I originally wrote this article for the American Physical Therapy Association, however, it’s good information for you, my favorite patients, to have! As many runners, cyclists and triathletes have shin splints at some point in their training, this gives you an initial guide to help control your symptoms.
Medial tibial stress syndrome (MTSS) is a condition that causes pain on the inside of the shin (the front part of the leg between the knee and ankle). MTSS is commonly referred to as shin splits due to the location of pain over the shin bone. MTSS is one of the most common athletic injuries. It affects both the muscle on the inside of the shin and the bone to which it attaches. MTSS may affect up to 35% of athletes who run and jump, such as distance runners, sprinters, basketball or tennis players, or gymnasts. Military personnel, dancers, and other active people can also develop MTSS. A physical therapist can help you recover from MTSS and teach you exercises and tactics to prevent reinjury.
What is Shin Splints (Medial Tibial Stress Syndrome)?
Medial tibial stress syndrome develops when too much stress is placed on the tibia (main shin bone). The muscles that attach to the tibia can cause an overload of stress on the bone. These muscles include the posterior tibialis muscle, the soleus muscle, and the flexor digitorum longus muscle.
The most common risk factors of MTSS include:
- Flattening of the arch of the foot while standing (over-pronation)
- Being an athlete who participates in repetitive jumping and/or running
- Being female
- Excessive hip range of motion
- Smaller calf girth in males
- A high body mass index (>20.2)
How Does it Feel?
You may have MTSS if you feel pain in the middle or bottom third of the inside of the shin. The pain may be sharp when you touch the tender area, or occur as an ache during or after exercise. When MTSS is developing, the pain may be present during the beginning of exercise and less noticeable as exercise progresses. Over time the condition can worsen and pain may be felt throughout any exercise regimen, and it also may continue after exercise.
How Is It Diagnosed?
Through a thorough evaluation, health history and physical examination, I can determine if you have MTSS. I will assess your overall strength, mobility, flexibility, and your walking and running movements. By applying gentle pressure to the shin, ankle, and foot areas, I can determine where your pain is and what is most likely causing it in order to diagnose MTSS. The most reliable symptom of MTSS is pain felt when pressure is applied to certain parts of the shin.
How Can I Help YOU?
Together, you and I will determine what risk factors have caused your MTSS and will teach you how to address those causes. A treatment plan will be developed that is specific to you and what your body needs to recover and to prevent reinjury. I may recommend activity modification to decrease the stress to the irritated tissue, strengthening for increasing the dynamic control of your foot and leg, stretching and mobilization to normalize your range of motion and mobility and possibly a footwear change.
Can this Injury or Condition be Prevented?
To prevent MTSS you should:
- Get an annual functional fitness examination, including strength, flexibility, mobility, and sport-specific analyses
- Perform dynamic stretches before exercising and static stretches after exercise
- Perform strength and endurance exercises for the foot, hip, and pelvic muscles
- Perform balance exercises on each leg
- Follow a recommended training program when starting or progressing your exercise program
I can teach you all of these exercises to ensure maximum strength and health, and prevent MTSS.
Real Life Experiences / Case Studies
John (name has been changed) is a 35-year-old recreational runner who is training for his third half-marathon. John begins to feel shin pain in both legs during the first mile of his runs, which goes away during the remaining miles. Over the next few days, the pain lasts longer during his run. Concerned that he might be injuring himself, John contacts his physical therapist (me).
I conduct a thorough examination to assess his pelvic, trunk, hip, leg, foot, and ankle strength. I ask him to try to hold test positions as I apply pressure to different areas. John can’t hold his position when force is applied to the hip area. During further tests, John demonstrates excessive flattening of each of his feet, and his knees show weakness. When applying pressure to the muscles surrounding the shins, John’s pain is reproduced over the muscles on the lower one-third of the inside of the shin on each leg. John is diagnosed with MTSS in both legs.
John is treated with manual therapy techniques for the painful area in both shins, and strengthening exercises for the hip and foot muscles. He is shown how to apply ice to the painful areas for 5-10 minutes, 1-3 times a day. It is recommended that he modify his training program to run fewer overall miles (temporarily), and a change in footwear for better support and cushioning.
Since John sought help when his symptoms began, after two weeks of treatment his pain is much less, and he is slowly rebuilding his training program back to its former level. He continues his prescribed exercise regimen and his physical therapy treatments. One month after his first session, John competed pain free in the half-marathon, and is proud of his finishing time!
Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes: a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:12.
Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome: a critical review. Sports Med.2009;39(7):523-546.