Medial Tibial Stress Syndrome

Original Editors - Karsten De Koster

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Definition/Description

The American Medical Association defines shin-splint syndrome as “pain and discomfort in the leg from repetitive activity on hard surfaces, or due to forceable, excessive use of the foot flexors. The diagnosis should be limited to musculoskeletal inflammation, excluding stress fractures or ischemic disorders.”  

Shin-splints is a general term for overuse injuries of the lower leg, except stress fractures and compartmental syndrome. Hutchins C.P. says that shin-splints is a controversial term, because authors disagree about the inclusion and exclusion criteria’s.

A synonym for shin-splints is medial tibial stress syndrome. But Bruckner and Kahn say: “A more descriptive term that accounts for the inflammatory, traction event on the tibial aspect of the leg common in runners is medial tibial traction periostitis or just medial tibial periostitis “.

There are five possibilities which can describe the experienced shin pain: bone stress, inflammation, vascular insufficiency, nerve entrapment and a raised intracompartmental pressure.

Clinically Relevant Anatomy

The most important clinical region is the lower leg. A dysfunction of tibialis anterior and posterior, of soleus muscles are commonly implicated, also the area of attachment of these muscles can be the location of pain. 

Figure1:
Chasan N., shin-splints, http://srcpt.blogspot.com/2009/02/shin-splints.html, 2 February 2009
anatomy lower leg

Epidemiology /Etiology 

Shin-splints is most common with athletes who made training errors, especially when they overload or when they run too fast for their potential. This injury can also be related to changes in the training program, such as an increase in distance, intensity and duration. (A1) Running on a hard or uneven surface and bad running shoes (like a poor shock absorbing capacity) could be one of the factors related to the casualty. Biomechanical abnormalities as foot arch abnormalities, hyperpronation of the foot, unequal leg length,.. (D) are the most frequently mentioned intrinsic factors.

Women have an increased risk to incur stress fractures, especially with this syndrome. This is due to nutrional, hormonal and biomechanical abnormalities. Individuals who are overweight are more susceptible to getting this syndrome. Therefore it is important that people who are overweight, combine their exercise with a diet or try to lose weight before starting therapy or a training program. These people, along with poor conditioned individuals, should always slowly increase their training level. Cold weather contributes to this symptom, therefore it’s important (even more than usual) to warm up properly. (A1)

Internally a chronic inflammation of the muscular attachment along the posterior medial tibia and bony changes are considered to be the most likely cause of the medial tibial stress syndrome. 

Characteristics/Clinical Presentation

The most common complication of shin-splints is a stress fracture, which shows itself by tenderness of the anterior tibia. Sensory and motor loss in association with exertional lower leg pain are another possible clinical symptoms. Pheripheral vascular disease could be a cause of the pain. (A1) The main symptom is pain on the medial side, in the second third of the leg. The pain is caused by repeated landing and take-off from a hard or uneven surface  . This pain worsens at each moment of contact. The symptoms are often bilateral.

At first the patient only feels pain when starting the training but further on the pain could remain even when in rest. In some cases we can also see a certain degree of swelling.

Differential Diagnosis

• Stress Fracture
• Chronic Compartmental Syndrome
• Sciatica
• Deep Vein Thrombosis (DVT)
• Popliteal Artery Entrapment
• Muscle Strain
• Tumour
• Infection

Diagnostic Procedures

Medial Tibial Stress syndrome causes pain in the second third of the lower leg, when the lower leg is under load. In all cases the lower leg is very sensitive.

Imaging studies are not necessary to diagnose shin-splints, but when a conservative treatment fails, it could be useful to undertake an echo. If the injury has evolved into a stress fracture, an x-ray scan can show black lines. A triple-phase bone scan can show the difference between a stress fracture and a medial tibial stress syndrome. The MRI can also exclude tumors/edemas. For the diagnostic procedure, a thorough history and physical examination are designated. Shin-splints can also be a symptom of a chronic posterior Compartment Syndrome of the Lower Leg.  Sometimes an elevated intracompartmental pressure in the deep compartment has been noticed says Puranen. (A1)

Some other risk factors for shin-splits are over-pronation, an increased varus tendency, increased muscular strength of the plantar flexors, increased double heel strikes during dance and an increased angular displacement during running.

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Examination

During examination the anamnesis and physical examination of the lower leg will be sufficient. For the physical examination a good palpation of the lower leg will be necessary.

Medical Management

In most cases conservative treatment will suffice, but for recalcitrant cases surgical treatment can be designated. They are often not a complete resolution but may improve symptoms of pain and function. A posterior fasciotomy is the common procedure performed. Surgical treatment can improve pain and functions. 

Physical Therapy Management

Shin-splints can be treated conservatively or surgically. Essentially the treatment may focus on: (a) reducing stress; (b) relieving pain; (c) providing alternative programs to maintain fitness; (d) correcting specific etiologic factors and (e) reintegration of the athlete into activity. We will start with a conservative treatment:

The conservative treatment of this injury starts with rest. A therapist will recommend you 2-6 weeks of rest. This rest should be strictly applied. Otherwise the symptoms can be worsened. Prolonged rest is not ideal for an athlete, thus other therapies are necessary for a quick and safe return after a period of rest. This rest can be assisted by medication. The second thing a therapist will say is to use ice and eventually analgesic gels. The cryotherapy can be used after exercise for a period of 20 minutes. There are a number of physical therapy modalities to use in the acute phase but there is no proof that these therapies (such as ultrasound, soft mobilization tissue,.. (A2) would be effective. (A1) A corticoid injection is contraindicated because this can give a worse sense of health. Because the healthy tissue is also treated. A corticoid injection is given to reduce the pain, but only in connection with rest. (D)

For the treatment of shin-splints it’s important to screen the risk factors, this makes it easier to make a diagnosis and to prevent this disease. In the next table you can find them(A1):

Intrinsic factors	Extrinsic factors
Age Sex Height Weight Body fat Femoral neck anteversion Genu valgus Pes clavus Hyperpronation Joint laxity Aerobic endurance/conditioning Fatigue Strength of and balance between flexors and extensors Flexibility of muscles/joints Sporting skill/coordination Physiological factors	Sports-related factors Type of sport Exposure (e.g., running on one side of the road) Nature of event (e.g., running on hills) Equipment Shoe/surface interface Venue/supervision Playing surface Safety measures Weather conditions Temperature

In the subacute phase, the treatment should aim to modify training conditions and to address eventual biomechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency. It is advised to avoid hills and uneven surfaces. During the rehabilitation period the patient can do low impact and cross-training exercises (like running on a hydro-gym machine). After a while the athlete should gradually return to his activities. In the next period they can increase some factors as intensity increases (A1). A stretching and strengthening (eccentric) program can be introduced to overcome detectable muscle imbalance or contractures. Proprioceptive training is designated, to improve the individuals joint position sense and therefore the stability and reaction of joints on strange uneven surfaces. A heat retrainer can be of value.

Another thing that can help prevent a new or re-injury is to choose good shoes with good shock absorption. Therefore it is important to change your shoes when the shock-absorbing mechanism of your shoes wears (after 250-500 miles). Some patients strap their leg or the longitudinal arch. This can be inconvenient for some people, but success indicates that an orthosis can be helpful. Another thing that can help to prevent shin-splints is to wear orthotics, in case of a biomechanical abnormality. An over-the-counter orthosis can help with excessive footpronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.

Manual therapy can be used to control several biomechanical abnormalities of the spine, sacro-illiacal joint and various muscle imbalances. They are often used to prevent relapsing to the old injury. But manual therapy is not the only therapy that can be used; we have also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but heir efficiency is not yet proved. (A1)

In most cases conservative treatment will suffice, but for recalcitrant cases surgical treatment can be designated. They are often not a complete resolution but may improve symptoms of pain and function.(A1)

Case Studies

• Diagnosis and management of acute medial tibial stress syndrome in a 15 year old female surf life-saving competitor
• Medial tibial stress syndrome: A skeleton from medieval Rhodes demonstrates the appearance of the bone surface – a case report
  

Resources

Primary resources:
GALBRAITH R.M. and LAVALEE M.E., ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med.; September 2009, 2(3):127-133. (E)
Craig D.I., ‘Medial Tibial Stress Syndrome: Evidence-based Prevention’, J Athl Training, June 2008; 43(3): 316-318. (A)
THACKER S.B.,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine & science in sports & exercises, the first of November 2002; 34(1):32-40. (A)
PURANEN J. and ORAVA S., (1979) ‘ Athletes’ leg pain’, British Journal of Sports Medcine, Spetmber 1979; 13(3):p.92-97. (C)

Secondary resources:

Broos P., Sportletsels, Leuven/Apeldoorn: Garant, 1991. (p.22, 179-181).
Kjær M. et al, Sports Medicine; Basic science and clinical aspects of sports injury and physical activity, Oxford: Blackwell Publishing,2003. (p.530-535).
Peterson L. and Renström Per, Sports injuries: their prevention and treatment, 3th edition, London: Dunitz, 2001. (p.11,339-342).
Reid D.C. et al., Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo: Churchill Livingstone,1992. (p.269-280).
BECK B., (1998) ‘Tibial stress injuries: an aetiological review for the purposes of guiding management’, Sports Medicine, 1998, 26(4) 265-279.
BRUCKNER P. and KHAN K., ‘Clinical sports medicine’, 3th edition,North Ryde: McGraw-Hill, 2007(p.555-575).
Chasan N., shin-splints, (http://srcpt.blogspot.com/2009/02/shin-splints.html), 2 February 2009.
Sportsinjuryclininc, shin splints, (http://www.youtube.com/watch?v=jg79mQqiacM), online video, last accessed, 13 October 2007.
Widmark E., How to indentify, treat and prevent medial tibial stress syndrome, (http://www.fysionutrition.se/wp-content/uploads/How-to-treat-and-prevent-medial-tibial-stress-syndrome.pdf), 2009.

Clinical Bottom Line

A good knowledge of the anatomy is always important, but it’s also important you know the other disorders of the lower leg, which makes it easier to understand what’s going wrong. Also a detailed screening of known’s risk factors to recognize factor that could add to the cause of the condition and address these problems.

Recent Related Research (from Pubmed)


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