Did you know that between 4-35% of running injury presentations are Medial Tibial Stress Syndrome (MTSS), also known as shin splints? If you’ve ever experienced MTSS, you’ll know that it is a very debilitating and stubborn overuse injury that can progress quickly if not managed properly. MTSS isn’t too serious and can be managed, but if left untreated, can force you to sit out of running for prolonged periods of time, or even indefinitely.
This blog reviews the current evidence and will tell you exactly how to best manage your MTSS to get back to running ASAP.
What is MTSS?
MTSS presents as diffuse pain that is 5cm or more in length along the inner shin. At first, the pain can be worst at the beginning of a running session and subside later in the session, but as the condition progresses, the pain can persist throughout sessions and appear at rest. MTSS is often believed to be caused by periostitis (inflammation to the outer surface of the tibia bone). However, new evidence suggests that MTSS can be caused by a variety of stress type injuries, such as tendinopathy (overuse reaction of tendon), periostitis, periosteal remodelling (reactive change to the tibia surface) and stress reaction of the tibia (Reactive changes to the tibia bone). Dysfunction, or weakness of some muscles of the lower leg such as tibialis posterior and anterior, and soleus may also play a part.
How do I prevent MTSS?
MTSS most commonly occurs due to alterations in tibial loading, such as recent or sudden onset of increased running/jumping activity, duration, speed or hill work. These are EXTERNAL factors that change mechanical loading to the body, and lead to overuse injuries such as MTSS when it outweighs INTERNAL factors that change the body’s ability to tolerate and adapt to mechanical loading (Figure 1).
A recent review have found that the five most significant INTERNAL risk factors for MTSS are:
- Female sex (1.5-2.5x more likely than males)
- Increased weight
- Previous running injury (Especially previous history of MTSS)
- Higher navicular drop (Foot pronation)
- Increased hip external rotation in hip flexion (Foot turned out posture)
The cause of MTSS is often multi-factorial, and is rarely caused by just ONE risk factor. Methods that are most promising to prevent the onset of MTSS is:
- Change any training variables (Speed, terrain, duration, frequency, running biomechanics) in small increments of anywhere between 10-30%. Follow-up any ‘shock’ weeks of increased training volumes or intensity with recovery weeks where you reduce your training variables by 20-35%.
- Maintain your weight in a ‘healthy’ BMI range
- Engage in preventative strengthening of the lower body, particularly the glutes, quads, hamstrings and calf and ankle complex which can improve running biomechanics, but mainly increases resilience of the body for lower MTSS risk and overall running performance too.
- Undergo gait re-education if needed. Changing running biomechanics only shifts the load around to different muscles and joints, so there isn’t any ONE ideal running gait pattern. For this reason, not everyone needs to change their running gait pattern, but this can be useful for individuals who have been previously injured with stress injuries to certain locations or if someone has an obviously and extremely poor biomechanics.
I’ve already got MTSS, what now?
Treatment and rehab for MTSS can look significantly different between two individuals, depending on your personal situation: Likely risk factors, training and injury history, current training, training goals, pain levels, current phase of the healing process etc.
The challenging thing with MTSS is that at this point in time, the literature has found no single treatment that is effective in treating MTSS.
The best management that is currently being suggested is increased-awareness of the risk-factors and injury pathophysiology (Partly taken-care of by reading this blog) and undergoing a graded loading exposure program. In addition, using other conservative methods in conjunction with this program is the most promising way to manage MTSS.
Below I will outline MTSS management strategies that has been shown to be effective, depending on the phase of the injury.
ACUTE phase (First few days to weeks of injury onset):
- ‘Relative rest’* (Reducing training loads to an amount that you can tolerate with NO pain- It might be complete rest from running, and going for walks ONLY, or it might be reducing running volumes down to 50%)
- Cross-training* (Engaging in lower-intensity forms of training eg. Swimming, cycling, cross-trainer, walking)
- Learn about MTSS pathophysiology and your own risk factors*
SUB-ACUTE phase (First few weeks up to 3 months of injury onset)
- Graded-loading exposure program* (Progress training loads depending on pain levels. Incremental increases in training volumes and duration, then adding in more intensity later in the phase). This is estimated to take up to on average 105 days to return to baseline levels.
- Cross-training* (During the earlier part of the phase)
- Lower body strengthening exercises* (Particularly ankle & calf complex, glutes, hamstrings, quads)
- Proprioceptive exercises* (Single leg stance, wobble board etc)
- Orthotics (Temporary use to off-load the tibia)
- Dry needling- Periosteal pecking
- Iontophoresis & phonophoresis
- Extra-corporeal shockwave therapy (ESWT)
LONG-TERM management (3 months onwards or after complete recovery)
- Graded-loading training program* (Only increase ONE variable of training at a time, and increase it by no more than 30%, with regular intervals of deload training weeks where volume/intensity is dropped by up to 35%)
- Ongoing strengthening exercises* (Increase external load for adequate strength)
*Listed in bold are the most important management strategies that increase the body’s tolerance levels to fix the root cause of MTSS. The other listed modalities have been shown to be effective, but are passive methods that help improve symptoms that do not change the body’s physical structures for better internal resilience vs external load (Figure 1). Utilise these passive methods as required to reduce symptoms, but wean-off them as soon as possible.
Now that you know what’s effective for MTSS management, it’s also useful to be aware of conservative treatment methods that are NOT effective for MTSS:
- Low laser treatment
- Sports compression stockings
- Lower leg braces
- Pulsed electromagnetic fields
These findings aren’t too surprising because most of these are ‘passive’ treatment methods, and don’t increase your body’s ability to tolerate and adapt to external mechanical loading, which after all, is the root cause of MTSS.
Wrapping it up
You’ve made it this far – Thanks for sticking it out to the end of the blog. At the end of the day, the pursuit of maximal running performance will always be a delicate balancing act with being able to tolerate the external loads put on the body to prevent injury. The main purpose of rehab is to reduce training loads whilst improving the body’s tolerance levels so that you are completely pain-free, which then facilitates the healing process of your MTSS. As you get stronger and symptoms start to subside, you can increase your training volumes and intensity gradually, maintaining pain-free running at all times. If at any time, your symptoms flare-up, take it back one-step in the training progressions to the previous phase. Good luck!!
Note: This is a general guideline for prevention and management of MTSS. If these methods still don’t work for you, please contact me directly at [email protected] and we can organise a consultation, or contact any Physiotherapist for proper assessment and an individualised treatment session.
- Medial tibial stress syndrome: diagnosis, treatment and outcome assessment (PhD Academy Award) – Marinus Winters (2018)
- Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors – Mark F. Reinking, PT, PhD, SCS, ATC,*† Tricia M. Austin, PT, PhD, ATC,‡ Randy R. Richter, PT, PhD,‡ and Mary M. Krieger, MLIS, RN (2017)
- Treatment of medial tibial stress syndrome: A critical review – Kyle K. Winters, ATC, Nicholas Kostishak, Jr., ATC, CSCS, Tamara Valovich McLeod, PhD, ATC, and Cailee E. Welch, PhD, ATC • A.T. Still University (2014)
- Treatment of Medial Tibial Stress Syndrome: A Systematic Review – Marinus Winters • Michel Eskes • Adam Weir • Maarten H. Moen • Frank J. G. Backx • Eric W. P. Bakker (2013)
- Medial tibial stress syndrome: conservative treatment options – R. Michael Galbraith • Mark E. Lavalle (2009)