Medial Tibial Stress Syndrome (Shin Splints)

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Medial Tibial Stress Syndrome
(Shin Splints)

Definition and Causes

Medial Tibial Stress Syndrome (MTSS), often referred to as “shin splints”, causes pain along the distal two-thirds of the medial tibial border. It is a common injury affecting athletes involved in running sports. Health practitioners need to differentiate MTSS from stress fractures and, more importantly, from Chronic Exertional Compartment Syndrome. Another lower leg syndrome of great importance is Acute Compartment Syndrome which is typically caused by local trauma (e.g., fracture of the tibia) resulting in acute loss of blood flow, constituting a medical emergency.

The pathophysiology of MTSS is thought to be a traumatic periostitis of the tibia involving the tendinous attachments of the soleus (primarily), flexor digitorum longus, and posterior tibialis, with tearing of Sharpey’s fibers at their bony insertion.

Risk Factors

• Obesity
• Female gender
• Excessive pronation
• Muscle dysfunction
• Incorrect footwear
• Running on hard or uneven surfaces
• Significant increase in running distance
• Fatigue
• History of previous tibial stress fractures
• Vitamin D deficiency and lower bone mineral density
• Leg length deficiency

• Exercise-induced diffuse pain along the posteromedial border of the distal two-thirds of the tibia
• Pain exacerbated by physical activity (e.g., running)
• Pain eases off with rest after several hours but may persist longer
• Absence of leg muscle tenseness, cramping, burning pain and numbness/tingling in the foot

• Diffuse tenderness along the distal two-thirds of the posteromedial tibial border (focal tenderness should alert the examiner to the possibility of a stress fracture)
• Absence of tenseness in the leg compartments (compartment tenseness is a feature of Acute or Chronic Exertional Compartment Syndrome)
• Normal distal pulses and an absence of severe swelling, erythema, or numbness

Medial Tibial Stress Syndrome is usually a clinical diagnosis with imaging typically used to help rule out other conditions. However, if diagnostic imaging is to be used, MRI is considered the most sensitive modality.

To rule out stress fractures, plain radiography is considered to have poor sensitivity while MRI is considered to be the most sensitive modality for detecting stress fractures.

The following are examples of “red flags” for patients presenting with leg pain:

• History of a significant injury
• Severe or focal pain
• Unrelenting pain
• Nocturnal pain
• Unexplained weight loss
• Fever
• Deformity
• Significant swelling
• Leg pain arising after a prolonged period of immobility or bed rest
• Presence of tingling, numbness, burning or other neurological impairment
• Loss of distal leg pulses
• Significant loss of range of motion
• Severe tenderness on palpation or severe pain with any examination procedure

If any “red flags” are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Distal Tibia Pain Key Differential Diagnosis

Medial Tibial Stress Syndrome

• • Diffuse Pain: Aching pain along the distal two-thirds of the medial tibial border.
  • Aggravation with Activity: Pain worsened by running and other weight-bearing activities.
  • Relief with Rest: Pain gradually subsides with rest but may take several hours to resolve.
  • Tenderness: Diffuse tenderness along the medial tibial border.
  • Unilateral Symptoms: Typically affects one leg.

Chronic Exertional Compartment Syndrome

• • Pain and Tightness: Deep, aching pain or tightness in the affected compartment, typically starting after a certain duration or intensity of exercise.
  • Relief with Rest: Pain subsides within 10 to 30 minutes after stopping the activity.
  • Swelling: May notice swelling in the affected area during exercise.
  • Neurological Symptoms: Numbness, tingling, or weakness in the affected limb.
  • Bilateral Symptoms: Often affects both legs.

Stress Fracture

• • Localized Pain: Sharp, localized pain at the site of the fracture.
  • Aggravation with Activity: Pain worsened by weight-bearing activities and may persist at rest in advanced cases.
  • Tenderness: Focal tenderness at the fracture site on palpation.
  • Swelling: Possible mild swelling over the affected area.