Medial Tibial Stress Syndrome; Cause, Symptom, Treatment

Medial tibial stress syndrome

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Medial tibial stress syndrome (MTSS) is an overuse injury or repetitive-stress injury of the shin area. Various stress reactions of the tibia and surrounding musculature occur when the body is unable to heal properly in response to repetitive muscle contractions and tibial strain.

Shin splints also are known as medial tibial stress syndrome (MTSS), is defined by the American Academy of Orthopaedic Surgeons as “pain along the inner edge of the shinbone this can cause your shins a great deal of pain. (tibia).Shin splints are usually caused by repeated trauma to the connective muscle tissue surrounding the tibia. They are a common injury affecting athletes who engage in running sports or other forms of physical activity, including running and jumping. They are characterized by general pain in the lower region of the leg between the knee and the ankle. Shin splints injuries are specifically located in the middle to lower thirds of the anterior or lateral part of the tibia, which is the larger of two bones comprising the lower leg.

Medial tibial stress syndrome (MTSS) is an overuse injury or repetitive-stress injury of the shin area. Various stress reactions of the tibia and surrounding musculature occur when the body is unable to heal properly in response to repetitive muscle contractions and tibial strain.

Types of Medial Tibial Stress Syndrome

Anterior Shin Splints

Anterior shin splints are located on the front (or anterior) part of the shin bone and involve the tibialis anterior muscle. The tibialis anterior lifts and lowers your foot. It lifts your foot during the swing phase of a stride. Then, it slowly lowers your foot to prepare your foot for the support phase.

If your anterior shin pain increases when lifting your toes up while keeping heels on the ground – you are likely to suffer from anterior shin splints. Medically anterior shin splints can also be referred to as anterior tibial stress syndrome (ATSS).

Posterior Shin Splints

Posterior shin splints are located on the inside rear (or medial/posterior) part of the shin bone and involve the tibialis posterior muscle. The tibialis posterior lifts and controls the medial aspect of your foot arch during the weight bearing support phase. When your tibialis posterior is weak or lacks endurance your arch collapses (overpronation), which creates torsional shin bone Shin splints


Causes of Medial Tibial Stress Syndrome

  • Exercising with improper or worn-out footwear
  • Exercising too hard or trying to exercise beyond your current level of fitness can strain muscles, tendons, bones and joints. Overuse is one of the most common causes of shin splints.
  • The shin muscles are involved in maintaining the instep or arch of the foot. Flat feet can pull at the shin tendons and cause slight tearing.
  • Poor running form, such as ‘rolling’ the feet inwards (pronation), can strain the muscles and tendons.
  • The impact of running on hard or uneven surfaces can injure the shin muscles and tendons.
  • A sudden change in your activity level – such as starting a new exercise plan or suddenly increasing the distance or pace you run
  • Running on hard or uneven surfaces
  • Wearing poorly fitting or worn-out trainers that don’t cushion and support your feet properly
  •  A rapid change in training, such as increasing volume or intensity, can bring on shin splint pain. Shin splints are common early in a sports season when people start or intensify training.
  • Excessive pronation refers to when most or all of the body’s weight rest on the inside sole of the foot. Hyperpronation can cause increased eccentric loading of the soleus and tibialis posterior muscles in the calf, which can lead to shin splint pain.
  • Like people who hyperpronate, people who have flat feet, called pes planus, tend to put more stress on the inside sole of the foot.
  • A person can have slightly different leg lengths and not be aware of it. A relatively small leg length difference can cause problems in running biomechanics, leading to shin splints or other repetitive use injuries
  • Running on hard or angled surfaces
  • Decreased flexibility at your ankle joint
  • Poor knee flexion alignment
  • Poor buttock control at in the stance phase
  • Poor core stability
  • Tight calf muscles, hamstrings
  • Being overweight
  • Having flat feet or feet that roll inwards (known as over-pronation)
  • Having tight calf muscles, weak ankles, or a tight Achilles tendon (the band of tissue connecting the heel to the calf muscle)
  • Weak quadriceps, foot arch muscles
  • Having flat feet or abnormally rigid arche for Shin splints

Symptoms of Medial Tibial Stress Syndrome

Mild swelling sometimes occurs, notable swelling of the lower leg, numbness, and weakness are not associated with shin splints and should prompt evaluation for other disorders.

  • Aches and pains are felt along the shinbone.
  • The area is tender and sore to touch.
  • The overlying skin may be red and inflamed.
  • The pain may be felt before, during or after running.
  • Athletes report a dull pain that affects most of the inside shin (medial tibia), particularly in the middle or lower part of the shin.
  • Shin pain typically develops while running or doing other athletic activities, such as dancing, or shortly after these activities. As the condition progresses, pain may be noticeable even when walking.
  • The inside of the shin may be tender and painful if pressed or squeezed.
  • Athletes may notice their calf muscles are tight.
  • Just as the calf muscles may become tight, the ankle may become less flexible.
  • Medial Tibial Stress Syndrome
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Differential Diagnosis of Medial Tibial Stress Syndrome

Treatment of Medial Tibial Stress Syndrome


  • Rest – Because shin splints are typically caused by overuse, standard treatment includes several weeks of rest from the activity that caused the pain. Lower impact types of aerobic activity can be substituted during your recovery, such as swimming, using a stationary bike, or an elliptical trainer.
  • Ice – Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin. Most literature supports “rest” as the most important treatment in the acute phase of MTSS [ ]. For many athletes, however, prolonged rest from activity is not ideal, and other therapies are necessary to help the athlete return to activity quickly and safely. Patients may require “relative” rest and cessation of sport for prolonged periods of time (from 2 to 6 weeks), depending on the severity of their symptoms. NSAIDs and Acetaminophen are often used for analgesia. Cryotherapy is also commonly used in the acute period. Ice may be applied to the affected area directly after exercise for approximately 15–20 min.
  • Therapy – Physical therapy modalities, such as ultrasound, whirlpool baths, phonophoresis, augmented soft tissue mobilization, electrical stimulation, and unweighted ambulation, may be used in the acute setting, but they have not been shown to be definitively efficacious over other treatment options [].
  • Compression – Wearing an elastic compression bandage may prevent additional swelling.
  • Flexibility exercises – Stretching your lower leg muscles may make your shins feel better.
  • Supportive shoes – Wearing shoes with good cushioning during daily activities will help reduce stress in your shins. People who have flat feet or recurrent problems with shin splints may benefit from orthotics. Shoe inserts can help align and stabilize your foot and ankle, taking stress off of your lower leg. Orthotics can be custom-made for your foot, or purchased “off the shelf.”
  • Return to exercise – Shin splints usually resolve with rest and the simple treatments described above. Before returning to exercise, you should be pain-free for at least 2 weeks. Keep in mind that when you return to exercise, it must be at a lower level of intensity. You should not be exercising as often as you did before, or for the same length of time.



Phase 1 – Early Injury Protection: Pain Reduction & Anti-inflammatory Phase

In the early phase you may be unable to walk or run without pain, so your shin muscles and bones need some active rest from weight-bearing loads. Your physiotherapist will advise you on what they feel is best for you.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication.

Phase 2: Regain Full Range of Motion

If you protect your injured shin muscles while they heal and strengthen. This may take several weeks.

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During this time period you should be aiming to optimally remould your scar tissue to prevent a poorly formed scar that will re-tear in the future.

It is important to lengthen and orientate your healing scar tissue via massage, muscle stretches, neurodynamic mobilisations and specific exercises.

Your physiotherapist will guide you.

Phase 3: Normalise Foot Biomechanics

Shin splints commonly occur from poor foot biomechanics eg flat foot.

In order to prevent a recurrence, your foot will be assessed. In some instances you may require a foot orthotic (shoe insert) or you may be a candidate for the Active Foot Posture Stabilisation program.

Your physiotherapist will happily discuss the pros and cons of both options to you.

Phase 4: Restore Muscle Strength

Your calf and shin muscles will need to strengthened to enable a safe resumption of sport or training.

Phase 5: Modified Training Program & Return to Sport

Most shin splints occur due to excessive training loads. Running sports place enormous forces on your body (contractile and non-contractile).

In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with training schedules and exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance. Depending on the demands of your chosen sport, you will require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

Subacute phase

  • Modify the training routine – After the acute phase, the goal of treatment should focus on modifying training regimens and addressing biomechanical abnormalities [,]. Decreasing weekly running distance, frequency, and intensity by 50% will likely improve symptoms without complete cessation of activity []. Runners are encouraged to avoid running on hills and uneven or very firm surfaces []. Synthetic track or a uniform surface of moderate firmness provides more shock absorption and cause less strain on the lower extremity.
  • Stretching and strengthening exercises – Literature has widely supported a daily regimen of calf stretching and eccentric calf exercises to prevent muscle fatigue ) []. Other exercises focus on strengthening the tibialis anterior and other muscles controlling both inversion and eversion of the foot.Patients may also benefit from strengthening core hip muscles []. Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. Developing muscle strength will improve endurance, but should not be done in the acute phase as they may exacerbate the injury due to increased strain on the tibia [].
  • Footwear – Many reports have found that appropriate footwear can reduce the incidence of MTSS []. Athletes should seek out shoes with sufficient shock-absorbing soles and insoles, as they reduce forces through the lower extremity and can prevent repeat episodes of MTSS [,]. Shoes should fit properly with a stable heel counter. Some physicians recommend alternating running shoes especially when one pair is wet, as this compromises the shoe’s integrity. Runners should also change running shoes every 250–500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities and overall support [].
  • Orthotics – Individuals with biomechanical problems of the foot may benefit from orthotics []. Often, over-the-counter orthosis (flexible or semi-rigid) are sufficient to help with excessive foot pronation and pes planus. Mal-alignments caused by forefoot or rearfoot abnormalities may benefit from custom orthotics []. Treatment for MTSS should include correction of key dysfunctions of the kinetic chain [,]. Manual therapy may be used to correct musculoskeletal abnormalities of the spine, sacroiliac joint, pelvis, and various muscle imbalances. A wide variety of manual medicine techniques, including osteopathic manipulation and physical therapy, can be used to address these dysfunctions []. The goal of manual medicine is to restore normal range of motion of joints, improve symmetry of muscles and soft tissues and, ultimately, restore maximal function of the body as a unit []. Correcting musculoskeletal dysfunctions can improve pain and overall function and may be helpful in preventing recurrence. Manual medicine has been commonly used to treat other lower extremity injuries with the benefit of improved pain and function []. However, there is a paucity of RCTs about the role of manual medicine in treating specifically MTSS.
  • Proprioceptive training – Proprioceptive balance training is crucial in neuromuscular education []. This can be done with a one-legged stand, wobble board, or balance board. Improved proprioception will increase the efficiency of joint and postural-stabilizing muscles and help the body react to running surface incongruities, also key in preventing re-injury.
  • Intrinsic factors and gender – Clinicians may need to address certain intrinsic factors with at-risk female athletes, including nutritional, hormonal, and other medical abnormalities []. Proper calcium replacement (ranging from 1000 to 2000 mg daily) and Vitamin D (800 IU daily) are essential for bone strength and commonly prescribed for females []. Estrogen supplementation (i.e., oral contraceptive pills) may be considered to help restore normal menstruation and increase bone density []. Female athletes with the above disorders should have a thorough medical evaluation with a DEXA scan and proper psychosocial evaluation and treatment [].
  • Splinting/bracing – Crutches may be necessary for temporary non-weightbearing and rest. Casting of the limb or a pneumatic brace is only recommended for more severe cases of MTSS and tibial stress fractures [].
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  • Extracorporeal shock wave therapy—Extracorporeal shock wave therapy (ESWT) has been used to treat various tendinopathies of the lower extremity with varying success. Studies show mixed results with ESWT for treating tendinopathies of the foot and ankle, including plantar fasciitis and Achilles tendonitis []. No RCTs were identified for ESWT and MTSS.
  • Injections – Various injection methods, including cortisone, have successfully been used for decades to treat injuries of the lower extremity []. Newer methods, such as dry-needling, autologous blood injection, platelet-rich plasma, and prolotherapy, seek to stimulate a local healing response in injured tissues. Some physicians have proposed injecting the spring and short plantar ligaments to treat laxity and poor mechanics of the foot arch, which are common factors contributing to hyperpronation []. However, no RCTs have been performed with these different injection techniques for MTSS.
  • Acupuncture – One study identified benefit of acupuncture for MTSS, but the study had a small sample size and various methodological shortcomings []. One case report and review article showed potential benefit with acupuncture for plantar fasciitis, but no other studies were identified for acupuncture for other lower extremity injuries [].

Prevention of Medial Tibial Stress Syndrome

To help prevent shin splints

  • Analyze your movement – A formal video analysis of your running technique can help to identify movement patterns that can contribute to shin splints. In many cases, a slight change in your running can help decrease your risk.
  • Consider shock-absorbing insoles – They might reduce shin splint symptoms and prevent recurrence.
  • Lessen the impact – Cross-train with a sport that places less impact on your shins, such as swimming, walking or biking. Remember to start new activities slowly. Increase time and intensity gradually.
  • Add strength training to your workout – Exercises to strengthen and stabilize your legs, ankles, hips and core can help prepare your legs to deal with high-impact sports.
  • Avoid overdoing – Too much running or other high-impact activity performed for too long at too high an intensity can overload the shins.
  • Choose the right shoes – If you’re a runner, replace your shoes about every 350 to 500 miles (560 to 800 kilometers).
  • Consider arch supports – Arch supports can help prevent the pain of shin splints, especially if you have flat arches.
  • Do not overstride – Overstriding when walking can contribute to getting shin splints. Keep your stride longer in back and shorter in front. Go faster by pushing off more with the back leg
  • Get fitted for running and walking shoes – Overpronation is a risk factor for shin splints, according to studies. A technical running shoe store will assess you for overpronation and recommend a motion control shoe if needed.
  • Shock-absorbing insoles for boots – Military boots and hiking boots lack cushioning. Adding a shock-absorbing insole has been shown to be helpful in studies of military personnel.
  • Choose walking shoes with flexible soles and low heels – If you wear inflexible shoes with rigid soles, your feet and shins fight them with each step. Walkers can avoid shin splints by choosing flexible shoes, even if they are labeled as running shoes. Walking shoes should be relatively flat, without a built-up heel.
  • Replace old shoes – The cushioning and support in your athletic shoes is exhausted every 500 miles, often long before the soles or uppers show wear.
  • Warm-up before going fast – Warm up at an easy pace for 10 minutes before you begin a faster-paced or more intense workout.
  • Alternate active days – Don’t engage in vigorous activity two days in a row. Give your shins and your other muscles a recovery day in between hard workouts or long activity days.

After Recovery from Medial Tibial Stress Syndrome

Once you have been pain-free for two weeks, you might start back to the physical activity that triggered it. Use these tactics.

  1. Seek softer surfaces – Avoid concrete and other hard surfaces for running, walking, or sports where possible.
  2. Stretch after warming up – Stop and do your stretching routine, especially the legs, after your warm-up.
  3. Speed up only after warming up – If you feel the calf pain, slow down.
  4. Slow or stop if you feel shin splint pain – If the pain does not go away quickly at a lower speed, end your running or walking workout.
  5. Ice after exercise – Ice your shins for 20 minutes after exercise.
  6. Easy does it – Increase your exercise load by only 10 percent per week (mileage, duration, or intensity). Avoid competition until you have continued to be pain-free.


Medial Tibial Stress Syndrome

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