Medial Tibial Stress Syndrome (MTSS)


Commonly known as ‘shin splints’, medial tibial stress syndrome (MTSS) is an exertional lower leg pain, seen in athletes and those starting or returning to activities.  There is often angst about the underlying cause, when patients can safely return to activity and how to prevent recurrence.


Why does it happen?

It is an overuse/repetitive stress type injury of the tibia and/or surrounding soft issues.  It results from the stressed tissue being unable to heal in time before repeat strain on the bone or contraction of tissue.


What are the signs?

Patients usually describe a vague, diffuse pain along the middle to distal aspect of the tibia. The pain starts on exertion, and in initial stages, may improve with running, however at later stages the pain comes on earlier and lasts for longer.


What are the risk factors?

This can be broadly classified into three groups: training errors, biomechanical causes and endocrinology problems (such as Vitamin D deficiency).  Females tend to be at more risk, and for this reason the female athlete triad must be investigated (amenorrhoea, eating disorders and osteoporosis).


Training errors include not undergoing an appropriate neuromuscular warm up prior to activity, not using appropriate equipment, a sudden increase in training intensity and duration, and change of training.


It is important to assess the patient’s mechanical axis, as this may be a cause for developing MTSS, from the hip to the foot. Assessment will look at the position of the hip joint and thigh bone (femur), alignment of the knee and tibia (shin bone) and looking for any abnormalities in the foot and ankle (such as flat feet or high arches).


What else can it be?

Other conditions that may cause similar symptoms include chronic compartment syndrome (associated with increased pressure within the muscle compartments with exertion), peripheral vascular disease (altered blood supply to the area), muscle tears and stress fractures.


Management options

This typically involves a period of rest and time to address the underlying cause for developing MTSS.  This may include all or some of the following:


  • During rest periods consider ultrasound therapy, anti-gravity weightbearing and extracorporeal shockwave therapy
  • Addressing biomechanical abnormalities; may involve orthotics and adjusting footwear
  • Address endocrinology abnormalities
  • Modify training regimens, reducing intensity, frequency and duration
  • Core stability training and neuromuscular strength and conditioning as part of warm-up, not just stretches
  • Work to ensure muscle strength is balanced
  • Using appropriate training equipment, including footwear with appropriate shock-absorbing ability
  • If these measures fail, then further investigations may be required, such as an MRI or bone scan


How long to recover?

Most people can return to activities by up to six weeks, but this does vary for each individual and a delayed return is not uncommon.  However, a full recovery should be expected and recurrence avoided if all underlying causes managed appropriately.


Mr Bal Dhinsa, Consultant Foot and Ankle surgeon at One Ashford Hospital


About Mr Bal Dhinsa

Mr Bal Dhinsa is a Consultant Foot and Ankle Orthopaedic Surgeon at One Ashford Hospital in Kent.  He is available every Monday from 6:00pm – 7:30pm, offering consultations for self-pay, insured and NHS patients. To learn more on Mr Dhinsa, click here