Current Concepts In Treating Medial Tibial Stress Syndrome

Kevin A. Kirby, DPM

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

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