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Fellows Podiatry Blog

Medial Tibial Stress Syndrome (AKA shin splints)

By July 5, 2023September 17th, 2023No Comments
shin splints pain injuries

Medial Tibial Stress Syndrome

 

June 2023

What are Shin Splints?

Shin splints or medial tibial stress syndrome (MTSS) is a common overuse injury in running and jumping athletes and is defined as exercise induced pain along the medial border of the tibia. (Shin bone) The pain is often over 5cm’s or more of the lower length of the tibia when it is palpated/pressed, made worse by activity and eases with relaxation.  According to military studies, MTSS is one of the most common injuries with 4-10% of recruits diagnosed with them throughout their 8-12 week of basic training.

Symptoms

The pain of MTSS can be described as razor sharp but can also be referred to as a dull ache or throbbing sensation that can present with or without swelling.  Pain is provoked by (during or after) activity such as running or jumping and reduces with rest.  The impact of MTSS can be long term and duration of symptoms can be 6 months to 2 1/2years according to some studies and athletes can endure reoccurring episodes of MTSS in their recovery.  Therefore, athletes should slowly build up training, follow a suitable programme for their ability and be aware of potential risk factors to prevent overuse injuries.

Diagnosis

It is hugely important to have an accurate diagnosis as there are other injuries that need to be ruled out such as stress fracture, tendonitis, and chronic exertional compartment syndrome.  MTSS can usually be diagnosed with good medical history and discussion without the use of any imaging or X-ray, however some injuries can coexist alongside MTSS.  Tingling or numbness in the foot, localised redness or severe pain or swelling to the lower leg should be investigated further and may not be caused by MTSS.

In conclusion, the location of the pain, aggravating factors of what makes it better and when the pain occurs are important for differentiating between other overuse injuries before an accurate diagnosis can be made.

 

Risk factors/Prevention

MTSS commonly occurs in runners and jumpers who overexert themselves or progress too quickly in training for their ability.  Sudden increase in pace, intensity, frequency, or distance can be associated with the condition and it is important to follow a training plan that is tailored to your own fitness level.

External risk factors such as running on hard or uneven surfaces, hill running, wearing unsuitable running trainers with limited shock absorption are thought to be contributing risk factors to MTSS.

Potentially, there are 100’s of risk factors that researchers have identified in the literature however, 4 are deemed to be more significant risk factors.  These risk factors are increased BMI, navicular drop, (increased movement of a foot bone when walking/running and associated with increased pronation) increased ankle plantar flexion and increased hip external-rotation range of motion.

Other biomechanical risk factors such as flat feet, excessive pronation, (rolling in on the foot) and leg length difference are also thought to increase likelihood of developing MTSS.   Females are at greater risk of MTSS as their anatomy (such as a pelvic anatomy and a shorter, average leg length in relation to marching stride length compared with males) predisposes them to more impact injuries than males.  In a military setting, athletes carrying heavy loads during training effectively increases body mass and therefore the stress throughout the kinetic chain, leading to further risk of lower leg injury,

What is good to know is that during intense exercise, the tibia will adapt in response to gradual, increased load/activity and can cause microtrauma.  This is a normal response to increased load which is necessary to strengthen, built and adapt.  However, if Musculo-skeletal stress is caused by over training and the threshold of tibia and musculature around it is exceeded, then MTSS can occur as the load is too great for the body.

 

Treatment

All treatments for MTSS should be individual and adjustments to training programs should be varied accordingly with a tailored rehabilitation programme.  Ask a strength and conditioning coach or a registered health professional such as a Podiatrist or a Physiotherapist for advice.  As discussed above, prevention is the best first line therapy.

Here are some of the researched methods which include, rest and ice, massage, some with the use of instrument assisted soft tissue mobilisation and myofascial release performed by a health professional.

Stretching and strengthening is widely used as a treatment for MTSS despite some literature suggesting it is ineffective.  However, the most prescribed treatment is calf stretching.  By increasing the length of the calf complex at the back of the lower leg, the opposing muscles at the front of the leg don’t work as hard to maintain ankle dorsiflexion, therefore reducing stress to the anterior leg muscles and tendons such as tibialis anterior and flexor digitorum longus.

 

Improving running mechanics such as increased stabilisation and strength around the hip, developing a strong core, and strength in gluteal muscles can be beneficial along with proprioceptive balance exercises such as single limb standing and the use of balance boards.

A good running trainer with sufficient cushioning and shock absorption is hugely important.  A podiatrist would recommend a trainer with a 10-12 mm heel to toe drop (this will take some tightness out of the calf complex without increasing the plantar flexion range of the ankle too much) and one that has some stiffness through the heel cup and upper materials.  Unless you are used to wearing a low-profile trainer such as barefoot runners, avoid introducing them or think about ditching them if you have suffered already with injury or MTSS.

 

An orthotic/insole can be used to address excessive pronation, (flat foot) and other imbalances in the foot and lower limb mechanics.  By controlling excessive pronation, this can reduce the range of movement around the ankle joint and therefore take some of the strain for the anterior muscles in the lower leg such as tibialis anterior.

 

Management

Exercises such as heel walking can improve anterior muscle strength and endurance or resistance band exercise to pull the ankle into dorsiflexion and slowly control plantarflexion in an eccentric movement.

 

heel walks tibialis anterior

         Hip Tilts for pelvic strength

 

Gastrocnemis stretch soleus stretch

Calf Raises and eccentric loading on single leg/ heel drops to increase range of motion

calf/quad strength wall sit

The above exercises are just a few movements that can start to help get you back on track as well as general isolated strength, not forgetting the importance of core strength, balance/stability, proprioception and compound movements such as squats.

Changing from impact exercise cardio training to exercises such as swimming, cross training or cycling where possible to reduce stress/strain in the lower leg.

Weight loss should be considered where appropriate and calorie reduction managed accordingly in line with exercise and activity structure.

Conclusion

Exercise prescriptions for MTSS and other injuries are individual to every person and there isn’t a quick fix or a programme that fixes all.  This document outlines some of the risk factors and ways in which you can minimise your risk and some exercises that can help treat and manage.  To reiterate, to train successfully and minimise risk of injury, built up exercise and intensity over time.

Book your appointment today for a podiatry assessment in Heswall, Wirral or at West kirby Footworks.

References

 

Winter, M. (2019). The Diagnosis and Management of Medial Tibial stress syndrome: An evidence update.  Undallchirug, 1-5. Retrieved 6 8, 2023 from https://ncbi.nlm.gov/pubmed/31098646

Deshmukh, N,S., Phansopkar, P. (2022). Medial Tibial Stress Syndrome: A Review Article

Cureus 14(7): e26641. doi:10.7759/cureus.26641

Winkelmann ZK, Anderson D, Games KE, Eberman LE. Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. J Athl Train. 2016 Dec;51(12):1049-1052. doi: 10.4085/1062-6050-51.12.13. Epub 2016 Nov 11. PMID: 27835043; PMCID: PMC5264561.

Pulsone R., Williams C., (2022)  Medial Tibial Stress syndrome and Female Military Recruits.  Health, 14, 273-280

Ross, J.  Medial Tibial Stress syndrome in Military Recruits.  Journal of Military and Veterens’ Health. Volume 2, No.2

Goon, T. Exercises for Medical Tibial Stress Syndrome. AKA Shin Splints. The Physio Network- Lower leg