Medial Tibial Stress Syndrome

Medial Tibial Stress Syndrome (MTSS), commonly called “shin splints”, is a common injury affecting runners and sports people in general and has been shown to be perhaps the single most common sports injury affecting the lower limb, accounting for as many as 25% of all running injuries. Women tend to be more often affected than men.

The affected person will usually complain of recurrent pain along the inner aspect of the shin bone (posterior-medial aspect of tibia) that occurs during exercise and is better for rest. The front portion of the shin bone (anterior aspect of the tibia) may also be painful in some cases. Often the runner or athlete will say that they are able to run through the pain, but that the pain intensifies shortly after the person ceases exercising and begins to rest. Pain can last from a few minutes to several hours or days after exercise and can become chronic in nature (greater than 6 weeks) if left untreated. While it is often called an “overuse injury”, this term is misleading, firstly, as their are other causes of MTSS than overuse, but also the term “overuse” does not take into account what is actually occurring, namely an accumulative load on the tissue that is higher than the tissue can accommodate without injury. This is also called a “training load error”. It isn’t being “overused”, the tissue simply isn’t prepared to deal with the load placed on it over time. With an appropriate training programme, this type of injury could be avoided, if it is due to insufficient tissue capacity and accumulative loads that are too high for the tissue repair before the next injury occurs.

While some sources assert that the cause of this condition is currently considered as “unknown”, other sources suggest that this pain arises from overuse of the soleus fascia as it inserts (attaches to) the posterior-medial crest of the tibia, or the periosteal tissue underlying the the posterior tibial muscle. Both of these muscles play key parts in normal lower limb function and are put under significant stress when running or taking part in high impact sports. If a person trains in a sporadic and irregular way (lots today, little tomorrow, at random) or increases the amount of exercise they are doing too quickly (either a specific exercise or exercise in general), the aforementioned tissues do not have time to adapt and repair, and MTSS can develop. There are often underlying biomechanical factors that predispose an individual to developing MTSS. Typically, many podiatrists will blame excessive foot pronation for MTSS. However, this view isn’t entirely correct. A more accurate view would be that MTSS is the result of “bending moments” acting upon the Tibia due to a runner’s varus, and the interaction or relationship between of the degree and direction of ground-reaction forces and bodyweight across the joints axes of the foot and lower limb and the forces these apply to the Tibia. In MTSS, these forces are such that they apply a force on the Tibia that tries to bend the Tibia in a medial direction, leading to increased tissue stress and injury. Research has also shown that the shockwaves travelling through the shin bone (tibia) during running or high impact sports reduces the ability of the body to heal the affected areas of the bone and fascia, further compounding the condition.

Diagnosis is usually made by taking a detailed history of the symptoms and the person’s activities, along with palpation of the affected areas. X-ray and MRI are not considered to be an effective means of diagnosing this condition, although these may be helpful in ruling out other potential diagnoses, such as a tibial stress fracture.

Podiatric management of MTSS may include: rest and non-weightbearing exercise for a period of several days, especially during the acute phase; biomechanical assessment and the prescription of therapeutic foot orthoses (insoles); soft-tissue assessment and the prescription of therapeutic exercises; changes in footwear; acupuncture; shockwave therapy; steroid injections; and in stubborn cases, surgery.

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