Shin Splints - Medial Tibial Stress Syndrome
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.
Available information suggests that the medial tibial stress syndrome most likely represents a periostitis at this location of the leg.
Available information suggests that the medial tibial stress syndrome most likely represents a periostitis at this location of the leg.
Pathophysiology
Many believe the main cause of MTSS involves underlying periostitis of the tibia due to tibial strain when under a load. However, new evidence indicates that a spectrum of tibial stress injuries is likely involved in MTSS, including tendinopathy, periostitis, periosteal remodelling, and stress reaction of the tibia. Dysfunction of the tibialis posterior, tibialis anterior, and soleus muscles are also commonly implicated. These various tibial stress injuries appear to be caused by alterations in tibial loading, as chronic, repetitive loads cause abnormal strain, torsion and bending of the tibia. Although sometimes composed of different aetiologies, MTSS and tibial stress fractures may be considered on a continuum of bone–stress reactions.
Causative factors- “too much, too soon”
In general, “shin splints” develop when the muscle and bone tissue (periosteum) in the leg become overworked by repetitive activity. Shin splints often occur after sudden changes in physical activity. These can be changes in frequency, such as increasing the number of days you exercise each week. Changes in duration and intensity, such as running longer distances or on hills, can also cause shin splints.
Other factors that contribute to shin splints include having flat feet or abnormally rigid arches, and exercising with improper or worn-out footwear. Runners are at highest risk for developing shin splints. Dancers and military recruits are two other groups frequently diagnosed with the condition.
Symptoms
The most common symptom of MTSS is pain along the border of the tibia. Mild swelling in the area may also occur.
MTSS pain may:
- Be sharp and razor-like or dull and throbbing
- Occur both during and after exercise
- Be aggravated by touching the sore spot
Physical examination
A combination of training errors and biomechanical abnormalities are key risk factors for developing MTSS. Clinicians should complete a thorough musculoskeletal examination of the patient, with special focus on the lower extremity. The medial ridge of the tibia (origin of the tibialis posterior and soleus muscles) is often tender to palpation, especially at the distal and middle tibial regions. The anterior tibia, however, is usually non-tender. Neurovascular symptoms are usually absent.
MTSS is associated with biomechanical abnormalities of the lower extremity. Physicians should carefully evaluate for possible knee abnormalities (especially genu varus or valgus), tibial torsion, foot arch abnormalities, or a leg-length discrepancy. Ankle movements and subtalar motion should also be evaluated. Hyper-pronation of the subtalar joint is one of the most common and well-documented risk factors for MTSS.
Muscle imbalance and inflexibility, especially tightness of the triceps surae (gastrocnemius, soleus, and plantaris muscles), is commonly associated with MTSS. Athletes with muscle weakness of the triceps surae are more prone to muscle fatigue, leading to altered running mechanics, and strain on the tibia. Clinicians should also examine for inflexibility and imbalance of the hamstring and quadriceps muscles.
Conservative treatment options
Acute phase
Rest, ice
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 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
Physiotherapy modalities, such as ultrasound, soft tissue therapy, electrical stimulation, strapping/taping techniques and unweighted ambulation, may be used in the acute setting.
Subacute phase
Modify the training routine- Decreasing weekly running distance, frequency, and intensity by 50% will likely improve symptoms without complete cessation of activity. So long as the patient remains pain-free with this program.
Stretching and strengthening exercises- A daily regime 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.
Footwear- 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.
Orthotics- Individuals with biomechanical problems of the foot may benefit from orthotics. Often, over-the-counter orthosis (flexible or semi-rigid) are sufficient.
Proprioceptive training- 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.
I hope this summary will help you or someone you know. As always, we are here at The Physio Nook to help out with any musculoskeletal disorders you may have, shins or otherwise! Feel free to call us, email, or drop in for a great service.
Paul Woodward
Principal Physiotherapist
The Physio Nook.
Many believe the main cause of MTSS involves underlying periostitis of the tibia due to tibial strain when under a load. However, new evidence indicates that a spectrum of tibial stress injuries is likely involved in MTSS, including tendinopathy, periostitis, periosteal remodelling, and stress reaction of the tibia. Dysfunction of the tibialis posterior, tibialis anterior, and soleus muscles are also commonly implicated. These various tibial stress injuries appear to be caused by alterations in tibial loading, as chronic, repetitive loads cause abnormal strain, torsion and bending of the tibia. Although sometimes composed of different aetiologies, MTSS and tibial stress fractures may be considered on a continuum of bone–stress reactions.
Causative factors- “too much, too soon”
In general, “shin splints” develop when the muscle and bone tissue (periosteum) in the leg become overworked by repetitive activity. Shin splints often occur after sudden changes in physical activity. These can be changes in frequency, such as increasing the number of days you exercise each week. Changes in duration and intensity, such as running longer distances or on hills, can also cause shin splints.
Other factors that contribute to shin splints include having flat feet or abnormally rigid arches, and exercising with improper or worn-out footwear. Runners are at highest risk for developing shin splints. Dancers and military recruits are two other groups frequently diagnosed with the condition.
Symptoms
The most common symptom of MTSS is pain along the border of the tibia. Mild swelling in the area may also occur.
MTSS pain may:
- Be sharp and razor-like or dull and throbbing
- Occur both during and after exercise
- Be aggravated by touching the sore spot
Physical examination
A combination of training errors and biomechanical abnormalities are key risk factors for developing MTSS. Clinicians should complete a thorough musculoskeletal examination of the patient, with special focus on the lower extremity. The medial ridge of the tibia (origin of the tibialis posterior and soleus muscles) is often tender to palpation, especially at the distal and middle tibial regions. The anterior tibia, however, is usually non-tender. Neurovascular symptoms are usually absent.
MTSS is associated with biomechanical abnormalities of the lower extremity. Physicians should carefully evaluate for possible knee abnormalities (especially genu varus or valgus), tibial torsion, foot arch abnormalities, or a leg-length discrepancy. Ankle movements and subtalar motion should also be evaluated. Hyper-pronation of the subtalar joint is one of the most common and well-documented risk factors for MTSS.
Muscle imbalance and inflexibility, especially tightness of the triceps surae (gastrocnemius, soleus, and plantaris muscles), is commonly associated with MTSS. Athletes with muscle weakness of the triceps surae are more prone to muscle fatigue, leading to altered running mechanics, and strain on the tibia. Clinicians should also examine for inflexibility and imbalance of the hamstring and quadriceps muscles.
Conservative treatment options
Acute phase
Rest, ice
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 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
Physiotherapy modalities, such as ultrasound, soft tissue therapy, electrical stimulation, strapping/taping techniques and unweighted ambulation, may be used in the acute setting.
Subacute phase
Modify the training routine- Decreasing weekly running distance, frequency, and intensity by 50% will likely improve symptoms without complete cessation of activity. So long as the patient remains pain-free with this program.
Stretching and strengthening exercises- A daily regime 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.
Footwear- 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.
Orthotics- Individuals with biomechanical problems of the foot may benefit from orthotics. Often, over-the-counter orthosis (flexible or semi-rigid) are sufficient.
Proprioceptive training- 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.
I hope this summary will help you or someone you know. As always, we are here at The Physio Nook to help out with any musculoskeletal disorders you may have, shins or otherwise! Feel free to call us, email, or drop in for a great service.
Paul Woodward
Principal Physiotherapist
The Physio Nook.
