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Subject: Medial Tibial Stress Syndrome (MTSS)/Shin Splints
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The term medial tibial stress syndrome (MTSS) is currently preferred to “shin splints.” MTSS is aching pain along the inner edge of the tibial shaft that develops when the musculature and/or periosteum in the (lower) leg become irritated by repetitive activity. The condition is part of a continuum of stress-related injuries to the lower leg. MTSS does not encompass pain from ischemia (compartment syndrome) or stress fractures.
Tendonitis/periostitis of the medial soleus muscles, anterior tibialis, and posterior tibialis muscles
Synonyms: tibial stress reaction, anterior muscle syndrome, periostitis, perimyositis, soleus syndrome, shin splints
Multifactorial anatomic and biomechanical factors
Pathogenesis: theorized to be due to persistent repetitive loading, which leads to inadequate bone remodeling and possible microfissures causing pain without evidence of fracture or ischemia
Intrinsic (personal) risk factors:
External (environmental) risk factors
Other risk factors
Those typically affected by MTSS include:
Proper technique for guided calf stretching and lower extremity strength training
Rehabilitate prior injuries adequately.
Rule out stress fracture and compartment syndrome.
Pes planus (flat feet)
Patients typically describe dull, sharp, or deep pain along the lower leg that is resolved with rest.
Patients are often able to run through the pain in early stages.
Pain is commonly associated with exercise (also true with compartment syndrome), but in severe cases, pain may persist with rest.
Tenderness to palpation is typically elicited along the posteromedial border of the middle-to-distal third of the tibia.
Pain with plantar flexion
Ensure neurovascular integrity of the lower extremity, examining distal pulses, sensation, reflexes, and muscular strength.
Muscle/soft tissue injury
Plain radiographs help rule out stress fractures if >2 weeks of symptoms 3.
High-resolution MRI reveals abnormal periosteal and bone marrow signals, which are useful for early discrimination of tibial stress fractures.
Increased pain and localized tenderness warrants further imaging with MRI due to concern for tibial stress fracture.
Exclude compartment syndrome using intracompartmental pressure testing.
Activity modification with a gradual return to training based on improvement of symptoms
Patients should maintain fitness with low-impact activities such as swimming and cycling.
Continue activity modification until pain free on ambulation.
Good supportive footwear is recommended.
Analgesia with acetaminophen or other oral nonsteroidal anti-inflammatory agent
Cryotherapy (ice massage) is also advised to relieve acute-phase symptoms 4[C].
Stretching of the gastrocnemius, soleus, and peroneal muscles are treatment mainstays 4[C].
Calf stretch, peroneal stretch, TheraBand exercises, and eccentric calf raises may improve endurance and strength 5[A].
Compression stockings have been used to treat MTSS with mixed results.
Structured running programs with warm-up exercises have not been demonstrated to reduce pain in young athletes 6[B].
Surgical intervention includes a posterior medial fascial release in individuals with both
Extracorporeal shock wave therapy (ESWT) may decrease recovery time when added to a running program 5[A].
Individualized polyurethane orthoses may help chronic running injuries.
Special insoles, low-energy laser treatment, pulsed electromagnetic field, and knee braces have not been shown to improve outcomes 5[A].
Ultrasound, acupuncture, aquatic therapy, electrical stimulation, whirlpool baths, cast immobilization, taping, and steroid injection may help improve pain.
Physical therapy approaches including Kinesio tape and fascial distortion massage may yield quicker return to activity.
Avoid premature return to preinjury running pace.
Maintain stretching and strengthening exercises.
Identify and correct preinjury training errors.
Allow a gradual return to activity dictated by symptoms (pain).
Stress fractures and compartment syndrome
Undiagnosed MTSS or chronic exertional compartment syndrome can lead to a complete fracture or tissue necrosis, respectively.
Abelson B. The Tibialis Anterior Stretch-Kinetic Health. https://www.youtube.com/watch?v=6Z6XM63x2TM. Accessed June 19, 2014.
Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 2015;49(6):362–369.
Reshef N, Guelich DR. Medial tibial stress syndrome. Clin Sports Med. 2012;31(2):273–290.
S86.899A Other injury of other muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter
S86.891A Other injury of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
S86.892A Other injury of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
202888004 anterior shin splints (disorder)
202889007 Posterior shin splints
MTSS is the preferred term for “shin splints.”
Diagnosis is based on a reliable history of repetitive overuse accompanied by characteristic shin pain.
MTSS pain is typically along the middle and distal third of the posteromedial tibial surface, worsened with activity, and relieved with rest.
Treatment includes ice, activity modification, analgesics, eccentric stretching, gait retraining, and a gradual return to activity.
Symptoms recur if return to activity is “too much too fast.”