Medial tibial stress syndrome and Medial tibial stress fracture

Running is becoming extremely popular and systematic review found running is associated with 27%, 30%, and 23% reduced lower risk of all cause, cardiovascular and cancer mortality, respectively compared with no running. Significant reduction can be expected for any dose of running, even just once a week or 50 min a week. And here we are not even talking about other health parameters such as mental health.

On the downside, unfortunately there is a large injury rate, it can be anywhere from 15% to 85% in runners all though each studie is representing different definition of running injury and populatiton (Nigg, 2015).

In a prospective study on novice runners, one-third of novice runners stopped running within 6 month due to injury (Nielsen, 2014). One of the most commen injuries among those runners was medial tibial stress fracture, also commonly known as shin splints. However, that diagnose can be very vague and misleading.

To often mixed conditions are the medial tibial stress fracture (MTSS) and tibial stress fracture

When we talk about medial tibial stress fracture, it is a clinical diagnose where the patient describe

  1. Exercise induce pain along the postero-medial border of the tibia that occurs during impact exercise such as running, dancers, military personal and plyo / step aerobics.
  2. Pain on palpation of the medial tibial border of tibia (often 1/3 distal part of tibia) and related to periostitis.
  3. Radiation / site spreading of pain over mininum 5cm.

In tibial stress fracture its often more focal area of tenderness and less than 5cm radiation. One test to differentiate medial tibial stress fracture (MTSS) and tibial stress fracture could be hop test, as MTSS often can tolerate multiple jump whereas patients with a stress fracture experience severe pain immediately below landing (Kiel and Kaiser, 2018). However, do not base the diagnose solely on the basis of this, then people with severe MTSS may also experience rapid onset pain.

The cause

There are two main theories why it occurs 1. traction of crucal fasciopathy or 2. bone overload.


One of the predictors for medial tibial pain in woman is hip weakness. Hip weakness results altered movements that can compromise the ability to protect bone against excessive loads (Verrelst, 2014).

Look out for other diagnose as stress fracturs, chronic exertional compartmental syndrome (CECS), calf injuries (nerve entrapment or vascular pathology) (Reinking, 2007).


As clinician we want to know the patient irritability and tthe MTSS score questionnaire is a easy and simply tool to measure it. It is 4 questions and give a score 0-10. Where no symptoms is 0 and 10 is very severe. I can be used once a month to follow progression. The score has been validated by Winters and colleagues. Anecdotally, try to delay running is the score is above 4.

Further more it can be good to collect information about running the last 6 month (days of running / average of km per week, speed session, preferred running distance shoes, foot strike pattern, other sports activities).

Other checklist could be

  • Risk factors: Previously history of stress factors, female gender, low BMI (<19), current smoker
  • Female runner: menstrual irregularities, delayed menarche, eating disorders, decreased bone density
  • PMH: Osteoporosis, hyperthyroidism, low vitamin D
  • Medications: Oral steroids, long term use of PPI, anti-epileptics


Often it is able to see a bone stress reaction before the person develops pain.

The treatment

The treatment starts with patient education explaining the patient that the shin is sensitive but pain doesnt equal damage. Severity of symptoms is link with tissue overload, not damage. That symptoms can settle soon, but it can take a very long time to get back to pre-injury level and finally that set backs and flare up is very commonly during recovery.

According to Mulvad, 2018, that average recovery time is 70 days.

The main concepts of the training is

  1. regain ankle mobility if restricted dorsifleksion
  2. strengthening and endurance of calf (here you can consider foot position for gastroc hypertrophy Nunes, 2020) and posterior chain). But 1-2 training session per week.
  3. Hip stability exercises
  4. Cross-training or cycling 3 times per week.
  5. Graded running program after 20-30 minutets on low impact
  6. Running analysis and retraining (if your patient as a very narrow step you can work on get it wider as it has been associated with lower load on tibia, Heiderscheit, 2011. This can be use by external clues like imagine running with a foot on each side of a line or imagine the pedalling motion of cycling and keep your feet wide enough to pedal the bike, Kilgore, 2020).





More about bone stress see here (Clinical update on Bone Stress Injuries and Femoral Neck Stress Fracture. Can MRI Grade Help Predict Return-to-Running Time?, Ramey LN et al., Am J Sports Med.(2016) Preview


Aspetar Journal: MEDIAL TIBIAL STRESS SYNDROME Shin splints: aetiology, treatment and prevention – Written by Maarten Moen, The Netherlands

Verrelst R, Willems TM, De Clercq D, Roosen P, Goossens L, Witvrouw E. The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study. Br J Sports Med. 2014 Nov;48(21):1564-9. doi: 10.1136/bjsports-2012-091710

Reinking MF. Exercise Related Leg Pain (ERLP): a Review of The Literature. N Am J Sports Phys Ther. 2007;2(3):170-180.

Winters M, Moen MH, Zimmermann WO, et alThe medial tibial stress syndrome score: a new patient-reported outcome measureBritish Journal of Sports Medicine 2016;50:1192-1199.

Mulvad B, Nielsen RO, Lind M, Ramskov D. Diagnoses and time to recovery among injured recreational runners in the RUN CLEVER trial. PLoS One. 2018 Oct 12;13(10):e0204742. doi: 10.1371/journal.pone.0204742

Nunes JP, Costa BDV, Kassiano W, Kunevaliki G, Castro-E-Souza P, Rodacki ALF, Fortes LS, Cyrino ES. Different Foot Positioning During Calf Training to Induce Portion-Specific Gastrocnemius Muscle Hypertrophy. J Strength Cond Res. 2020 Aug;34(8):2347-2351. doi: 10.1519/JSC.0000000000003674

Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan MB. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc. 2011;43(2):296-302. doi:10.1249/MSS.0b013e3181ebedf4

Kilgore, Jack E. III; Vincent, Kevin R. MD, PhD, FACSM, CAQSM; Vincent, Heather K. PhD, FACSM Correcting Foot Crossover While Running, Current Sports Medicine Reports: January 2020 – Volume 19 – Issue 1 – p 4-5 doi: 10.1249/JSR.0000000000000670

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