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.

• Mesomorph

  On general examination, the built mesomorphic posture - anteroposterior view: No significant deviation, lateral view: Pes planus b/l, posterior view: b/l over pronation, right left, and gait - antalgic, and on local examination, there was no swelling, [sjosm.org]

• Noncompliance

  Flat feet or rigid arches[1] Being overweight[3] Excessively tight calf muscles (which can cause excessive pronation)[10] Engaging the medial shin muscle in excessive amounts of eccentric muscle activity[7] Undertaking high-impact exercises on hard, noncompliant [en.wikipedia.org]

• 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]

  Shin splints, or medial tibial stress syndrome, are the most common cause of lower-leg pain in athletes. [sports-health.com]

  The term shin splints has been widely used as a catch-all term referring to a collection of different conditions that cause lower leg pain. [lifecare.com.au]

• High Foot Arch

  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. [symptoma.com]

• Anterior Knee Pain

  knee pain overuse running injury. [austinpublishinggroup.com]

• Quadriceps Muscle Weakness

  Clinicians should also examine for inflexibility and imbalance of the hamstring and quadriceps muscles. Weakness of “core muscles” is an important risk factor for lower extremity injuries [16, 19–21]. [ncbi.nlm.nih.gov]

• Suggestibility

  The results of this study suggest that flexor digitorum longus and tibialis posterior stiffness could be related to MTSS. 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. [ncbi.nlm.nih.gov]

• Abnormal Gait

  Abnormal gait patterns should be evaluated with the patient walking and running, either in the office hallway or on a treadmill. The diagnosis of Shin splints can be made on a thorough history and physical examination. [boneandspine.com]

  Abnormal gait patterns should be evaluated with the patient walking and running on a treadmill. [11][12][13][14][15][3] [16][17][18][19][20][21][22] Medical Management Treatment is predominantly conservative and there is no treatment proven to be effective [physio-pedia.com]

  Abnormal gait patterns should be evaluated with the patient walking and running, either in the office hallway or on a treadmill [9, 10]. Making the diagnosis A thorough history and physical exam are usually sufficient to make the diagnosis of MTSS. [ncbi.nlm.nih.gov]

• Neglect

  An often cited weakness is the neglect of strain placed on the medial tibia which cannot be observed through traditional means. [austinpublishinggroup.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.

• Periostal Elevation

  Radiographs taken within the first 2-3weeks are not likely to show any signs of tibial stress fracture (periosteal elevation/callus formation or cortical lucency). [chiroup.com]

• Increased Bone Density

  oral contraceptive pills) may be considered to help restore normal menstruation and increase bone density [1, 10]. [ncbi.nlm.nih.gov]

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.

Surgical treatment is not required. It is only used when response to conservative management is limited. It is also not clear how beneficial it is.

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 [5] [6]. 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 [1] [7].

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 [8]. 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 [9]. 

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 [10].

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 [1]. MTSS occurs most frequently with running and is referred to as shin splints [2]. Young teenage runners and aerobic dancers are particularly susceptible to the condition [3] [4]. 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.

1. 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 Apr-May;32(3):772-80.
2. Cox JS, Lenz HW. Women midshipmen in sports. Am J Sports Med. 1984 May-Jun;12(3):241-3.
3. Bennett JE, Reinking MF, Pluemer B, Pentel A, Seaton M, Killian C. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther. 2001 Sep;31(9):504-10.
4. Taunton JE, McKenzie DC, Clement DB. The role of biomechanics in the epidemiology of injuries. Sports Med. 1988 Aug;6(2):107-20.
5. Almeida SA, Trone DW, Leone DM, Shaffer RA, Patheal SL, Long K. Gender differences in musculoskeletal injury rates: a function of symptom reporting? Med Sci Sports Exerc. 1999 Dec;31(12):1807-12.
6. Sharma J, Golby J, Greeves J, Spears IR. Biomechanical and lifestyle risk factors for medial tibia stress syndrome in army recruits: a prospective study. Gait Posture. 2011 Mar;33(3):361-5.
7. Brukner P. Exercise-related lower leg pain: an overview. Med Sci Sports Exerc. 2000 Mar;32(3 Suppl):S1-3.
8. Beck B. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med.1998;26(4):265–279. 
9. Fredericson M, Bergman G, Hoffman K, Dillingham M. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23:427–481.
10. Detmer D. Chronic shin splints. Classification and management of medial tibial stress syndrome. Sports Med. 1986;3(6):436–446.