synonyms: shin splints, Medial Tibial Stress Syndrome
A- initial encounter
D- subsequent encounter
MTSS Etiology / Epidemiology / Natural History
- An overuse injury often in patients who participate in jumping activities. It is considered to be the result of injury involving the fascial origin of the soleus muscle or the periosteum beneath the origin of tibialis posterior muscle.
- 13% of injuries in runners
- posteromedial tibial pain on exertion initially relieved with rest.
- Usually occur when activity has been significantly increased.
- Common in pediatric athletes
- Thought to be the result of injury involving the fascial origin of the soleus muscle or the periosteum beneath the origin of tibialis posterior muscle.
MTSS Clinical Evaluation
- pain over the middle and distal thirds of the posteromedial tibia, exacerbated by activity and partially relieved by rest.
- tenderness along posteromeidal border of tibia, usually beginning 4cm proximal to medial malleolus and extending proximally up to 12cm.
- usally painfree ankle, knee ROM
- active resisted plantar flexion and toe raises may elicit pain.
MTSS Xray / Diagnositc Tests
- xray usually normal, may be hypertrophy of posterior cortex of the tibia. May have subperiosteal lucency and scaoopoing on the anterior or medial aspect of tibia.
- r/o stress fx with serial radiographs or bone scan
- 3-phase bone scan: shows diffuse moderate increased activity along posteromedial border of tibia on delayed images. Phase one and two are always normal. Stress fx shows more focal, intense often fusiform reaction.
- MRI: best correlates with patients clinical symptoms. Fredericson Classification: Grade 1: periosteal oedema only. Grade 2: bone marrow oedema appreciated only on T2-weighted sequences. Grade 3: bone marrow oedema appreciated on both T1 and T2-weighted sequence. Grade 4a: multiple discrete areas of intracortical signal changes. Grade 4b: linear area(s) of intracortical signal change correlating with a frank stress fracture (Fredericson M, Am J Sports Med. 1995:23 (4):472-81).
- Consider checking routine metobolic bone labs and correcting any deficiency (vitamin D deficiency).
MTSS Classification / Treatment
- Non-operative: 7-10 days of rest, heel-cord stretching, ice 20 minutes 3x/day. NSAIDs for 2wks. Return to running at 2 wks with at 50% of previous pace, 50% previous distance. Gradual increase to normal over 3-6wks. Consider heel pads or casting. Naval academy study showed no combination was better than rest alone. Shin Splint Sleeve are often beneficial.
- Patients with varus heel may benfit from medal heel wedge. Varus foot may benefit from medial post beneath forefoot. Excessive pronation may benefit from orthotic device. Hindfoot valgus may benefit from heal cup.
- Operative Treatment: Consider surgical fascial release from the posteromedial tibia and periosteal stimulation with an osteotome. (JBJS, Yates, et al; 2003, Outcome of Surgical Treatment of Medial Tibial Stress Syndrome)
- Patient Guides: AAOS, eOrthopod,
- Shin Splint Patient Information
MTSS Associated Injuries / Differential Diagnosis
- Chronic exertional compartment syndrome: pts will have elevated compartment pressures after exercise
- Stress fracture: ruled out with bone scan
- Complex Regional Pain Syndrome
- Peripheral nerve entrapment
- DVT/ Venous stasis
- Arterial vascular disease
- Popliteal artery syndrome
MTSS Follow-up Care
MTSS Review References