk factors

Environmental risk factors for MTSS include the type of sport and the status of the athletic surface. Uneven terrain, poor footwear, extreme climate and weather may also increase the risk (Thacker, Gilchrist, Stroup, & Kimsey, 2002).  Clearly, the type of surface on which the activity occurs can change the stresses placed on the bone. Hard surfaces such as asphalt and uphill gradients or stairs can initiate bone pain.



Once the causes for the MTSS have been identified, the treatment involves addressing and correcting this. Coaches can play a key role here in terms of modifying training patterns (Brukner & Khan, 2017). Conservative measures involve: relative rest from sports, icing and pain medication as needed, gradual progression of exercise, cross-training with low-impact exercises including swimming, cycling and water running, calf muscle training, using anti-pronation orthotics, massage, maintaining aerobic fitness, and gait re-training (Brukner & Khan, 2017) (Fields, Skyes, Walker, Jackson, 2010). Changing a person’s running pattern can also potentially reduce their risk of stress fractures (Crowell, Milner, Hamill & Davis, 2010).


Craig (2009) found that athletes with MTSS had endurance deficits in the calves, which should be targeted through training design. Craig (2009) also reported that rest is consistently the most effective treatment to allow microfractures to heal. Training should then be a graduated process to allow tissues to adapt.


Surgical intervention is a last resort and includes cutting of the connective tissue to relieve pressure (fasciotomy). Injections of blood plasma may also be performed. These treatments are not always successful and there is poor research on the effectiveness of it, further highlighting the importance of good conservative rehabilitation (Brukner & Khan, 2017).  




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Moen, M.H., Tol, L.T., Weir, A., Stenebrink, M. & De Winter, T.C. (2009). Medial tibial stress syndrome: A critical review. Sports Med; 39 (7). 523 – 546.


Napier C, Cochrane CK, Taunton JE et al. Gait modifications to change lower extremity gait biomechanics in runners: a systematic review. Br J Sports Med 2015;49(21):1382-8.


Thacker, S.B., Gilchrist, J., Stroup, D.F. & Kimsey, C.D. (2002). The prevention of shin splints in sports: A systematic review of literature. Medicine and Science in Sports & Exercise.

Winkelmann, Z.K., Anderson, D., Games, K.E. & Eberman, L .E. (2016). Risk factors for medial tibial stress syndrome in active individuals: An evidence-based review. Journal of athletic training 51(12), 1049 – 1052.


Winters M, Moen MH, Zimmermann WO et al. The medial tibial stress syndrome score: a new patient-reported outcome measure. Br J sports Med. 2016;50(19):1192-9.


Young AJ, McAllister DR. Evaluation and treatment of tibial stress fractures. Clin Sports Med 2006;25(1):117-28.






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