This blog post is largely derived from our podcast interview with Tom Goom and complemented with scientific evidence. It is by no means a complete overview of the scientific literature on MTSS but aims to provide important information to the reaeder. Enjoy reading!
Medial Tibial Stress Syndrome (MTSS), commonly known as shin splints, is a prevalent overuse injury that primarily affects athletes involved in running and high-impact sports. MTSS occurs when the bone and surrounding soft tissues are subjected to repetitive stress. While it is a well-known condition among runners, MTSS also affects athletes in sports like football, basketball, and volleyball. Understanding the causes, pathophysiology, risk factors, and the best strategies for treatment and recovery is essential for managing MTSS effectively. This blog post offers an in-depth exploration of MTSS, focusing on insights shared in a recent podcast with Tom Goon, a leading physiotherapist in the subject.
What is MTSS?
MTSS refers to pain along the medial border of the tibia, typically associated with repetitive stress on the bone. It is commonly seen in athletes who perform high-impact activities such as running, particularly those who suddenly increase the intensity or duration of their training. The pain typically presents as a dull ache, which may intensify during or after running or other weight-bearing, high-impact exercises.
Common Symptoms of MTSS
- Pain along the medial border of the tibia: This pain is usually felt over a broader length of the distal third of the medial border of the tibia, tipically provoked by palpation along at least 5 consecutive centimetres.
- Pain with activity: The discomfort usually increases with physical activity, especially during running or after long periods of exercise involving the lower limb.
- Swelling: Unlike some other injuries, MTSS rarely leads to swelling, however, the severely irritated cases present swelling on the distal lower leg.
- Pain reduces with rest: The pain often diminishes or disappears after a period of rest, only to return when the activity resumes.
While MTSS shares some characteristics with other conditions like stress fractures, it is typically less localized and involves a more diffuse pattern of pain. Stress fractures, on the other hand, are more focused on a single point of the bone and require more intensive management.
Causes and Pathophysiology of MTSS
The primary cause of MTSS is repetitive stress and overload on the tibia and its surrounding tissues, particularly when the bone is not able to cope with the cumulative forces. This continuous strain can lead to inflammation of the periosteum (the connective tissue surrounding the bone) and may eventually lead to bone marrow edema and even stress fracture.
Pathophysiology
Muscle fatigue: When the muscles of the hip and leg become fatigued, they are less able to absorb shock and stabilise the lower leg. This increases the load on the bone, contributing to the development of MTSS.
Overuse and microtrauma: The repeated impact from activities like running causes small, repetitive microdamage. Over time, these micro damages to the bone tissue do not heal adequately and accumulate, leading to inflammation and pain.
Bone remodelling: The tibia undergoes a natural process of remodelling to cope with these stress forces. However, if the volume and intensity of training exceed the body’s ability to adapt, it can result in inflammation, periosteal irritation and potentially bone marrow edema or stress fracture.
Risk Factors for MTSS
Several factors increase the likelihood of developing MTSS. These include both intrinsic factors and extrinsic factors. Key factors that have been found to be significantly associated with MTSS are: female gender, previous history of MTSS, fewer years of running experience, recent orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males (Newman et al., 2013).
Additional factors that have been associated with the occurrence of MTSS from clinical experience are:
1. Training Load:
An important risk factors for MTSS is an increase in training load, particularly sudden spikes in intensity or mileage. Rapidly increasing the volume of running or the intensity of training without allowing adequate time for the body to adjust can place excessive strain on the tibia and lead to the development of MTSS.
2. Footwear:
Suddenly changing to a shoe that provides less support, or improper footwear can significantly contribute to the development of MTSS.
3. Muscle Imbalance and Weakness:
Weakness or imbalances in the lower leg and core muscles, particularly the calves, can result in poor shock absorption, placing more stress on the tibia. If the muscles around the tibia aren’t strong enough to bear the load, the bone can take the brunt of the impact.
Strengthening exercises, particularly those targeting the calf muscles, play a critical role in preventing and managing MTSS. Building strength in the calves, hamstrings, quads and glutes helps support the tibia and reduces the likelihood of injury.
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Treatment of MTSS
1. Rest and Load Management:
The first step in treating MTSS is to reduce or modify training intensity. This could mean reducing mileage or switching to low-impact activities like cycling or swimming to maintain cardiovascular fitness without exacerbating the shin pain. Complete rest is often not necessary, but reducing high-impact activity is essential.
For example, a gradual return to running should be employed after a short offload period, with emphasis on starting with slow, short runs and progressively increasing distance and intensity based on the individual’s pain tolerance.
2. Strengthening Exercises:
Strengthening the muscles around the shin and lower leg is essential for recovery and preventing recurrence. Specific exercises should target the calves, quadriceps, hamstrings, glutes and the core. Strengthening these muscle groups enhances their ability to absorb shock and improve stability during high-impact activities, while strengthening them induces beneficial bone adaptations.
3. Plyometrics and Sport-Specific Training:
As the individual progresses in their recovery, sport-specific conditioning and plyometric exercises can be incorporated to simulate the demands of their sport. For example, a volleyball player may need exercises that replicate the explosive movements of jumping, whereas a runner would benefit from exercises that focus on improving running mechanics. At this stage it is necessary to closely monitor pain an symptoms in order to avoid exacerbating the injury.
4. Gradual Return to Activity:
One of the most critical aspects of recovery is a gradual return to running or sport-specific activities. A structured return-to-play plan is vital for minimising the risk of re-injury.
Return to sport could for example begin with pain-free walking, followed by jogging at a slow pace. It is important to monitor symptoms and reduce the volume or intensity if there is a flare-up. A return to full training should occur only when the athlete can perform the activity pain-free.
5. Adjunct Treatments for MTSS
While conservative treatment methods like rest, strengthening, and load management are often sufficient, adjunct treatments such as ice, shockwave therapy, and anti-inflammatory medications are sometimes used. However, these should be seen as supplementary, rather than primary, treatment options.
- Ice and NSAIDs: While ice and anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation, they do not address the root cause of MTSS, which is overuse. Additionally, some evidence suggests that NSAIDs may inhibit bone healing, making them less ideal to use in bone stress injuries.
- Shockwave Therapy: Though some evidence supports the use of shockwave therapy for treating bone stress injuries, it is not a first-line treatment for MTSS. It may be considered in persistent cases where conservative measures have not worked.
Preventing MTSS
Once an athlete has recovered from MTSS, it is essential to implement strategies to prevent recurrence. These include:
- Gradual training progression: Avoid sudden increases in intensity or mileage. Incremental changes allow the body to adapt and reduce the risk of re-injury.
- Strength training: Continue strengthening exercises for the lower leg, quads, hamstring, glutes and core muscles to maintain appropriate leg alignment, stability and stimulate bone adaptation to running.
- Proper footwear: Ensure that shoes are properly fitted and provide sufficient support.
- Cross-training: Consider including low-impact activities to reduce the overall load on the tibia, especially in the early phases of returning to sport.
