Medial Tibial Stress Syndrome

Figure 1 - Medial Tibial Stress Syndrome. Set in Motion Physiotherapy, Frenchs Forest.

Medial Tibial Stress Syndrome (MTSS), commonly known as "shin splints," is a condition characterized by pain along the inner (medial) aspect of the shinbone (tibia). It is considered an overuse injury and often occurs in individuals who engage in repetitive, high-impact activities, such as running, jumping, or sports with sudden stops and starts. MTSS is prevalent among athletes, particularly runners, dancers, and military personnel.

Possible causes of MTSS include:

• Overload (too much training over a long period of time) or training error (sharp increase in load over a short period of time)

• Poor biomechanics or running technique

• Unsupportive or worn out footwear

• Choice of training surface

• Obvious muscle weakness or imbalance

• Calf or Achilles tightness

• Previous history of MTSS or other bony stress injuries

Signs and symptoms of MTSS are:

 Physical Findings:

• Pain along the inner edge of the shinbone, normally reproduced by touch (or palpation). The pain is typically diffuse and may extend over a larger area rather than being localized to a specific point (an area of > 5cm is required for a diagnosis of MTSS).

• Some individuals may experience mild swelling in the affected area.

Painful Patterns:

• Pain is often experienced during or after engaging in activities that involve repetitive stress on the lower legs, such as running or jumping.

• Unlike fractures or stress fractures, MTSS is not typically associated with a specific traumatic event. It develops gradually over time due to repeated stress on the shinbone.

• The pain may be more pronounced at the beginning of the exercise but can subside somewhat as the activity continues. However, it may return after the activity is completed.

• Pain may persist even after a period of rest, especially when waking up in the morning.

Figure 2 - A flat foot can increase the risk of MTSS, by placing greater stress through nearby musculature, Set in Motion Physiotherapy, Frenchs Forest.

To diagnosis MTSS, your physiotherapist will undertake:

1. A thorough history taking, including past injuries and medical history which can usually point to MTSS even before a physical examination

2. A review of training load, surface and footwear, to identify what may be causing repetitive stress to your tibia

3. A physical examination, including measuring the range of motion, strength and function of your lower leg

4. Gait or running analysis, to identify any potential biomechanical factors contributing to your presentation

5. Ordering imaging studies if more detail is required. X-rays are rarely useful in the diagnosis of MTSS, as the insult to the bone is quite subtle. An MRI is normally required to visualise bony swelling or oedema (a product of bone stress injury).

Figure 3 - The bone stress continuum, with patients suffering from MTSS likely on the right hand side of the scale. Set in Motion Physiotherapy, Frenchs Forest.

Treatment of MTSS – a multifactorial approach:

1.  To treat Medial Tibial Stress Syndrome, a step by step approach must be undertaken, to ensure each of the contributing factors of your condition are addressed.

2.  Education is the most important aspect of addressing MTSS – what is causing your pain, why, and what can you do about it? When will you be able to return to running? This timeframe can vary depending on the level of bony stress injury you have sustained.

3. Load management and activity modification – guided by your physiotherapist, a period of reduced loading and then a graduated return to activities will give your bone time to recover, then adapt to being able to tolerate the demands of your chosen sport or activity.

4. Anti-Inflammatory medications may reduce the symptoms of MTSS (always use as directed by your GP).

5. Strengthening exercises – should your physiotherapist identify any weak muscle groups, strengthening of these areas will help alleviate the load placed on the medial shin bone.

6. Updating or changing footwear – this can offload the affected area, reducing the amount of stress the tibia has to absorb or transmit during activity.