What is Medial Tibial Stress Syndrome (MTSS)?
Medial tibial stress syndrome (MTSS), commonly encompassed under the umbrella term shin splints, occurs along the bottom two-thirds of the shin. Pain is more diffused than “pin pointed” and will spread out at least 5 cm over a large area of the inner shin.
Symptoms of pain may be experienced at the beginning of activity, subside during activity, but then return following completion. It is one of the most common overuse injuries among runners or jumping athletes, and tends to affect females more than males.
There is no true definition of MTSS, likely due to the inconsistent use of terminology within the current research. This leads to a lack of understanding surrounding this syndrome and the exact musculature involved. However, a range of hypotheses have been proposed around this syndrome, ranging from periostitis (inflammation of the connective tissue surrounding the muscle), enthesopathy (involving the muscle’s tendon attachment to the bone), to myofascial strain, or even a bone stress reaction.
What do people experience?
- Sharp pain along the lower, inside part of the shin.
- Pain following the completion of exercise will usually occur in the early stages of MTSS. However, it can then progress to being felt at the beginning and even during exercise.
- Diffused inner shin pain that becomes evident during palpation over a distance of at least 5 cm.
- Trouble running up or down hills.
Risk factors & how to avoid discomfort
- Increased navicular drop (>10mm)
- Previous history of MTSS
- Females are at a higher risk than males for developing MTSS Increased body mass index (BMI)
- New or beginner level runner
- Increased external rotation of the hip (in males)
- Running surface (hard surfaces)
- Uphill or downhill running
- Too old or worn footwear that is improper for your activity
- Participating in high impact sports (basketball, volleyball, racket sports, etc.)
Avoid discomfort through:
- Proper footwear selection based on your biomechanics and foot type
- Slowly progress into activity; avoid too much, too soon, too fast
- Minimize over-training through the proper progression of activity and adequate rest
- Proper strength and flexibility in the lower limb given your activity
What are my options for treatment? Who else can help?
As always, utilizing the proper healthcare professional during the rehabilitation process is important in order to implement changes in a controlled manner. With the amount of information available in books and on the internet, it can be difficult to know what information will be useful and beneficial to you.
- Nonsteroidal anti-inflammatory drugs (NSAIDS). These can help decrease pain and swelling within your lower leg. Please contact your family physician for more information before utilizing this as an appropriate method of treatment.
- Footwear change. Changing your footwear if it is old and worn should be your first option. Well-worn shoes may exaggerate your biomechanics in a way that your body may not respond well to, which can ultimately lead to injury. Also, making sure that you are in the proper footwear given your biomechanics and foot type is important when being active. Ensure that you are getting the proper amount of support and cushioning for your activity. Contact your pedorthist to have your biomechanics assessed properly and for a proper footwear recommendation.
- Stretching and strengthening. Ensuring that you have the adequate strength and flexibility for the activity you are participating in is always crucial. Having the proper flexibility in the calf muscles (soleus and gastrocnemius) is beneficial in minimizing the risk of MTSS. Consult a physiotherapist or pedorthist for the proper protocols regarding this musculature.
- Rest. The literature supports the use of rest and icing when MTSS is in the acute phases. Because MTSS is an overuse injury commonly found in athletes, many find it hard to decrease the level of activity for an extended period of time. Ice applied for 15-20 minute intervals to the area of concern can provide some pain relief. Talk to your healthcare professional about the proper protocol that can be implemented given the duration of your symptoms.
- Modified Training. Your training regimen should be modified with the presence of pain. Intensity, duration, and frequency should be decreased while pain is present. During this time, low impact and cross-training exercises (such as swimming, biking, or elliptical running), can be performed in a controlled manner. Ask your healthcare professional about other exercises you can perform during this rehabilitation period.
If conservative treatment does not seem to prove beneficial, it is advised that you visit your family physician and rule out other pathologies also commonly found in the lower leg, such as tibial stress fractures and compartment syndrome. MRIs are commonly recommended and can help grade the severity of tibial injuries to ensure the proper treatment is implemented.
Staying active with pain
When experiencing pain caused by MTSS, there are a few things that should be done to stay active:
- Decrease the intensity, duration, and frequency of exercise. This does not mean ceasing activity altogether but limiting the factors that contribute to overuse injuries.
- Participate in low impact or cross-training exercises. Instead of going for a run on the treadmill, go for a swim, ride a bike, or use an elliptical machine to remain active.
- Avoid training on hills. This means no excessive running up or down hills. This can stress the lower limb musculature and delay the rehabilitation process.
- Allow for adequate rest between training sessions.
- Once symptoms have resolved, progress slowly back into activity rather than ramping up all at once.