By: Lauren Crockett, MS, ATC, VATL
Medial tibial stress syndrome (MTSS) is commonly referred to as “shin splints” and is an overuse or repetitive stress injury from which a variety of athletes suffer. MTSS is the stress reactions that occur on the tibia and in the surrounding musculature in response to repetitive muscle contractions and limited healing time. The most common area of pain is along the medial aspect of the inferior tibia, but some athletes have pain that is anterior and more proximal on the tibia.
Athletes in the early stages of MTSS will complain of diffuse pain that occurs primarily at the beginning of the workout or practice and gets better as the workout progresses or within a few minutes of the workout ending. As MTSS progresses, it takes less activity for the pain to begin and more time for the pain to cease post activity. MTSS is caused by improper training and abnormal biomechanics of the knee, ankle and foot. Running on hard or uneven surfaces, wearing old or improper shoes, and increasing workout intensity too quickly are common risk factors. MTSS is a common injury in athletes that participate in sports that involve a lot of running such as track, cross country, soccer, basketball and field hockey. Dancers and football players are also at a higher risk. Early treatment consists of gastrocnemius and soleus stretches along with icing the painful area. Ankle strengthening with resistance bands and proprioception exercises are also utilized. As MTSS progresses, athletes will have a reduction in practice and play time to allow for healing. Athletes might be removed completely from competition depending on the severity of the injury. Pool and bike workouts are often used to allow the athlete to maintain their fitness levels when they are required to rest. Biomechanical errors should also be addressed, regardless of the stage of the injury.
While MTSS is a common injury that seems relatively harmless, it can progress into a more severe stress reaction. Stress fractures can occur if proper healing of the tibia is not allowed. Females are 1.5 to 3.5 times more likely to suffer from a stress fracture due to eating disorders, amenorrhea, and bone density loss. People in the military are also very susceptible to developing stress fractures. Stress fractures most commonly occur in the tibia but can also be seen in the metatarsals, fibula and navicular.
Clinicians should be concerned when athletes complain of localized pain along the tibia because this is indicative of more than MTSS. Athletes who have had a sudden increase in activity with minimal rest are more at risk for developing stress fractures. Patients will present with localized pain on the anterior tibia and associated edema. Tuning fork tests are commonly used to help diagnose stress fractures when imaging is not readily available. Athletes suspected of having a stress fracture should be removed from play immediately and sent for further diagnostics, including x-rays or an MRI. X-rays will not show a stress fracture unless the fracture has been there for several weeks, but they are low cost and readily available. MRIs are one of the best tools for diagnosing stress fractures. Healing time for stress fractures varies between athletes, ranging from 4-12 weeks. Athletes will be non-weight bearing for a period of time and will progress to weight bearing as healing occurs. Many athletes are also placed in a boot to help with pain reduction and will slowly be allowed return to play based on follow up exams and diagnostics.
In summary, MTSS is a common overuse injury that many athletes will experience during their athletic career. They will complain of diffuse pain either on the lateral or anterior aspect of their tibia that usually only lasts a couple of days. Some may last longer if they do not have proper rest periods. Ice, stretching, rest and rehab exercises normally resolve the injury. However, when an athlete complains of localized pain and has associated edema, they need to be sent for imaging and removed from play.
References:
- Galbraith RM and Lavalee ME. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009 Sep; 2(3): 127–133.
- Patel DS, Roth M and Kapil N. Stress Fractures: Diagnosis, Treatment and Prevention. Am Fam Physician. 2011 Jan 1;83(1):39-46.
- https://www.freelapusa.com/shin-splints-how-smart-coaches-avoid-them/
- http://www.healio.com/orthopedics/journals/ortho/2014-4-37-4/%7B6dd3d359-8ec2-447b-ade4-5a1a2748f210%7D/multiple-anterior-tibial-stress-fractures-complicated-by-acute-complete-fracture-of-the-distal-tibia
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