About Medial Tibial Stress Syndrome
Medial Tibial Stress Syndrome, more commonly known as “shin splints,” refers to exercise-induced pain along the lower half of the medial edge of the tibia (shin bone). Medial Tibial Stress Syndrome (MTSS) is one of the most frequently reported lower leg injuries in athletics, and accounts for up to 16% of all running injuries. For as common of an injury as it may be, the exact cause of MTSS is still undergoing much debate. Though it is relatively speaking not a serious injury, MTSS can be very chronic and irritating, and can lead to more serious conditions, such as stress fractures. 
The primary symptom of shin splints is a dull aching pain that is made worse with exercise. The site of the injury is often sensitive to pressure and in some cases there may be minor swelling and redness. This is the result of inflammation of the periosteum (a membrane surrounding the bone) and the muscles that attach to it. The lower leg muscled most commonly associated with MTSS are the tibialis muscles, anterior and posterior. The posterior muscle, which is located deep within the lower leg, runs from the top of the shin bones to the foot. This muscle primarily performs ankle inversion and is unique in the sense that it nearly makes a 90 degree turn as it enters and attaches to the foot. Because of its attachment on the navicular bone, the tibialis posterior is integral in maintaining the medial longitudinal arch of the foot. Thus, the tibialis posterior is placed under a lot of stress in individuals who overpronate (roll their foot inward) during weight-bearing, as this is virtually the opposite motion of ankle inversion. The anterior tibialis muscle may also be associated with MTSS as it, too, runs from the proximal tibia to the foot and helps to perform ankle inversion. Risk Factors
- Too much, too soon: The most common cause of shin pain is a rapid increase in training. MTSS is a very common injury in runners, and especially among those just starting a running program. In these cases, the tibialis muscles are not given adequate time to adjust and strengthen accordingly to the increased load, and inflammation is likely to occur.
- Foot mechanics: Overpronation and low arches have been linked to MTSS. Because the insertion location of the posterior tibialis muscle is the keystone of the medial longitudinal arch of the foot, fallen or strained arches often transfer stress through the muscle, causing the characteristic pain and inflammation of shin splints. For more information on pronation and foot mechanics, see plantar fasciitis.
Treatment
Medial Tibial Stress Syndrome is treated conservatively and only requires injections or surgery in very rare cases, usually complicated by other factors. However, these simple at-home treatments require discipline and often must be applied frequently and aggressively in order to have a timely recovery. Treatment should begin immediately upon the onset of symptoms.
- Rest: The first and foremost step to treating MTSS is to avoid the activities that cause pain. These are usually weight-bearing exercises, such as running. However, resting does not mean that all physical fitness must be compromised. Low-impact activities such as swimming, aqua jogging, biking, and using elliptical trainers can serve as painless alternatives to running and can help maintain a relatively high degree of fitness.
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| Ice massage cup |
- Ice and Elevate: Ice treatment can be effective in treating the pain and inflammation associated with shin splints. Ice should be applied several times a day, for no longer than 15 to 20 minutes in duration. Ice treatments lasting longer than 20 minutes may actually have reverse effects on the anti-inflammatory process. Ice can be applied in the form of frozen cold packs, bags of ice cubes, or even bags of frozen vegetables. However, many runners and long-time sufferers of shin splints have noted that ice massages can be even more effective. This can easily be performed at home by freezing small paper cups filled with water. The resulting large cube is used to massage the painful region, and the paper can be peeled back as the ice melts. Finally, if athletic training facilities are available, cold whirlpool treatments have also provided relief to some sufferers of MTSS.
- Proper Footwear and Inserts: Individuals suffering from shin splints should make sure they are wearing shoes with good shock absorption and arch support at all times. Various heel and arch inserts may be considered to dissipate the amount of force acting on the inflamed areas. These types of shoes and inserts should be worn whenever possible, not just during times of exercise.
- Return Gradually: Once the symptoms are gone and the individual is ready to return to normal activity, it is very important to do so slowly. If for example, the activity that caused the injury is running, and the athlete has been aqua jogging as a form of cross training, the return to running should begin as splitting the workout between running and aqua jogging. The duration of running can then increase by a couple of minutes each day, assuming the athlete is pain free, until normal activity levels are resumed. Careful precaution should be taken to prevent the reoccurrence of shin pain. Suggestions for prevention are listed below.
An Ounce of Prevention
Medial Tibial Stress Syndrome can be difficult to prevent. Those who are prone to shin pain, or have the biomechanical risk factors explained above, should take special care when beginning a training program or sports season. The key to avoiding shin splints is to ease gradually into weight-bearing exercise routines.
MTSS can also be prevented by ensuring that proper footwear is worn at all times, and especially during weight-bearing exercise. Individuals who pronate excessively should look for a shoe marked “stability” or “motion control.” Athletes can be fitted for proper running shoes at virtually any local running store. Footwear is also important during everyday activity. If one is prone to MTSS, he or she should avoid wearing flip-flops and other shoes with thin soles and low arch support, as stress can be placed on the tibia and its surrounding muscles simply by walking around.
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| Theraband exercise for ankle dorsiflexion |
Strengthening exercises focusing on the tibialis muscle groups may also play a role in preventing MTSS. These exercises can be as simple as a few sets of toe-walking, heel-walking, and walking on the insides and outsides of the foot. These lower leg muscles can also be strenghtened by using a towel or TheraBand as resistance for dorsi and plantar flexion, as well as inversion and eversion.
Finally, runners looking to prevent MTSS should try to vary the terrain of training wherever possible. Running on grass and softer surfaces dissipates more force away from the lower leg and helps with shock absorption. Grass, soft dirt trails, and rubber tracks are preferable to asphalt and cement.