Medial tibial stress syndrome presents with pain in the shin area. The pain can either be sharp and razor-like or it can have a dull and throbbing quality. It usually worsens with palpation of the affected region. The pain usually occurs in the middle or lower shin on the inner edge. It is present after exercising, particularly running. As the condition progresses, however, it may start to occur during the performance of sporting activity. Climbing stairs can trigger the pain when the condition is severe.
Entire Body System
Bone pain mechanism When the bone is overloaded and micro-damage accumulates, pain may occur. The pain mechanism of overloaded bone has only recently been established. [aspetar.com]
The outcomes of the surgery were determined by comparing preoperative and postoperative pain levels as indicated on a visual analog pain scale and ascertaining the ability of the athletes to return to presymptom levels of exercise. [ncbi.nlm.nih.gov]
MTSS may cause: Shin pain at a very specific point Pain when running which gets more severe with continued exercise Pain when bearing weight on the leg Pain that is intensified by touching the affected area Pain may be throbbing, aching, or sharp. [lahey.org]
Surgery significantly reduced pain levels (p < 0.001) by an average of 72% as indicated on the visual analog pain scale. An excellent result was achieved in 35% of the limbs; a good result, in 34%; a fair result, in 22%; and a poor result, in 9%. [insights.ovid.com]
It is often due to inflammation of the outside covering of the bone (known as periosteum). This inflammation causes pain over the tibia during activity and to touch. [connecticutchildrens.org]
RESULTS: Until recently, inflammation of the periosteum due to excessive traction was thought to be the most likely cause of medial tibial stress syndrome. [ncbi.nlm.nih.gov]
This is thought to be caused by the shearing away of the muscle from the tibia and/or inflammation creating pressure within the anterior compartment of the lower leg. [blog.nasm.org]
Shin splints occur due to damage and inflammation of the muscle tendons attached to the tibia. The pain can be rather unbearable, forcing individuals to take prolonged periods of rest to allow for the inflammation to heal. [actionsportphysio.com]
Periostitis is inflammation of the lining of the bone (periosteum). [emoryhealthcare.org]
The evidence surrounding running shoes is very weak, and the traditional methods of advising on the type of shoe have no scientific support. [complete-physio.co.uk]
Biomechanical abnormalities, such as increased knee movement or excessive foot pronation, muscular tightness and weakness have all been identified as risk factors for this condition (Galbraith & Lavallee, 2009). [run3d.co.uk]
If these muscles are tight and overworked, or weak and underactive, their repetitive in-efficient use manifests itself as pain at the origin. [blog.nasm.org]
[…] pain increases with running earlier onset of pain with more frequent training (later stages) Physical exam tenderness along posteromedial border of tibia 4cm proximal to medial malleolus, extending proximally up to 12cm pes planus tight Achilles tendon weak [orthobullets.com]
[…] activity or exercise Icing the tender area for 5 to 10 minutes, 1 to 3 times a day Exercises to gently stretch the muscles around the shin Taping the arch of the foot or the affected leg muscles Hands-on massage of the injured tissue To help strengthen weak [choosept.com]
- Military Personnel
Prevention programs do not seem to influence the rate of MTSS, though shock-absorbing insoles have reduced MTSS rates in military personnel, and ESWT has shortened the duration of symptoms. [ncbi.nlm.nih.gov]
Introduction Medial tibial stress syndrome (MTSS) is a frequent overuse lower extremity injury in athletes and military personnel. [statpearls.com]
MTSS, or shin splints, are most common in those who do intense exercises like runners or military personnel. Muscle and Bones of Lower Leg Copyright © Nucleus Medical Media, Inc. [lahey.org]
KEYWORDS: Accelerometer; Body-worn sensor; Complexity; Fatigue; Overuse injury; Running [ncbi.nlm.nih.gov]
Runners with (n=14) and without (n=16) history of MTSS performed an outdoor fatigue run of 3200m. [pesquisa.bvsalud.org]
He raised 3 key points; You don’t necessarily have to work to fatigue to get stronger and you’d want to consider the impact of working to fatigue on his running and other training sessions. [running-physio.com]
Medial tibial stress syndrome includes periostitis, traction peristalgia, tendonopathy and fatigue failure of the connective tissue connecting muscle to bone. Medial tibial stress syndrome occurs at the posteriomedial aspect of the tibia. [togct.com]
The tendons and muscles are unable to absorb the impact of the shock and so become fatigued, transferring the impact to the connective tissue which becomes overloaded. [pafootdoctors.com]
- Medial Tibial Stress Syndrome
A significant relationship existed between gender and medial tibial stress syndrome (P =.012), with female recruits more likely to develop medial tibial stress syndrome than male recruits (53% vs 28%). [ncbi.nlm.nih.gov]
In the past, many different authors used different names to describe MTSS: shin soreness, tibial stress syndrome, medial tibial syndrome, medial tibial stress syndrome and shin splints syndrome. [aspetar.com]
[…] stress fracture from MTSS. [chiroup.com]
fractures and periostitis' - stress fractures may take up to 12 weeks to heal completely; - casting may be indicated; - fasciotomy of the posterior superior compartment may be indicated in severe cases The medial tibial stress syndrome. [wheelessonline.com]
Chronic presentations are more likely in females, those with a running history less than 5 years, increased body mass index, larger calf girth, increased hip rotation, standing foot pronation and a history of orthotics use, MTSS or stress fracture. [bjsm.bmj.com]
BACKGROUND: Various tibial dimensions and geometric parameters have been linked to stress fractures in athletes and military recruits, but many mechanical parameters have still not been investigated. [ncbi.nlm.nih.gov]
However not every patient that experiences MTSS develops a tibial stress fracture. Severe tibial stress fractures may require surgical intervention. [statpearls.com]
- Lower Leg Pain
In addition, to further explain lower leg pain, the authors investigated the crossing point of tibialis posterior and flexor digitorum longus; a mean distance for this to occur in the same ten specimens was 8.16 cm. proximal to the medial malleolus. [ncbi.nlm.nih.gov]
Broadly, it represents exertional lower leg pain centred on the posteromedial tibial border and being diffuse/linear (greater than 5 cm) rather than focal. [bjsm.bmj.com]
Differential Diagnosis – MTSS vs Compartment Syndrome vs Stress Fracture MTSS – Medial Tibial Stress Syndrome is the most common presentation of lower leg pain, with pain localized to the inner portion of the tibia in the middle/lower thirds of the lower [lifecare.com.au]
Basketball Dancers Gymnastics Military personnel Other factors that may increase your chances of MTSS: Overtraining or recently increasing the intensity of your workout or miles run A strength imbalance in the leg Amenorrhea (absent menstruation) and osteoporosis [lahey.org]
Female athlete triad of osteoporosis, amenorrhea, and disordered eating is thought to be responsible for increased risk of progression to stress fractures. [boneandspine.com]
Low bone density is most commonly found in women with a history of osteoporosis but can also be found in young women athletes. Activities that require a lot of running and activities on hard surfaces also increase the risk of developing MTSS. [zionphysicaltherapy.com]
These studies showed osteopenia in the tibial cortex in most of the patients. However, in 45% of the tibiae in asymptomatic runners, osteopenia was also found. [aspetar.com]
It may reveal mild osteopenia as an early sign of fatigue damage of cortical bone in tibial diaphysis 3,4. [radiopaedia.org]
Type 1 shows distributed and slightly reduced cortical attenuation without osteopenia. Type 2 shows osteopenia with or without cavitations or striations. The majority of asymptomatic runners had Type 0 CT scan findings. [journalmsr.com]
High resolution computer tomography (CT) scans revealed osteopenia in the involved tibial cortex [ 7 ]. However, histological studies are needed in which the bone overload theory is confirmed. [bmcsportsscimedrehabil.biomedcentral.com]
The muscles and tendons over the shin become irritated and inflamed. Both the inflammation and the pressure it creates cause pain. [lahey.org]
Medial tibial stress syndrome develops when there is irritation where the calf muscles attach to the shin bone. It can also occur when running on a slanted surface or downhill, or when someone participates in a sport with frequent starts and stops. [columbiaortho.org]
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. [unboundmedicine.com]
Radiations to the foot and dysesthesia have been reported. These presenting symptoms are similar in other overuse injuries such as stress fractures. [journalmsr.com]
Medial tibial stress syndrome is usually diagnosed clinically. There is localized tenderness on physical exam and pain is elicited with palpation of the tibial area. X-rays are not necessary and are usually unremarkable.
The physical exam is of critical importance during the evaluation of the patient, as it can direct the physician towards a category of conditions causing the particular symptomatology. Conditions that cause similar symptoms include tendinitis, stress fractures and chronic exertional compartment syndrome.
Stress fractures should be suspected when treatment response in cases diagnosed with shin splints is poor. It is diagnosed with a bone scan or an MRI, showing mild, hairline fractures of the tibia.
Tendinitis, on the other hand, refers to the inflammation of the tendons. Like shin splints, it is a painful condition, especially when a partial tear of the tendon occurs. Diagnosis is established with MRI.
Chronic exertional compartment syndrome is an uncommon condition present on the differential diagnosis of medial tibial stress syndrome. It presents very similarly to MTSS and is caused by the gradual buildup of pressure within the fascia of the lower leg, which can reach dangerous levels. Unlike other types of compartment syndrome, it results from excessive exercising. The pain usually stops when no activity is performed. Diagnosis is established by measuring pressure before and after exercise.
Treatment of medial tibial stress syndrome is generally provided in the form of activity modification, stretching and non-steroidal anti-inflammatory medication (NSAIDs).
Running should be completely avoided, until it no longer causes any symptoms. Early treatment consists of ice packs, stretching of the anterior and posterior calf muscles, as well as NSAIDs. It is not necessary to stop all sorts of sporting exercises. Exercises such as swimming that do not involve repetitive weight bearing are actually encouraged.
After symptoms resolve, the patient can gradually return to running, but there needs to be at least a 2-week interval from the time the symptoms disappear. It is important to exercise at low intensity with gradual increase and to avoid running on hard surfaces. Patients should also adequately warm up and stretch before they start their running exercise. If pain recurs, the exercise should be immediately stopped and ice packs need to be applied. It may also be required to take one or two days off before exercising again. Adequate footware with solid heal counters and support for the arch of the foot can also help in preventing complications. Strengthening the muscles of the lower leg by dorsiflexion against resistance can additionally help to decrease the risk and prevent recurrence.
Medical treatment is directed at pain and swelling and usually consists of NSAIDs such as ibuprofen, aspirin and naproxen. Ice in the form of cold packs is usually applied for 20 minutes a few times every day. Patients should be advised, however, not to place ice directly on the skin. Swelling can be also controlled with elastic compressions. On the other hand, individuals with flat feet or recurrent shin splints may benefit from orthotics.
Outcomes are excellent for medial tibial stress syndrome when treatment is initiated and rest requirements are followed. Nonetheless, the underlying cause will have to be prevented or treated to limit recurrence.
A better outcome is also expected if the patients consult a physiotherapist or podiatrist, who can modify the exercise regimen and provide an accurate assessment of the shoes, feet and legs. They may also detect problems like overpronation of the foot while running, shoes that do not fit properly and suggest insole insertion. This can be critical in reducing risks for the development of MTSS.
The underlying causes of medial tibial stress syndrome (MTSS) remain unknown. Nonetheless, proposed mechanisms include inflammatory processes of the periosteum or a periosteal traction reaction. The most recent evidence suggest a stress reaction of the bone. Individuals subject to a hyperpronation of the foot or history of previous MTSS are faced with an increased risk. The disease is also more likely to occur in women rather than men.
Medial tibial stress syndrome tends to affect individuals in the military, as well as runners and dancers  . Incidence ranges from 4% to 35% in populations at risk. A number of other risk factors are associated with the condition and include excessive tightness in calf muscles causing hyperpronation, eccentric muscle activity that engages the medial shin muscle, smoking, low fitness level, intense exercises that are performed on hard surfaces and excessive subtalar joint pronation  .
MTSS is the most common variant of shin splints, with the other variants being compartment syndrome and stress fractures. Women are at a higher risk of developing subsequent stress fractures than men, with odds ranging from 1.5 to 3.5. This is thought to take place because of decreased bone density and higher prevalence of osteoporosis.
Periostitis is thought to be the principal pathophysiological mechanism involved in the onset of medial tibial stress syndrome. It results from strain to the tibia due to excessive load. Normally, this occurs when chronic repetitive stress is applied, leading to exaggerated bending and strain on the tibia.
Most scientists and clinicians believe that medial tibial stress syndrome manifests along a spectrum of tendinopathy, inflammation of the periosteum, stress reactions that involve the tibia and periosteal remodeling . Furthermore, MTSS and tibial stress fractures are not necessarily different conditions but are rather on a linear continuum of tibial reactions to increased stress and loading .
Muscles also play a particularly important role in the pathophysiology of the disease. Dysfunction of the tibialis posterior, the tibialis anterior and the soleus can all contribute to complications and exacerbations of MTSS .
There is no single method that has proven to be particularly effective for the prevention of shin splints. Nonetheless, a number of actions can be taken and the combination may significantly reduce the risk. Footwear plays a crucial role: shock-absorbent insoles placed within the shoes have shown a tendency to prevent the occurrence of shin splints. They also help by correcting overpronation when it occurs. It is important to replace running shoes in a regular fashion and to chose footwear that properly fits the foot. Footwear should also correspond to the sporting activity being performed. Patients can use the "wet test" to determine the size of the foot or detect abnormalities that may increase their risk for medial tibial stress syndrome. The wet test is performed by stepping out of a shower and stepping on a paper bag. If the individual has a flat foot, the corresponding impressions consists of the whole foot. In contrast, individual with a high foot arch will only have the ball of the foot and the heel imprinted.
Recovering patients or beginner runners should follow running programs that include rest days. Duration, intensity and frequency of the activity should be increased in a programmed and regimented fashion. It may be very useful to alternate running with other cardiovascular activities with a much lower level of stress on the foot such as swimming or cycling.
Barefoot running has emerged as a popular method of performing the sporting activity. Some research indirectly suggests that barefoot running may decrease the incidence of medial tarsal stress syndrome by spreading the loading and stress area over the whole foot. Nonetheless, studies have not provided any conclusive evidence for a significant decrease in risks for injury. Like running, barefoot running should be started in a gradual fashion over short distances.
Medial tibial stress syndrome (MTSS) is a condition in which pain occurs along the medial sides of the tibia. It is the most common lower leg injury and usually results from excessive stress to the tibia, leading to tendinopathy and periostitis . MTSS occurs most frequently with running and is referred to as shin splints . Young teenage runners and aerobic dancers are particularly susceptible to the condition  . MTSS is included in the group of conditions referred to as shin splints, that also includes stress fractures and may need to be differentiated from more serious conditions such as exercise-induced compartment syndrome.
Diagnosis is clinical and typical physical exam findings consist of tenderness upon palpation of the lower tibia. A bone scan may be occasionally performed to rule out a stress fracture. Exercise-induce compartment syndrome, on the other hand, is determined after an assessment of compartment pressures within the lower legs before and after exercise.
Treatment consists of rest, stretching, strengthening of the calf muscles of the lower leg, ice packs and non-steroidal anti-inflammatory drugs. The choice of footwear is critical in avoiding complications and assuring recovery and patients are generally advised to visit a physiotherapist or a podiatrist to accurately assess underlying causes and prevent recurrences. Individuals are advised to follow an exercise program with a slow increase in duration, intensity and frequency of the workout. Those with abnormalities in foot anatomy, such as flat feet or a high arch of the foot, may necessitate the use of orthotics. Prognosis is excellent as long as patients abide by recommendations and take the necessary amount of rest before they resume activity.
Medial tibial stress syndrome is more commonly known as shin splints and occurs very frequently among runners, particularly high-school ages runners and aerobic dancers. It results from excessive stress and loading on the tibia, the bone present of the lower leg. Increased stress can result in inflammation of the components of the bone and may also affect tendons and muscles. Shin splints present with pain during the performance of the exercise and disappears when the exercise is stopped, although pain persists and may be elicited by climbing stairs when the condition becomes severe. The physician will diagnose the condition clinically and may rarely need to do imaging tests to rule out more serious causes. Treatment consists of rest, ice packs, non-steroidal anti-inflammatory agents (NSAIDs) and exercises that strengthen the muscles of the lower leg. It is very important for patients to chose the correct type of footwear required while performing the exercise. This may limit and prevent further complications. Patients are also advised to follow an exercise program with a slow increase in duration, frequency and overall intensity. Prognosis is excellent when treatment is followed.
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