Medial Tibial Stress Syndrome (MTSS)

By Dr David Cork, Osteopath

Shin splints is a slang term for pain anywhere along the shin bone (tibia) from the knee to the ankle. Shin splints as a term is not specific and actually has little meaning in terms of diagnosis.

There are many different sources of shin pain.  Today we will focus on Medial Tibial Stress Syndrome (MTSS) which accounts for 12-18% of all running injuries, making it the most common cause of shin pain.


What are the symptoms of Medial Tibial Stress Syndrome (MTSS)?

  • Pain felt along the shin, usually on the inner side of the shin
  • Tenderness to touch along an area >5cm along the shin
  • Pain worsening with running, jumping, hopping, and sometimes walking, that often eases with rest
  • In severe cases it can cause people to walking with a limp

What is Medial Tibial Stress Syndrome (MTSS)?

Usually, our bones adapt to the forces placed on it by becoming stronger in coping with similar forces over time. In MTSS the bone cannot adapt fast enough to the forces, leading to the accumulation of microscopic trauma, which makes the bone tender to touch and painful when repeatedly loaded. This boney overload condition most commonly occurs as a result of a sudden return to, or increase in, running or jumping (for example, starting sport again after missing a whole year, like many of us have!), or changes in surfaces* and footwear altering the loading.

*Although synthetic surfaces (such as those used for soccer, hockey, tennis) often appear to be the same, the type of underlay can vary (e.g. from rubber to concrete) and this will affect the level of impact and load on the body.  Similarly, grass-based surfaces can also vary – think of a muddy football field compared to one with a lot of grip.

What are the risk factors for MTSS?

  • Participation in sports involving running and jumping
  • Rapid increase in physical training program or poor pre-season physical condition. This can include changes in frequency, duration or intensity of physical activity; changes in footwear or surfaces
  • History of Medial Tibial Stress Syndrome (MTSS) or stress fracture of the tibia
  • High levels of fatigue due to high training volume
  • Poor recovery, poor sleep or high levels of psychological stress
  • Inadequate muscle strength or poor flexibility/mobility
  • Bone Health conditions (e.g. Osteoporosis) or drugs that affect bone health (e.g. corticosteroids or anti-convulsants)
  • Nutritional deficiencies (e.g. very low calories diets, low calcium, vitamin D and protein intakes)
  • Extremes of body size and composition (obesity (BMI >30) or low bodyweight (BMI <19))
  • Menstrual irregularities in women
  • Women are more prone to MTSS than men (due to a number of factors, including the shape of the female pelvis, bone density and oestrogen levels)

It is important to have a detailed screening performed by one of our experienced practitioners, of known risk factors that could cause or contribute to the condition, and to address these factors where possible.

How is MTSS managed?

As stated above, there are many causes of shin pain. It is important to get the correct diagnosis and to rule out other possible causes, particularly a shin (tibia) stress fracture, which can have serious complications. It is also important to get MTSS managed effectively as it can eventually become a stress fracture if not managed properly.  At South Eastern Active Health, we treat MTSS by addressing the following 6 components:

  1. Improvement of your training regimen.  Alter duration, intensity and frequency of training loads so that the bone can adapt to the loads and doesn’t accumulate boney overload.
  2. Address biomechanical factors e.g. running technique, footwear, surfaces, movement control etc.
  3. Improve calf and ankle strength via a structured exercise program.
  4. Improve muscle flexibility and joint mobility of calf, foot and ankle.
  5. Address general health factors including diet, stress, and sleep.
  6. Graded return to sport to reduce the chance of reoccurrence.

To make sure your shin pain is looked after properly, come and see one of our experienced practitioners. To make an appointment, scroll down.

Winters, M. (2019). The diagnosis and management of medial tibial stress syndrome. Der Unfallchirurg, 123(S1), 15–19.

Winters, K. K., Kostishak, N., Valovich McLeod, T., & Welch, C. E. (2014). Treatment of Medial Tibial Stress Syndrome: A Critical Review. International Journal of Athletic Therapy and Training, 19(4), 27–31.

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