Synonym: medial tibial stress syndrome
This is a complex syndrome characterised by exercise-induced pain in the lower leg. However, the term is not diagnostically precise and can be open to misinterpretation.
Medial tibial pain can be caused by stress fractures, periostitis, tendinopathy (tibialis posterior) and compartment syndrome (rarely). Interosseous membrane tears and fascial hernias are extremely rare causes.
Lateral shin splints are caused by anterior compartment syndrome.
With experience, the diagnosis can be made from the history and careful palpation to elicit particularly any tenderness. MRI scan is the most useful investigation.
- Medial shin splints are caused by traction of tibialis posterior muscle origin on the interosseous membrane and tibia. It may even show radiologically as periostitis.
- Medial shin splints are usually an overuse phenomenon.
- Other possible predisposing causes include:
- Poorly fitting shoes.
- Running on hard surfaces.
- Running on cambered surfaces.
- Hyperpronation when running.
- Change of running pattern - for example, from road running to running on a synthetic running track.
- Shin splints tend to occur most often in athletes, military personnel and dancers.[1, 2]
- Female gender, previous history of shin splints, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing shin splints.[3, 4]
- People who are unfit who suddenly start exercising are at risk of developing a stress fracture of the tibia.
- Contributing factors may include varus hind foot, excessive forefoot pronation, genu valgum, excessive femoral anteversion and external tibial torsion.
The history is particularly important to make a precise diagnosis. Stress fractures should be considered in any patient who presents with tenderness or oedema after a recent increase in activity or repeated activity with limited rest.
The pain and tenderness may be severe and are localised to the posteromedial border of the middle and distal third regions of the tibia. However, note particularly:
- Stress fracture causing crescendo pain (the person has to stop running). Tenderness is usually more localised with stress fractures.
- With other causes the pain initially tends to occur after running but later also occurs during running (although not enough to cause the person to stop running usually).
- When severe, climbing stairs can also be painful.
- In compartment syndrome the patients stop running after about fifteen minutes. The pain eases with rest straightaway although the muscle feels very tight (but with no bony tenderness).
Pain over the anterior aspect of the proximal tibia is often caused by referred pain from the patellofemoral joint (anterior knee pain). Other causes of shin pain include:
- Stress fracture (localised bone tenderness and overlying oedema).
- Chronic compartment syndrome (lateral shin pain may be due to a compartment syndrome of the tibialis anterior - see 'Lateral shin splints', below).
- Muscle strain.
- Paget's disease of bone.
- Tabes dorsalis.
- X-rays: these are usually normal in periostitis; initial X-rays may be normal with stress fractures and so repeat X-rays are often indicated if clinical suspicion persists (bone scan is much more sensitive and preferred if available).
- MRI and bone scintigraphy have comparable specificity and sensitivity. It is important to first make a clinical diagnosis of shin splints because of high percentages of positive MRI scans in asymptomatic patients.
There is only limited evidence for specific methods of prevention. Stretching exercises, modification of training schedules and the use of protective devices such as braces and insoles are often advocated for prevention.
- Rest is the key to treatment of stress fractures and periostitis.
- Management in the acute stage is rest, ice, mild elevation and a non-steroidal anti-inflammatory drug (NSAID).
- Advise the patient to wear shock-absorbing insoles in shoes and maintain fitness with non-weight-bearing exercises such as swimming or cycling.
- Once symptoms subside, the patient should start a steadily increasing exercise programme.
- A podiatrist can fit orthotics to prevent hyperpronation, if this is the causative factor.
- Stress fractures may take up to 12 weeks to heal completely.
- Casting may be indicated.
- Fasciotomy of the posterior superior compartment may be indicated in severe cases.
Lateral shin splints
- These are caused by a compartment syndrome due to swelling of the tibialis anterior muscle.
- The muscle swells with exercise, producing relative muscle ischaemia due to the restriction of muscle expansion caused by the fascial compartment.
- They most often occur due to long-distance running, hill running or an over-flexible shoe.
- Pain is lateral to the tibia. There may be numbness of the big toe.
- Immediate treatment is rest, ice and slight elevation.
- Increase cushioning in shoes.
- Avoid compression, as this will aggravate the condition.
- Fasciotomy may be required for severe cases or when conservative management is ineffective.
Further reading and references
Englund J; Chronic compartment syndrome: Tips on recognizing and treating, The Journal of Family Practice November 2005. Vol. 54, No. 11
Cosca DD, Navazio F; Common problems in endurance athletes. Am Fam Physician. 2007 Jul 1576(2):237-44.
Winters M, Eskes M, Weir A, et al; Treatment of medial tibial stress syndrome: a systematic review. Sports Med. 2013 Dec43(12):1315-33. doi: 10.1007/s40279-013-0087-0.
Reshef N, Guelich DR; Medial tibial stress syndrome. Clin Sports Med. 2012 Apr31(2):273-90. doi: 10.1016/j.csm.2011.09.008.
Newman P, Witchalls J, Waddington G, et al; Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013 Nov 134:229-41. doi: 10.2147/OAJSM.S39331.
Hamstra-Wright KL, Huxel Bliven KC, Bay C; Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 2014 Sep 3. pii: bjsports-2014-093462. doi: 10.1136/bjsports-2014-093462.
Patel DS, Roth M, Kapil N; Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011 Jan 183(1):39-46.
Craig DI; Current developments concerning medial tibial stress syndrome. Phys Sportsmed. 2009 Dec37(4):39-44.
Yeung SS, Yeung EW, Gillespie LD; Interventions for preventing lower limb soft-tissue running injuries. Cochrane Database Syst Rev. 2011 Jul 6(7):CD001256. doi: 10.1002/14651858.CD001256.pub2.
Shin Splints/Medial Tibial Stress Syndrome; Wheeless' Textbook of Orthopaedics
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