Shin Splints aka Medial Tibial Stress Syndrome
One of the most common injuries we see in the clinic at FTSPodiatry around this time of the year is Medial Tibial Stress Syndrome (MTSS), commonly referred to as “Shin Splints”.
MTSS is the cause of up to 60% of overuse injuries associated with running, and can quickly bring a halt to those new year fitness resolutions or pre-season training ambitions (17).
A study conducted at La Trobe University found that over a ten week running program a huge 35% of military recruits developed the condition, with females at more than twice the risk (19).
What is it?
MTSS presents as a dull, diffuse ache along the lower two thirds of the inside of shin, and is often described as feeling like a bruise when palpated (15). The pain comes and goes, and initially can deceive the runner by all of a sudden being relieved after warming up or “running it off” (1).
Failing to recognise the condition and continuing to run is the worst thing you can do, with the insidious nature of the symptoms increasing over time to eventually cause pain when walking or even at rest, which further delays recovery time (1).
Swelling, redness and warmth may also be present along the inner shin margin, and a similar condition can affect the outer margin as well.
“Shin Splints” is often used as an umbrella term to include other conditions that occur around the same area, such as compartment syndrome and tibial stress fractures.
It is important that an accurate diagnosis is made for your shin pain so that an appropriate rehabilitation plan can be developed specific to your individual needs.
What causes it?
There are often a combination of factors that contribute to the development of MTSS, and there are currently two primary working theories as to the cause of the pain itself;
1. The periosteal traction mechanism refers to how the medial and deep leg muscles that originate along the border of the tibia (flexor digitorum longus and soleus) become overloaded which causes irritation and inflammation of the lining of the bone (14).
2. The cortical stress theory explains how inadequate shock absorption capability of the lower limb leads to micro-fracturing of the bone itself (15).
This occurs in response to repetitive stress when our osteoblasts (the enzymes that build bone) are unable to keep up with the activity of osteoclasts (the enzymes that break down bone). This weakens the tibia by up to 15% (19).
It is unclear as to whether the periosteal traction mechanism leads to the cortical stress theory or vice versa, but both have been found to be present together in many cases of MTSS (8).
Biomechanics is the field of science that studies how internal & external forces act upon the musculoskeletal system, and the resultant effects of these forces.
A number of biomechanical factors have been identified as risk factors for MTSS in a number of studies, and are discussed below;
Pronation (inward rolling of the ankles or collapsing of the arch) is an important protective mechanism as it enables the foot to absorb and control shock up into the lower limb as we run. Pathologically excessive or inadequate amounts of pronation however have commonly been associated with MTSS development(3). A collapse of the medial arch and associated structures has been found to be significant predictor of MTSS (2,10).
Muscular & Movement Imbalances
The tibialis posterior (TP), flexor digitorum longus (FDL) and soleus (SOL) muscles are overloaded when there is reduced flexibility at the ankle and big toe joint (3).
Reduced big toe joint flexibility leads to inefficient propulsion mechanics, which overloads these muscles in close traction with the medial tibial border as they attempt to support the arch (3).
Ankle joint flexibility is also essential for shock absorption and to enable the leg to move over the foot (18). When restricted, the required amount of movement must be found elsewhere via excessive pronation and compensatory gait patterns (18). This further irritates the lining of the bone at the attachment of these muscles and reduces shock absorption potential during high impact gait.
Decreased Range of Motion
Greater ankle plantarflexion (toes pointing down) range of motion has also been identified as a risk factor for MTSS (10). This may be due to the increased likelihood of runners landing on their forefoot (in a plantarflexed position) which increases strain on the calf muscle complex as it is already in a pre-shortened position, losing its elastic capacity to absorb and produce force (10).
Females generally have a decreased stride length compared to men, which in theory increases stress up into the shins as they take more steps per distance covered (19). A more recent cadaveric study out of Japan found that women also had a significantly larger percentage of the FDL and SOL muscle attachment to the medial shin border as opposed to men, increasing the likelihood of irritation in this area (7).
Too much too soon as far as intensity and duration of running, as well as the surfaces run on can increase the risk of MTSS. Although current research isn’t extensive enough on the effectiveness of graduated return to run programs in preventing MTSS, we recommend them as they should allow enough time for the bones’ remodelling process to adapt to increasing amounts of stress.
Running on hard, non-compliant surfaces such as concrete or treadmills has been shown to increase the eccentric (muscle lengthening) activity and pre-activation of the medial shin muscles in an attempt to absorb shock, leading to quicker fatigue of these muscles (19).
Softer training surfaces such as grass are recommended to avoid repetitive stress related injuries.
What you wear on your feet when you run plays a major role in the prevention of lower limb injuries, as your runners now become to first point of contact with the ground with each step.
No two pairs of feet are the same, so not every shoe will be suitable for everyone. It is important to assess the shoe’s level of midfoot and rearfoot support, as well as levels of shock absorption and compare them to your individual foot type and biomechanics (don’t be fooled by the shoe store’s sales pitch, consult a podiatrist first).
Heel drop and forefoot design are also important features to consider that are often overlooked. Old, worn out runners that are easily compressed through the midsole are often compromised in their support levels, while you would be amazed at how many people we see who are wearing runners that are either too small or too big for them!
How Can We Help?
MTSS doesn’t usually require imaging to diagnose, and the most reliable methods of MRI and Bone Scan are often expensive. We will conduct a comprehensive biomechanical assessment of your movement patterns, force distribution, skeletal alignment, strength, balance and posture utilising some of the most advanced analysis technologies available in Australia to come to an accurate diagnosis. This combined with our clinical expertise will enable us to construct a thorough rehabilitation plan to reach your treatment goals and get you back to running pain free!
Our Podiatrists are able to perform a range of soft tissue & joint mobilisation techniques that aim to improve the functioning of the body’s musculoskeletal structures, including; muscles, tendons, fascia & joints. Manual therapies can assist the treatment process by decreasing the protective state the body is functioning in and allow the body to respond more effectively to the prescribed exercises &/or orthotic therapy.
Our Podiatrists are highly trained in the use of dry needling therapies for the treatment/management of many acute & chronic lower extremity conditions.
Sterile, thin-filament acupuncture needles are used to treat myofascial trigger points (TrPs) and help restore normal muscle function.
TrPs are commonly referred to as ‘muscle knots’, and are a very common cause of acute and chronic musculoskeletal pain.
TrPs often occur as a result of neuromuscular/motor dysfunctions and in areas of increased musculoskeletal stress. Neuromuscular dysfunctions can present as; muscle weakness, muscular rigidity/’tightness’ & generalised muscle pain. As a result of these dysfunctions TrPs can be a contributing factor to movement & muscular imbalances.
In a systematic review of over 26 000 participants, strengthening alone has shown to be 50% superior to stretching alone in preventing lower limb overuse injuries .
For example, calf stretching has proven ineffective in preventing MTSS on numerous occasions , whereas decreased ankle plantarflexor endurance strength is commonly seen in MTSS patients! .
The TP muscle is the largest controller of pronation throughout the stance phase of gait as it lengthens eccentrically, and it is well known that eccentric muscle and tendon strength is important to enable higher impact loads to be tolerated (11). Increasing TP eccentric strength is therefore important in preventing MTSS. Strength and endurance of the intrinsic muscles of the foot that stabilise the arches are also important to prevent pathological midfoot pronation, as increases in midfoot bone drop occur when these muscles are under fatigue (10). A good Podiatrist also assesses the hip and gluteal muscles for imbalances that may have an effect all the way down the kinetic chain.
A kinesiology taping technique for MTSS has shown to slow pronation throughout the stance phase of gait, decreasing the rate of medial plantar loading and therefore stress up into the leg in MTSS patients(9). This may help with pain levels initially or in preventing symptom recurrence during a return to run program.
At FTSPodiatry we also regularly use kinesiology tape to assess the suitability of orthotic therapy.
Custom foot orthoses can be used to reduce pathological levels of pronation or to more evenly redistribute plantar pressure in a high arched foot type. Pre-fabricated orthoses have recently been shown to significantly reduce the incidence of MTSS by 27% in an 11 week study of over 300 naval recruits (5). This is a breakthrough study as the effectiveness of orthoses for MTSS prevention has been tested many times before with varying degrees of success (6).
Here at FTSPodiatry we pride ourselves on our cutting edge biomechanical assessment & orthotic prescription services and aim to deliver results that far exceed industry standards.
To book your appointment with the Mid North Coast’s only dedicated Sports & Biomechanical Podiatry clinic click here.
1. Alfayez, S. M., Ahmed, M. L., & Alomar, A. Z. (2017). A review article of medial tibial stress syndrome. Journal of Musculoskeletal Surgery and Research, 1(1), 2-5. http://doi.org/10.4103/jmsr_13_17
2. Bandholm, T., Boysen, L., Haugaard, S., Zebis, M. K., & Bencke, J. (2008). Foot medial longitudinal-arch deformation during quiet standing and gait in subjects with medial tibial stress syndrome. Journal of Foot and Ankle Surgery, 47(2), 89-95. http://doi.org/10.1053/j.jfas.2007.10.015
3. Bartosik, K. E., Sitler, M., Hillstrom, H. J., Palamarchuk, H., Huxel, K., & Kim, E. (2010). Anatomical and biomechanical assessments of medial tibial stress syndrome. Journal of the American Podiatric Medical Association, 100(2), 121-132. http://doi.org/10.7547/1000121
4. Bennett, J. E., Reinking, M. F., Pluemer, B., Pentel, A., Seaton, M., & Killian, C. (2001). Factors contributing to the development of medial tibial stress syndrome in high school runners. Journal of Orthopaedic and Sports Physical Therapy, 31(9), 504-510. http://doi.org/10.2519/jospt.2001.31.9.504
5. Bonanno, D. R., Murley, G. S., Munteanu, S. E., Landorf, K. B., & Menz, H. B. (2017). Effectiveness of foot orthoses for the prevention of lower limb overuse injuries in naval recruits: a randomised controlled trial. British Journal of Sports Medicine, 52(5), 298-302
6. Craig, D. I. (2008). Medial tibial stress syndrome: evidence-based prevention. Journal of Athletic Training, 43(3), 316-318. http://doi.org/10.4085/1062-6050-43.3.316
7. Edama, M., Onishi, H., Kubo, M., Takabayashi, Yokoyama, E., Inai, T., … Kageyama, I. (2017). Gender differences of muscle and crural fascia origins in relation to the occurrence of medial tibial stress syndrome. Scandinavian Journal of Medicine and Science in Sports, 27(2), 203-208. http://doi.org/10.1111/sms.12639
8. Franklyn, M., & Oakes, B. (2015). Aetiology and mechanisms of injury in medial tibial stress syndrome: current and future developments. World Journal of Orthopedics, 6(8), 577-589. http://doi.org/10.5312/wjo.v6.i8.577
9. Griebert, M. C., Needle, A. R., McConnell, J., & Kaminski, T. W. (2016). Lower-leg kinesio tape reduces rate of loading in participants with medial tibial stress syndrome. Physical Therapy in Sport, 18, 62-67. http://doi.org/10.1016/j.ptsp.2014.01.001
10. Hamstra-Wright, K. L., Bliven, K. C., Bay, C. (2015). Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. British Journal of Sports Medicine, 49(6), 362-369. http://doi.org/10.1136/bjsports-2014-093462
11. Kulig, K., Lederhaus, E. S., Reischl, S., Arya, S., & Bashford, G. (2009). Effect of eccentric exercise program for early tibialis posterior tendinopathy. Foot & Ankle International, 30(9), 877-885. http://doi.org/10.3113/FAI.2009.0877
12. Lauersen, J. B., Bertelsen, D. M., & Anderson, L. B. (2014). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48(11), 871-877. http://doi.org/10.1136/bjsports-2013-092538
13. Madeley, L. T., Munteanu, S. E., & Bonanno, D. R. (2007). Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: a case-control study. Journal of Science & Medicine in Sport, 10(6), 356-362. http://doi.org/10.1016/j.jsams.2006.12.115
14. Noh, B., Masunari, A., Akiyama, K., Fukano, M., Fukubayashi, T., & Miyakawa, S. (2015). Structural deformation of longitudinal arches during running in soccer players with medial tibial stress syndrome. European Journal of Sport Science, 15(2), 173-181. http://doi.org/10.1080/17461391.2014.932848
15. Rathleff, M. S., Samani, A., Olesen, C. G., Kersting, U. G., & Madeleine, P. (2011). Inverse relationship between the complexity of midfoot kinematics and muscle activation in patients with medial tibial stress syndrome. Journal of Electromyography and Kinesiology, 21(4), 638-633. http://doi.org/10.1016/j.jelekin.2011.03.001
16. Rathleff, M. S., Kelly, L. A., Christensen, F. B., Simonsen, O. H., Kaalund, S., & Laessoe, U. (2012). Dynamic midfoot kinematics in subjects with medial tibial stress syndrome. Journal of the American Podiatric Medical Association, 102(3), 205-212. http://doi.org/10.7547/1020205
17. Sharma, J., Golby, J., Greeves, J., & Spears, I. R. (2011). Biomechanical and lifestyle risk factors for medial tibial stress syndrome in army recruits: A prospective study. Gait and Posture, 33(3), 361-365. http://doi.org/10.1016/j.gaitpost.2010.12.002
18. Tweed, J. L., Campbell, J. A., & Avil, S. J. (2008). Biomechanical risk factors in the development of medial tibial stress syndrome in distance runners. Journal of the American Podiatric Medical Association, 98(6), 436-444. http://doi.org/10.7547/0980436
19. Yates, B., & White, S. (2004). The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. American Journal of Sports Medicine, 32(3), 772-780. http://doi.org/10.1177/0095399703258776
Written by Jackson Tisdell (BPod) – February 2018
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