Shin Splints/Medial Tibial Stress Syndrome (MTSS)

1. What Are Shin Splints? Understanding Medial Tibial Stress Syndrome (MTSS)

Medial tibial stress syndrome (MTSS), commonly known as shin splints, is a frequent overuse injury, especially among athletes and military personnel. It is characterized by exercise-induced pain along the posteromedial border of the tibia. MTSS is one of the most common causes of exertional leg pain in athletes. Shin splints commonly affect runners, with overuse injuries like shin splints accounting for 10% to 20% of all runner injuries. MTSS also affects ballet dancers and military recruits.

Key aspects of MTSS include:

• Pain Location: MTSS is characterized by diffuse pain along the posteromedial border of the tibia. The pain is commonly located in the distal third of the tibia on the medial side.
• Nature of Pain: The pain is often described as dull and unpleasant.
• Association with Activity: The pain is activity-related. Typically, pain increases during activity and decreases with rest. In the early stages, pain may be worse at the beginning of exercise, gradually subsiding during training, but as the condition progresses, pain may occur with less activity and even at rest.
• Other symptoms: Tenderness upon palpation of the posteromedial tibial border. Mild oedema with subcutaneous thickening of the tibial line can also be seen in MTSS patients.

2. Anatomy of the Shin: Why the Tibia and Surrounding Muscles Matter

The anatomy of the shin is critical to understanding medial tibial stress syndrome (MTSS) because the condition involves the tibia, the periosteum, and the surrounding calf muscles.

Key anatomical aspects and their relevance to MTSS:

• Tibia: The tibia, or shinbone, is the larger of the two bones in the lower leg. MTSS presents as diffuse pain along the posteromedial border of the tibia. The pain is commonly located in the distal third of the tibia on the medial side. The narrowest part of the tibia is at the mid-to-distal third, making it susceptible to MTSS and bone stress injuries.
• Periosteum: The periosteum is the membrane of connective tissue that closely covers all bones except at the articular surfaces. Many believe the main cause of MTSS involves underlying periostitis of the tibia due to tibial strain when under a load. The traction theory suggests that repetitive stress on the tibial periosteum from plantar flexors contributes to MTSS.
• Calf Muscles: Dysfunction of the tibialis posterior, tibialis anterior, and soleus muscles are commonly implicated in MTSS. The soleus and flexor digitorum longus (FDL) both have origins from the posteromedial border of the tibia, which is one of the injury sites of MTSS. The muscles implicated in the traction theory are the tibialis posterior, flexor digitorum longus, and soleus.
• The relationship between these anatomical structures explains why pain occurs in MTSS:
• Overuse and Repetitive Stress: MTSS is an overuse injury, often resulting from repetitive stress on the tibia and surrounding muscles. Repetitive loading can lead to osseous microdamage.
• Traction Forces: Plantar flexor muscles, such as the soleus, exert traction forces on the tibia, leading to periosteal inflammation and pain.
• Muscle Imbalances: Muscle imbalances and inflexibility, especially tightness of the triceps surae, are commonly associated with MTSS.

3. How Do Shin Splints Develop? Causes and Risk Factors

Medial tibial stress syndrome (MTSS), or shin splints, develops due to a combination of factors, including overuse, biomechanical issues, training errors, and muscle imbalances.

Key factors contributing to the development of MTSS:

• Overuse: MTSS is primarily an overuse injury. Repetitive stress that generates microdamage beyond the repair threshold could be a mechanism for developing MTSS. Various stress reactions of the tibia and surrounding musculature occur when the body is unable to heal properly in response to repetitive muscle contractions and tibial strain.
• Biomechanical Factors:
  • Hyperpronation: Hyperpronation of the subtalar joint is one of the most common and well-documented risk factors for MTSS. A greater navicular drop is a risk factor for MTSS.
  • Flat Feet: People with flat feet are more prone to MTSS.
  • Gait Issues: Abnormal gait patterns should be evaluated to diagnose MTSS.
  • Leg length discrepancy: Leg length discrepancy is a possible intrinsic biomechanical anomaly that can lead to MTSS.
• Training Errors:
  • "Too much, too fast": Training errors appear to be the most common factors involved in MTSS, especially as athletes attempt to do "too much, too fast".
  • Increased Activity: Common training errors include a recent onset of increased activity, intensity, or duration. Increasing intensity and/or duration too quickly is a risk factor.
  • Hard or Uneven Surfaces: Running on hard or uneven surfaces is also a common risk factor.
  • Weekly Mileage: Individuals running more than 20 miles per week are especially predisposed to overuse injuries of the lower extremity, including MTSS. Increasing running distance by >30% per week = higher prevalence rate for MTSS.
• Muscle Imbalances:
  • Muscle Weakness: Athletes with muscle weakness of the triceps surae are more prone to muscle fatigue, leading to altered running mechanics and strain on the tibia.
  • Tightness: Muscle imbalance and inflexibility, especially tightness of the triceps surae (gastrocnemius, soleus, and plantaris muscles), is commonly associated with MTSS. Tighter iliotibial bands can be a risk factor.
• Weak Core: Weakness of "core muscles" is an important risk factor for lower extremity injuries.
• Other Risk Factors:
  • Female Sex: Female sex is a risk factor for the development of MTSS.
  • Increased Weight/BMI: Increased weight and higher BMI are risk factors. People who are obese are more likely to have this condition.
  • Low Calcium and Vitamin D: Low calcium and Vitamin D are risk factors.
  • Previous Running Injury: A previous running injury is a risk factor for MTSS.

4. Why Physiotherapy is Critical for Shin Splint Recovery

Physiotherapy plays a critical role in shin splint recovery by addressing the underlying root causes of medial tibial stress syndrome (MTSS), rather than just masking the pain. It focuses on restoring function, correcting biomechanical abnormalities, and preventing recurrence through various targeted interventions.

How physiotherapy addresses the root causes of MTSS:

• Biomechanical Correction and Gait Retraining:
  • Physiotherapists assess and correct biomechanical abnormalities such as hyperpronation, leg length discrepancies, and foot arch abnormalities. Orthotics may be recommended for individuals with biomechanical problems of the foot, such as excessive foot pronation and pes planus.
  • Gait retraining helps athletes modify their running technique to reduce stress on the tibia.
• Muscle Strengthening and Balance:
  • Core Stability: Physiotherapy includes exercises to strengthen the core, hip, and gluteal muscles to improve running mechanics and prevent lower-extremity overuse injuries.
  • Targeted Strengthening: Exercises focus on strengthening the tibialis anterior and other muscles controlling both inversion and eversion of the foot.
  • Calf Muscles: A daily regimen of calf stretching and eccentric calf exercises is important to prevent muscle fatigue.
  • Proprioceptive Training: Balance training using tools like a wobble board can improve joint and postural-stabilizing muscles, helping the body react to uneven surfaces and preventing re-injury.
• Manual Therapy:
  • Addressing Musculoskeletal Dysfunction: Manual therapy is used to correct musculoskeletal abnormalities in the spine, sacroiliac joint, pelvis, and muscles, restoring normal range of motion and symmetry.
• Training Modification and Gradual Return to Activity:
  • Modifying Training Regimen: Physiotherapists guide athletes in modifying their training regimens, gradually increasing intensity and duration while monitoring symptoms.
  • Low-Impact Exercises: Encouraging cross-training with low-impact activities like swimming and cycling during rehabilitation.
  • Graded Exposure Loading: Implementing a gradual return to play protocol is implemented, increasing load by 10-30% per week, prioritizing duration before intensity, and monitoring pain levels.
• Addressing Risk Factors:
  • Intrinsic Factors: Identifying and addressing intrinsic factors such as muscle inflexibility to mitigate their impact on MTSS development.
  • Footwear and Equipment: Evaluating and recommending appropriate footwear with sufficient shock absorption and fit, as well as advising on shoe replacement.

In contrast to simply masking pain with medications or rest, physiotherapy aims to correct the biomechanical, muscular, and training-related issues that contribute to MTSS. This comprehensive approach not only alleviates current symptoms but also reduces the risk of recurrence by promoting proper movement patterns and musculoskeletal health.

5. What to Expect: Prognosis and Recovery Timeline for Shin Splints

The prognosis and recovery timeline for medial tibial stress syndrome (MTSS), or shin splints, typically range from weeks to months, with several factors influencing the duration of recovery.

Realistic recovery timelines:

• Time to recover can be 60-100 days.
• The average recovery time is around 71 days.
• Clinical experience suggests recovery may take 9-12 months.
• One randomized controlled trial (RCT) reported a recovery time of 6 months.

Key factors affecting recovery:

• Adherence to physiotherapy and rehabilitation programs: Following a structured physiotherapy program is crucial for addressing the root causes of MTSS, correcting biomechanical issues, and preventing recurrence.
• Rest and Activity Modification:
  • Acute Phase: Initial treatment typically involves 2-6 weeks of rest from the aggravating activity.
  • Relative Rest: Continuing to perform low-impact exercises such as swimming or cycling can help maintain fitness without stressing the tibia.
  • Gradual Return to Play: A graded exposure loading approach is essential, with load increases of 10-30% per week, focusing on duration before intensity, and ensuring pain does not increase beyond 2/10 during activity.
• Addressing Training Errors:
  • "Too much, too fast": Avoiding sudden increases in activity, intensity, or duration is critical. Training errors are the most common factors involved in MTSS.
  • Surface: Modifying training to avoid running on hard or uneven surfaces.
• Biomechanical Factors:
  • Hyperpronation: Addressing hyperpronation with appropriate orthotics or arch support. Insoles controlling pronation are advantageous, especially for persons with a navicular drop.
  • Muscle Imbalances: Correcting muscle imbalances and inflexibility through targeted stretching and strengthening exercises.
• Individual Factors:
  • Severity of Symptoms: The extent of the injury, including the presence of periosteal or bone marrow edema, can influence recovery time.
  • Underlying Conditions: Addressing any underlying conditions, such as low bone mineral density or hormonal imbalances in female athletes.
• Compliance with Treatment:
  • Rest and Ice: Following recommendations for rest and ice application.
  • Footwear: Wearing appropriate footwear with good shock absorption and replacing shoes regularly.
  • Orthotics: Using orthotics as prescribed to correct biomechanical issues.

6. Physiotherapy Treatment Approaches for Shin Splints

Best exercises for shin splints and physio rehab for MTSS.

Here are physiotherapy treatment approaches for shin splints, broken down into subheadings:

6.1. Biomechanical Assessment: Identifying the Root Cause

• A thorough musculoskeletal examination is completed by clinicians with a special focus on the lower extremity.
• Gait analysis should be performed with the patient walking and running, either in the office hallway or on a treadmill. Abnormal gait patterns should be evaluated.
• Biomechanical abnormalities of the lower extremity should be assessed, including possible knee abnormalities, tibial torsion, femoral anteversion, foot arch abnormalities, or a leg-length discrepancy.
• Foot posture is evaluated. Hyperpronation of the subtalar joint is a common risk factor for MTSS. A greater navicular drop is a risk factor for MTSS.
• Range of motion in the ankle joint, especially ankle joint dorsiflexion or extension, should be checked to exclude a tight/short gastroc-soleus-tendon complex. Excess forefoot pronation may indicate tibialis anterior/posterior weakness and thus greater tibial torque on running.

6.2. Strengthening Exercises for the Lower Leg and Core

• Core Strengthening: Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. Core and pelvic muscle stability may be assessed by evaluating a patient’s ability to maintain a controlled, level pelvis during a pelvic bridge from the supine position, or a standing single-leg knee bend.
• Lower Leg: Exercises focus on strengthening the tibialis anterior and other muscles controlling both inversion and eversion of the foot.
• Calf Muscles: Eccentric calf exercises can help prevent muscle fatigue.

6.3. Stretching and Flexibility Techniques

• Calf Stretching: A daily regimen of calf stretching is widely supported to prevent muscle fatigue. Most commonly prescribed treatments for shin splints are triceps surae complex stretches. Calf stretches can be done in sitting and standing positions.
• Plantar Stretching: Plantar stretching can be used in patients with MTSS.
• Hamstring and Quadriceps: Clinicians should also examine for inflexibility and imbalance of the hamstring and quadriceps muscles.

6.4. Manual Therapy and Soft Tissue Release

• Manual therapy can restore ROM, decrease pain, and improve function and symmetry of soft tissue.
• Pressure to the medial soleus aponeurosis and FDL can be applied. This can be combined with passive and active dorsiflexion (DF) and plantarflexion (PF).
• Sustained myofascial tension along the soleus aponeurosis, combined with active DF and PF can be performed.
• Wanting to avoid periosteal attachment.
• Transverse frictions are frequently used to treat focal regions of muscle thickening.
• Treat key dysfunctions of the entire kinetic chain and use manual therapy.

6.5. Gradual Return to Activity Plan

• Athletes may slowly increase training intensity and duration and add sport-specific activities, jumping exercises, and hill running to their rehabilitation program as long as they remain pain-free. Athletes should scale back any exercises that exacerbate their symptoms or cause pain.
• Gradual return to play (graded exposure loading) + plantarflexor strengthening & stretching.
• Soft Surface: When returning to activity, a soft surface should be used.
• Increase Load: Increase load by 10-30% per week, prioritizing duration before intensity. Do not let pain increase >2/10 during activity.
• Increasing running distance by >30% per week = higher prevalence rate for MTSS.
• During the subacute phase, athletes can benefit from cross-training with other low-impact exercises, such as pool running, swimming, using an elliptical machine, or riding a stationary bicycle.

7. Preventing Shin Splints: Tips for Long-Term Relief

To prevent medial tibial stress syndrome (MTSS) and avoid shin pain recurrence, it's crucial to focus on proper footwear, orthotics, and training modifications. Addressing these aspects can significantly reduce the risk of developing MTSS and promote long-term relief.

7.1. Footwear and Orthotics: Choosing the Right Support

Selecting appropriate footwear and orthotics plays a vital role in preventing MTSS.

• Proper Footwear: Athletes should choose shoes with sufficient shock-absorbing soles and insoles to reduce forces through the lower extremity. Shoes should fit properly and have a stable heel counter. It may be helpful to alternate running shoes, especially if one pair gets wet, compromising its integrity.
• Regular Shoe Replacement: Runners should replace their running shoes every 250–500 miles. Shoes lose up to 40% of their shock-absorbing capabilities and overall support at this mileage.
• Orthotics: Individuals with biomechanical foot problems may benefit from orthotics. Flexible or semi-rigid over-the-counter orthotics can help with excessive foot pronation and pes planus. Insoles controlling pronation are advantageous, especially for individuals with a navicular drop.

7.2. Training Modifications to Reduce Overload

Modifying training routines is essential to prevent overuse and reduce stress on the tibia.

• Gradual Progression: Avoid sudden increases in activity, intensity, or duration. Training errors, especially doing "too much, too fast," are common factors in MTSS.
• Activity Reduction: Reduce weekly running distance, frequency, and intensity by up to 50% to improve symptoms without complete cessation of activity.
• Surface Considerations: Avoid running on hills and uneven or very firm surfaces. Uniform surfaces of moderate firmness, like synthetic tracks, offer better shock absorption and reduce lower extremity strain.
• Cross-Training: Incorporate low-impact exercises like swimming or cycling to maintain fitness while reducing tibial stress.
• Graded Exposure Loading: Gradually increase load by 10-30% per week, prioritizing duration before intensity.
• Pain Monitoring: Ensure that pain does not increase beyond 2/10 during activity. Increasing running distance by >30% per week raises the prevalence rate for MTSS.

Additional tips for long-term relief:

• Warm-up and Stretching: Warm-up for 10-15 minutes before exercise and include stretching exercises.
• Address Biomechanical Issues: Correct biomechanical abnormalities, such as hyperpronation, through appropriate interventions like orthotics.
• Strengthen Supporting Muscles: Strengthen the tibialis anterior and other muscles controlling foot inversion and eversion. Develop core stability with strong abdominal, gluteal, and hip muscles to improve running mechanics and prevent lower-extremity overuse injuries.
• Proprioceptive Training: Incorporate balance training to improve the efficiency of joint and postural-stabilizing muscles.
• Monitor and Address Intrinsic Factors: Be aware of intrinsic factors, such as low calcium and vitamin D levels, especially in female athletes with abnormal menses, and address them accordingly.

By following these preventative measures, athletes can reduce their risk of developing MTSS and promote long-term relief from shin pain.

8. FAQs About Shin Splints and Physiotherapy

Here are some frequently asked questions (FAQs) about shin splints and physiotherapy:

• Can shin splints lead to stress fractures? Medial tibial stress syndrome (MTSS) and tibial stress fractures (TSFs) may be considered on a continuum of bone-stress reactions. Although sometimes composed of different etiologies, MTSS and tibial stress fractures may be related. The most common complication of MTSS is a stress fracture of the tibia, manifested by focal tenderness of the anterior tibia. MTSS is most commonly found in the same location as TSFs, at the junction of the mid and distal thirds of the tibia.
• How serious is MTSS? Although often not serious, MTSS can be quite disabling and progress to more serious complications if not treated properly. If pain is felt even while resting, this may indicate severe and persistent MTSS. Restrictions develop as a result of frequent shocks. Early diagnosis and management of MTSS is important in helping athletes return to full activity in a timely fashion.
• What is the best treatment for shin splints? Rest is considered to be the best treatment for shin splints.
• What are the risk factors for MTSS? A combination of training errors and biomechanical abnormalities are key risk factors for developing MTSS. Other risk factors include female sex, increased weight, higher navicular drop, previous running injury, and greater hip external rotation with the hip in flexion.
• What kind of exercises should I do? You can do eccentric calf exercises to help prevent muscle fatigue.
• Should I use ice? Ice is widely used to treat lower-extremity overuse ailments like shin splints. Ice should be applied to the affected area directly after exercise for approximately 15–20 min.
• When should I change my running shoes? Runners should change their running shoes every 250–500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities and overall support.

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