Current Concepts In Treating Medial Tibial Stress Syndrome
Medial tibial stress syndrome is relatively common in running and jumping athletes. Accordingly, this author offers a thorough review of the literature and shares insights from his experience in treating this condition and facilitating a rapid, pain-free return to full activity.
Medial tibial stress syndrome (MTSS) is one of the most common injuries that occurs among running and jumping athletes. Even though use of the term “shin splints” started over 40 years ago to describe the leg pain which occurred in athletes with MTSS, “shin splints” has also been in use over the years to describe a number of other diagnoses that cause leg pain in athletes.1
For this reason, “exercise-induced leg pain” and “exertional leg pain” have become more popular terms.2,3 These terms describe the multitude of diagnoses that may, along with MTSS, cause leg pain during athletic activities. Such terms include tibial or fibular stress fracture, chronic exertional compartment syndrome, muscle strains or tears, focal nerve entrapment, fascial herniation, lumbosacral radiculopathy, vascular claudication and popliteal artery entrapment syndrome.4,5
Drez first coined the term “medial tibial stress syndrome” in the early 1980s.6 In 1974, researchers first used the terms “tibial stress syndrome” and “medial tibial syndrome” to describe the medial tibial pain that often occurs in the legs of active individuals.7,8 Other names that have been used over the past 30-plus years for this relatively common condition include posterior tibial syndrome, inflammatory shin pain, traction periostitis, tibial periostitis, medial shin splint syndrome, soleus syndrome and tibial fasciitis.9-15
The vast majority of individuals who develop the pain from MTSS participate in either running or jumping activities, and MTSS represents a significant percentage of all athletic injuries. In runners, MTSS accounts for 9.4 to 17.3 percent of all injuries and accounts for 22 percent of all injuries in aerobic dancers.13,16-18
In a prospective study of 124 military recruits, 35 percent developed MTSS during basic training.19 In two separate prospective studies of high school cross-country runners, 12 percent of 125 runners and 15.2 percent of 130 runners developed MTSS.20,21 In another prospective study of 146 collegiate athletes who participated in running and jumping sports, 19.9 percent developed MTSS during their competitive seasons.22
Females also seem to be much more likely than males to develop MTSS. In a study of military recruits during basic training, researchers found female recruits developed MTSS at a rate that was 10 times greater than their male counterparts.23 In another prospective military study, females were only twice as likely to develop MTSS.19 In two prospective studies of high school cross-country runners, female runners were 2.5 to 6.5 times more likely to develop MTSS than their male counterparts.20,21
Essential Diagnostic Insights
In order to diagnose MTSS properly and rule out other pathologies that may cause exercise-induced leg pain, it is imperative that the clinician takes a good history and performs a proper physical examination of the patient’s foot and lower extremity. Patients with MTSS invariably complain that their medial leg pain developed along with a recent increase in running or jumping activities.
The pain from MTSS generally only occurs during the activity with the pain diminishing rapidly within five minutes of activity cessation. If the pain persists during walking activities, the clinician should have a high index of suspicion for medial tibial stress fracture (MTSF). These may occur in the same areas of the medial tibial border as does MTSS.24 Clinical examination of the patient with MTSS will show a characteristic diffuse tenderness that occurs along the distal two-thirds of the medial tibial border.25 On occasion, the exam may show localized induration within the soft tissues just posterior to the medial tibial border.26
Diagnostic testing is indicated in the patient with the symptoms of MTSS, especially if one suspects MTSF. Plain film radiographs are invariably normal in MTSS and will also be normal in early stages of MTSF.27 Triple-phase bone scans are very sensitive in detecting MTSS with a diffuse marker uptake along a relatively long section of the medial tibia. In contrast, MTSF generally demonstrates a more intense and focused marker uptake within the medial tibial border.28-31 However, in those patients with early stages of MTSS, bone scan imaging is not always positive.32,33
Magnetic resonance imaging (MRI) has greatly enhanced the ability to diagnose MTSS and MTSF in the injured athlete. A MRI allows the determination of the three-dimensional location of edema within the bone and soft tissues of the medial tibia. This has helped researchers and clinicians develop a better understanding of the pathophysiology of both MTSS and MTSF.
Fredericson and colleagues used both MRI and bone scan studies to develop a new MRI grading system for MTSS and MTSF based on the location and extent of edema within the periosteum and bone marrow of the medial tibia.34 Their research, along with the research from others, clearly indicates that MTSS may actually be, in many patients, a precursor or an intermediate step in the progression toward MTSF.35,36
Understanding The Tissue Stress Physiology Of MTSS
Over the years, there has been considerable interest as to which structures along the medial tibial border are responsible for the pain of MTSS. Many researchers speculated that the periosteum of the medial tibia was the source of the injury since periosteal thickening, increased vascularity and loss of osteocytes in the medial tibia were present in those patients with MTSS.37
However, in soft tissue biopsies of the medial tibial tissues in patients with MTSS, Johnell and co-workers found evidence of periostitis in only one of 33 samples.38 Similarly, Detmer showed no evidence of periostitis in 10 patients who had fasciotomy for MTSS.39
Others have speculated that the bone of the medial tibia itself was the location of the tissue injury in MTSS. In support of this theory, Magnusson and colleagues found a 23 percent decrease in bone mineral density in athletes with MTSS.40 In a later study, which found bone density to increase in athletes who had recovered from MTSS, researchers hypothesized that the bone mineral density losses that occur with MTSS are reversible and not inherited.41 In addition, histological study has confirmed that patients with MTSS had increased metabolic activity within the bone of the medial tibia, which led to speculation that MTSS was due to a “stress microfracture” of the tibia.38
Since both MRI and histological studies point to a continual process of stress-induced bone injury over time, there is now considerable evidence to suggest that MTSS and MTSF are best classified as points along a continuum of stress reaction of bone.42 This idea that MTSS and MTSF represent different points along a continuum of bone stress injury is in agreement with the classic research by Johnson and colleagues over 47 years ago.43 These researchers showed a continuum of histological changes in bone, including increased loss of bone density with increased bone stress, which ultimately lead to stress fractures.
Bone is a dynamic tissue that will lose density with increased stress and will gain density over time to strengthen and remodel itself. Given that, the application of too much stress over too short of a period of time, without sufficient time being allowed for the bone remodeling, will result in a stress reaction injury within the bone.44,45
Therefore, in the specific example of the running or jumping athlete with medial tibial pain, MTSS and MTSF both represent different points along the continuum of stress reaction injury to their medial tibia. This is ultimately due to changes in the microscopic structure within the bone of the medial tibia.38,40,43
Weighing Soft Tissue Traction Versus Bone Bending As Possible Etiologies
Even though most experts consider MTSS to primarily be a bone injury, there is still considerable debate as to what mechanical factors are most responsible for the bone injury of the medial tibia that results in MTSS. One of the proposed biomechanical etiologies for MTSS is that muscle or fascia exerts excessive traction or tensile forces on the medial border of the tibia. Researchers have implicated the posterior tibial (PT), flexor digitorum longus (FDL) and soleus muscles as being possible sources for a traction injury to the medial tibia that could cause MTSS.14,39,46-49
The other proposed biomechanical etiology for MTSS and the one that has recently been gaining increasing favor is that the bone injury of MTSS is due to excessive bending of the tibia during running and jumping activities. In engineering, it is a well known fact that when one places eccentric axial loads across a relatively long and narrow structure, bending moments will occur within that structure. These bending moments will, in turn, cause excessive stresses in the area of that structure with the narrowest cross-section. The greater the forces acting on the structure and the further one directs these forces away from the midline axis of the structure, then the greater will be the bending and stress within that structure.50,51
In support of the idea that excessive tibial bending moments may be responsible for medial tibial stress injuries, such as MTSS or MTSF, Milgrom and colleagues prospectively studied 295 military recruits.52 The researchers found that the recruits with narrowest tibias were also the recruits more likely to experience MTSF during basic training. Another study of military recruits also found that smaller tibial cross-sectional diameters increased the likelihood of tibial stress fractures.53
Pertinent PearlsOn Biomechanical Treatment
The treatment of patients with MTSS involves not only determining the biomechanical causes of the injury but also instituting mechanical treatments that will enable the athlete to achieve a more rapid recovery toward full activities.
After making the diagnosis of MTSS, one should instruct the patient to apply ice to the medial tibia for 20 minutes twice daily. Also tell patients to reduce running activities, run on softer surfaces and wear appropriate anti-pronation shoes. At the initial visit, modify shoe insoles or over-the-counter orthoses with adhesive felt padding at the medial heel, medial arch and medial forefoot to simulate the mechanical effects of a custom foot orthosis. Custom foot orthoses are recommended for the vast majority of these individuals unless their symptoms are mild and have resolved quickly with the aforementioned initial therapeutic measures.
Previous research has indicated that factors such as increased foot pronation and increased varus forefoot and rearfoot alignment are associated with an increased risk of developing MTSS and MTSF. Research has also shown that medial tibial soft tissue traction and tibial bending are the most likely mechanical causes of MTSS.19,54-60
Due to that research, when it comes to reducing subtalar joint (STJ) pronation and tibial bending, physicians specifically design foot orthoses for MTSS with the following features:
• 5 to 80 of inverted balancing position;
• a 2 to 4 mm medial heel skive;
• minimal medial expansion plaster;
• a 16 to 18 mm heel cup;
• 40/40 rearfoot posts;
• a full length top cover; and
• a varus forefoot extension plantar to the first, second, third and fourth metatarsal heads only.24
In effect, one should specifically design custom foot orthoses for MTSS to shift ground reaction force (GRF) toward the medial aspect of the plantar foot. This not only reduces STJ pronation moments but also reduces the abnormal valgus bending moments on the tibia that cause MTSS. By supporting the foot during running or jumping with a varus-wedged foot orthosis, GRF shifts medially. This will align the loads through the tibia more along its long axis, thereby decreasing the bending stress on the medial tibia border.24
In addition, these specifically designed orthoses for MTSS will also lessen the STJ pronation moments. This will decrease the tensile force from the medial tibial muscles and fascia that also may contribute to the pain of MTSS. In my 25 years of treating athletes, such custom orthoses have proven very effective at allowing a more rapid return to running and jumping activities.
Understanding the diagnosis, pathophysiology, biomechanical etiology and effective orthosis treatment methods for medial tibial stress injuries (such as MTSS and MTSF) is the key to allowing active patients to resume their activities as soon as possible.
Sports medicine podiatrists who can use their knowledge and clinical skills to facilitate quick and successful healing will have the reward of the satisfaction that their efforts will allow these individuals to continue their active lifestyles, pain-free, for years to come.
Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is in private practice in Sacramento, Calif.
Editor’s note: For related articles, see “Conquering Medial Tibial Stress Syndrome” in the January 2006 issue or “How To Triumph Over Shin Pain” in the June 2003 issue. For other articles, please visit the archives at www.podiatrytoday.com.
1. Slocum DB. The shin splint syndrome. Medical aspects and differential diagnosis. Am J Surg 1967; 114(6):875-881.
2. Korkola M, Amendola A. Exercise-induced leg pain. Sifting through a broad differential. Phys Sports Med 2001; 29(6):35-50.
3. Ugalde V, Batt ME. Shin splints: current theories and treatment. Crit Rev Phys Rehab Med 2001; 13:217-253.
4. Fredericson M, Wun C. Differential diagnosis of leg pain in the athlete. JAPMA 2003; 93(4):321-4.
5. Schon LC, Baxter DE, Clanton TO. Chronic exercise-induced leg pain in active people: more than just shin splints. Phys Sports Med 1992; 20:100-114.
6. Mubarak SJ, Gould RN, Lee YF, et al. The medial tibial stress syndrome: a cause of shin splints. Am J Sp Med 1982; 10(4):201-5.
7. Clement DB. Tibial stress syndrome in athletes. J Sports Med 1974; 2(2):81-5.
8. Puranen J. The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. JBJS 1974; 56-B(4):712-15.
9. James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med 1978; 6(2):40-50.
10. Brukner P, Khan K. Shin pain. In Brukner P, Khan K (eds.): Clinical Sports Medicine, McGraw-Hill, Sydney, 2001, pp.518.
11. Tweed JL, Campbell JA, Avil SJ. Biomechanical risk factors in the development of medial tibial stress syndrome in distance runners. JAPMA 2008; 98(6):436-444.
12. Mann RA, Baxter DE, Lutter LD. Running symposium. Foot Ankle 1981; 1(4):190-224.
13. Pagliano JW. A clinical study of running injuries. Presented at the American College of Sports Medicine Annual Meeting, San Diego, 1984.
14. Michael RH, Holder LE. The soleus syndrome. A cause of medial tibial stress (shin splints). Am J Sports Med 1985; 13(2):87-94.
15. Bouche RT, Johnson CH. Medial tibial stress syndrome (tibial fasciitis). A proposed pathomechanical model involving fascial traction. JAPMA 2007; 97(1):31-36.
16. Clement D, Taunton J, Smart G, McNicol KL. A survey of overuse running injuries. Phys Sports Med 1981; 9:47-58.
17. Epperly T, Fields K. Epidemiology of running injuries. In O’Connor F, Wilder R (eds.): Textbook of Running Medicine. McGraw-Hill, New York, 2001, pp.1-11.
18. Taunton JE, McKenzie DC, Clement DB. The role of biomechanics in the epidemiology of injuries. Sports Med 1988; 6(2):107-120.
19. Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med 2004; 32(3):772-80.
20. Bennett JE, Reinking MF, Pluemer B, et al. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther 2001; 31(9):504-510.
21. Plisky MS, Rauh MJ, Heiderscheit B, Underwood FB, Tank RT. Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. J Orthop Sports Phys Ther 2007; 37(2):40-47.
22. Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors to medial tibial stress syndrome: a prospective investigation. Med Sci Sports Exerc 2009; 41(3):490-6.
23. Reinker KA, Ozburne S. A comparison of male and female orthopaedic pathology in basic training. Military Med 1979; 144(8):532-6.
24. Kirby KA. Foot and lower extremity biomechanics II: Precision Intricast newsletters, 2002-2008. Precision Intricast Inc., Payson, Ariz., 2009.
25. Kortebein PM, Kaufman KR, Basford JR, Stuart MJ. Medial tibial stress syndrome. Med Sci Sports Exerc 2000; 32(3Suppl):S27-33.
26. Moore MP. Shin splints: diagnosis, management, prevention. Postgrad Med 1988; 83(1):199-210.
27. Couture CJ, Karlon KA. Tibial stress injuries: decisive diagnosis and treatment of shin splints. Phys Sports Med 2002; 30:29-36.
28. Roub LW, Gumerman LW, Hanley EN. Bone stress: a radionuclide imaging perspective. Radiology 1979; 132(2):431-8.
29. Holder LE, Michael RH. The specific scintigraphic pattern of “shin splints in the lower leg”: concise communication. J Nuclear Med 1984; 25(8):865-9.
30. Zwas ST. Ekanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nuclear Med 1987; 28(4):452-7.
31. Chisin R, Milgrom C, Giladi M, et al. Clinical significance of nonfocal scintigraphic findings in suspected tibial stress fractures. Clin Orthop Rel Res 1987; 220:200-205.
32. Milgrom C, Chisin R, Giladi M, et al. Negative bone scans in impending tibial stress fractures. A report of three cases. Am J Sports Med 1984; 12(6):488-91.
33. Nielsen MB, Hansen K, Holmer P, Dyrbye M. Tibial periosteal reactions in soldiers: scintigraphic study of 29 cases of lower leg pain. Acta Orthop Scand 1991; 62(6):531-4.
34. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995; 23(4):472-81.
35. Anderson MW, Ugalde V, Batt M, Gacayan J. Shin splints: MR appearance in a preliminary study. Radiology 1997; 204(1):177-180.
36. Batt ME, Ugalde V, Anderson MW, Shelton DK. A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc 1998; 30(11):1564-71.
37. Bhatt R, Lauder I, Finlay DB, Allen MJ, Belton IP. Correlation of bone scintigraphy and histological findings in medial tibial syndrome. Br J Sports Med 2000; 34(1):49-53.
38. Johnell O, Rausing A, Wendeberg B, Westlin N. Morphological bone changes in shin splints. Clin Ortho Rel Res 1982; 167:180-4.
39. Detmer DE. Chronic shin splints: classification and management of medial tibial stress syndrome. Sports Med 1986; 3(6):436-46.
40. Magnusson HI, Westlin NE, Nyqvist F, Gardsell P, Seeman E, Karlsson MK. Abnormally decreased regional bone density in athletes with medial tibial stress syndrome. Am J Sports Med 2003; 29(6):712-15.
41. Magnusson HI, Ahlborg HG, Karlsson C, Nyqvist F, Karlsson MK. Low regional tibial bone density in athletes with medial tibial stress syndrome normalizes after recovery from systems. Am J Sports Med 2003; 31(4):596-600.
42. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med 1997; 16(2):291-306.
43. Johnson LC, Stradford HT, Geis RW, Dineen JR, Kerley E. Histogenesis of stress fractures. JBJS 1963; 45A:1542.
44. Anderson MW, Greenspan A. Stress fractures. Radiology 1996; 199(1):1-12.
45. Roub W, Gumerman LW, Hanley EN, et al. Bone stress: a radionuclide imaging perspective. Radiology 1979; 132(2):431-8.
46. Garth WP, Miller ST. Evaluation of claw toe deformity, weakness of the foot intrinsics and posteromedial shin pain. Am J Sports Med 1989; 17(6):821-7.
47. Saxena A, O’Brien T, Bunce D. Anatomic dissection of the tibialis posterior muscle and its correlation to medial tibial stress syndrome. J Foot Surg 1990; 29(2):105-8.
48. McKeag DB, Dolan C. Overuse syndromes of the lower extremity. Phys Sports Med 1989; 17:108-123.
49. Beck BR, Osternig LR. Medial tibial stress syndrome: the location of muscles in the leg in relation to symptoms. JBJS 1994; 76(7):1057-61.
50. Gere JM. Mechanics of Materials, Fifth Edition. Brooks/Cole, Pacific Grove, Calif., 2001, pp. 371-2.
51. Beck BR. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med 1998; 26(4):265-79.
52. Milgrom C, Giladi M, Simkin A, et al. The area moment of inertia of the tibia: a risk factor for stress fractures. J Biomech 1989; 21(11-12):1243-8.
53. Beck TJ, Ruff CB, et al. Dual energy X-ray absorptiometry derived structural geometry for stress fracture prediction in male U.S. Marine Corps recruits. J Bone Miner Res 1996; 11(5):645-53.
54. Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20(5):501-5.
55. Craig DI. Medial tibial stress syndrome: evidence-based prevention. J Athl Train 2008; 43(3):316-18.
56. Viitsalo JT, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sports Med 1983; 11(3):125-130.
57. Krivickas LS. Anatomical factors associated with overuse sports injuries. Sports Med 1997; 24(2):132-46.
58. Gehlsen GM, Seger A. Selected measures of angular displacement, strength and flexibility in subjects with and without shin splints. Res Quarterly Exerc Sports 1980; 51(3):478-85.
59. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes: a study of 320 athletes. Am J Sports Med 1987; 15(1):46-57.
60. Sommer HM, Vallentyne SW. Effects of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc 1995; 27(6):800-804.