Conditions & Treatments - Shin Splints - Medial Tibial Stress Syndrome

The term shin splints is an umbrella term utilized to describe pain at the anterior aspect of the lower leg. There are a variety of conditions which are often times classified in the category of shin splints. They can include anterior shin splints, medial tibial stress syndrome, tibial stress fracture, fibular stress fracture, acute compartment syndrome, chronic exertional compartmental syndrome, congenital anomaly and tumor (1). Stress fractures, chronic compartment syndrome, and medial tibial stress syndrome (MTSS) are the 3 most common forms of exercise induced leg pain, with MTSS having the highest prevalence (2). (image from 20th U.S. edition of Gray's Anatomy of the Human Body published in 1918)

Medial tibial stress syndrome usually develops as a result of exertion from exercise. Activities such as running, jumping, or ambulating extended distances may often lead to the development of MTSS. Therefore, MTSS is most often found in runners and military personnel (2).

Medial Tibial Stress Syndrome Etiology
The exact cause or etiology of MTSS is not definitive. Until recently, the most likely cause of MTSS was associated with traction or pulling of the periosteum, a fibrous sheath that covers bones and contains the blood vessels and nerves that provide nourishment and sensation to the bone, by the soleus or flexor digitorum longus muscle origins in the lower leg (1,2,3, 4). As a result of the traction on the periosteum, inflammation and tearing away of the muscle fibers at the muscle-bone interface may occur resulting in periostitis (1, 2, 4).

However, the most recent studies suggest that MTSS is in fact not an inflammatory process of the periosteum but rather the result of periostalgia, a stress reaction of bone that has become painful (2, 4). Various studies have shown that when an individual begins an exercise program, the bone undergoes metabolic changes in the tibia which are characterized by initial bone porosity due to osteoclastic channeling (resorbing of bony tissue) on the concave posteromedial border of the tibia (2, 4, 5, 6). This is followed by the laying down of new bone in order to strengthen the bone so as resist these compressive forces (2, 4, 5, 6).

Causes of Medial Tibial Stress Syndrome
The most common causes of MTSS are training errors, poor footwear, fatigue, abnormal subtalar joint pronation, training on uneven or hard surfaces, decrease flexibility, and other biomechanical abnormalities. Pain associated with medial tibial stress syndrome is usually described as a dull ache located at the posterior medial border of the tibia following exercise which may last for several hours or days (2, 7). In severe cases, pain may ensue even during rest or with low activity. Upon palpation of the tibia, there is often marked tenderness at the posterior-medial tibial border with swelling in rare cases (2, 7). Radiographs and bone scans taken of this area are usually unremarkable as well (1, 2, 7).

Medial Tibial Stress Syndrome Treatment Options for a PT
• Rest
• Postural/Functional Training
• ROM exercises (see videos 3 and 4a&b for LE/Ankle/Foot)
• Stretching (see videos 8 & 9 for LE/Ankle/Foot)
• Strengthening/Stabilization (see videos 1 and 2 for LE/Ankle/Foot)
• Massage/Soft Tissue Mobilization
• Modalities (ice, iontophoresis, ultrasound, phonophoresis, e-stim)
• Obtain an orthotic if structural problems of foot exist

Last revised: May 15, 2010
by Jennifer Hill, MPT, CSCS

References
1) Brotzman S.B., Wilk K. (2003). Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby.
2) Yates B & White S. The Incidence and Risk Factors in the Development of Medial Tibial Stress Syndrome Among Naval Recruits. The American Journal of Sports Medicine 2004;32:772-780.
3) http://www.nlm.nih.gov/medlineplus/ency/article/002280.htm
4) Tweed J, Avil S, et al. Etiologic Factors in the Development of Medial Tibial Stress Syndrome. Journal of the American Podiatric Medical Association 2008;98(2):107-111.
5) http://www.podiatrytoday.com/current-concepts-in-treating-medial-tibial-stress-syndrome
6) Gaeta M, Minutoli F, et al. High-Resolution CT Grading of Tibial Stress Reactions in Distance Runners. American Journal of Roentgenology 2006;187:789-793
7) Edwards P, Wright M, et al. A Practical Approach for the Differential Diagnosis of Chronic Leg pain in the Athlete. The American Journal of Sports Medicine 2005;33:1241-1249.