Medial Tibial Stress Syndrome (MTSS)/Shin Splints

Michael Y. Yang, MD and Marc W. McKenna, MD Reviewed 06/2017
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Subject: Medial Tibial Stress Syndrome (MTSS)/Shin Splints

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BASICS

DESCRIPTION

  • 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

EPIDEMIOLOGY

Incidence

Common, can account for between 5% and 35% of novice-running injuries. Frequently occurs bilaterally 1

Pediatric Considerations

MTSS may account for up to 31% of all overuse injuries in high school athletes. 

ETIOLOGY AND PATHOPHYSIOLOGY

  • Multifactorial anatomic and biomechanical factors

    • ▪ Overuse injuries causing or limited by
      • * Microtrauma from repetitive motion leading to periosteal inflammation
      • * Overpronation of the subtalar joint and tight gastrocnemius/soleus complex with increased eccentric loading of musculature inserting along the medial shin
      • * Interosseous membrane pain
      • * Periostitis
      • * Tears of collagen fibers
      • * Enthesopathy
    • ▪ Anatomic structures affected include:
      • * Flexor hallucis longus
      • * Tibialis anterior
      • * Tibialis posterior
      • * Soleus
      • * Crural fascia
  • 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

RISK FACTORS

  • Intrinsic (personal) risk factors:

    • ▪ Greater ranges of internal and external (>65 degrees) hip rotation
    • ▪ Significant overpronation at the ankle
    • ▪ Imbalance of musculature of the ankle and foot (inversion/eversion misbalance)
    • ▪ Female gender
    • ▪ Lean calf girth
    • ▪ Femoral neck anteversion
    • ▪ Navicular drop
    • ▪ Genu varum
    • ▪ History of previous MTSS
  • External (environmental) risk factors

    • ▪ Lack of physical fitness
    • ▪ Inexperienced runners—particularly those with rapid increases in mileage and inadequate prior conditioning
    • ▪ Excessive overuse or distance running, particularly on hard or inclined (crowned) surfaces
    • ▪ Prior injury
    • ▪ Equipment (shoe) failure
  • Other risk factors

    • ▪ Elevated BMI
    • ▪ Lower bone mineral density
    • ▪ Tobacco use
  • Those typically affected by MTSS include:

    • ▪ Runners
    • ▪ Military personnel—common in recruit/boot camp
    • ▪ Gymnasts, soccer, and basketball players
    • ▪ Ballet dancers

GENERAL PREVENTION

  • Proper technique for guided calf stretching and lower extremity strength training

  • Rehabilitate prior injuries adequately.

  • Other recommendations

    • ▪ Gait analysis and retraining, particularly for overpronation
    • ▪ Orthotic footwear inserts

COMMONLY ASSOCIATED CONDITIONS

  • Rule out stress fracture and compartment syndrome.

  • Pes planus (flat feet)

DIAGNOSIS

HISTORY

  • 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.

PHYSICAL EXAM

  • 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.

DIFFERENTIAL DIAGNOSIS

  • Bone

    • ▪ Tibial stress fractures
      • * Typically, pain persists at rest or with weight-bearing activities.
      • * Focal tenderness over the anterior tibia
  • Muscle/soft tissue injury

    • ▪ Strain, tear, tendinopathy
    • ▪ Muscle hernia
  • Fascial

    • ▪ Chronic exertional compartment syndrome 2[C]
      • * Pain without direct tenderness on exam
      • * Pain increases with exertion and resolves at rest.
      • * Pain is described as cramping or squeezing.
      • * Pain with possible weakness or paresthesias on exam
    • ▪ Interosseous membrane tear
  • Nerve

    • ▪ Spinal stenosis
    • ▪ Lumbar radiculopathy
    • ▪ Common peroneal nerve entrapment
  • Vascular

    • ▪ DVT
    • ▪ Popliteal arterial entrapment
      • * Rare but limb-threatening disease
      • * History of intermittent unilateral claudication
      • * MRI reveals compression of the artery by the medial head of the gastrocnemius muscle.
  • Infection

    • ▪ Osteomyelitis
  • Malignancy

    • ▪ Bone tumors

DIAGNOSTIC TESTS & INTERPRETATION

  • Plain radiographs help rule out stress fractures if >2 weeks of symptoms 3.

  • Bone scintigraphy

    • ▪ Diffuse linear vertical uptake in the posterior tibial cortex on the lateral view.
    • ▪ Stress fractures demonstrate a focal ovoid uptake.
  • 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.

TREATMENT

GENERAL MEASURES

  • 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.

MEDICATION

  • Analgesia with acetaminophen or other oral nonsteroidal anti-inflammatory agent

  • Cryotherapy (ice massage) is also advised to relieve acute-phase symptoms 4[C].

ADDITIONAL THERAPIES

  • 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].

SURGERY/OTHER PROCEDURES

  • Surgical intervention includes a posterior medial fascial release in individuals with both

    • ▪ Severe limitation of physical activity and
    • ▪ Failure of 6 months of conservative treatment
    • ▪ Counsel patients that complete return of activity to sport may not be always achieved postoperatively. Surgical risks include infection and hematoma formation.
  • Extracorporeal shock wave therapy (ESWT) may decrease recovery time when added to a running program 5[A].

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • 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.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • 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).

PROGNOSIS

The condition is usually self-limiting, and most patients respond well with rest and nonsurgical intervention. 

COMPLICATIONS

  • Stress fractures and compartment syndrome

  • Undiagnosed MTSS or chronic exertional compartment syndrome can lead to a complete fracture or tissue necrosis, respectively.

REFERENCES

Fullem  BW. Overuse lower extremity injuries in sports. Clin Podiatr Med Surg.  2014;32(2):239–251.  [View Abstract]
Hutchinson  M. Chronic exertional compartment syndrome. Br J Sports Med.  2011;45(12):952–953.  [View Abstract]
Chang  GH, Paz  DA, Dwek  JR, et al. Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment. Clin Imaging.  2013;37(5):836–846.  [View Abstract]
Fields  KB, Sykes  JC, Walker  KM, et al. Prevention of running injuries. Curr Sports Med Rep.  2010;9(3):176–182.  [View Abstract]
Winters  M, Eskes  M, Weir  A, et al. Treatment of medial tibial stress syndrome: a systematic review. Sports Med.  2013;43(12):1315–1333.  [View Abstract]
Moen  MH, Holtslag  L, Bakker  E, et al. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol.  2012;4:12.  [View Abstract]

ADDITIONAL READING

  • 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.

CODES

ICD10

  • 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

ICD9

844.8 Sprains and strains of other specified sites of knee and leg 

SNOMED

  • 202888004 anterior shin splints (disorder)

  • 202889007 Posterior shin splints

CLINICAL PEARLS

  • 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.”

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