Medial Tibial Stress Syndrome (MTSS)
Medial tibial stress syndrome (MTSS), commonly known as “shin splints,” is a common injury of the lower limb and one of the most common causes of exertional leg pain in athletes.
It is defined as exercise induced pain along the posteromedial tibial border and being diffuse/linear (greater than 5cm along the inside of the bone), that is caused by repetitive loading stress during running and jumping.
The most likely cause of MTSS is the chronic inflammation of the muscular attachment along the posteromedial tibia and bony changes, including periostitis or local bone stress reaction. The muscular attachments most often implicated include the Tibialis Posterior, Soleus and Flexor Digitorum Longus.
The risk factors of MTSS are multi-factorial and can include:
· Training errors - especially when overloading (too much too soon)
· Sudden changes in the training program, such as an increase in distance, intensity and/or duration.
· Training on hard or uneven surfaces, especially in combination with improper running shoes (i.e. a poor shock absorbing capacity)
· Running more than 30km/week
· History of previous lower extremity injury/ MTSS – which can change the anatomical alignment through the foot and alter loading patterns through the leg.
· Biomechanical abnormalities, such as hyper-pronation (flattening) of the foot, unequal leg length, flat feet.
· Female gender, due to nutritional, hormonal and biomechanical differences.
· Fewer years of running experience.
· Weakness through the muscles of the lower leg
· Overweight or increased BMI
The symptoms of MTSS present as a vague, dull pain along the lower two third of the posteromedial tibial border. The pain is normally diffuse over a 5cm length of the bone and is often bilateral (affects both sides).
The most common complication of MTSS is stress fractures to the medial tibial border, which presents as a constant aching with extreme tenderness along the tibia, it is important to differentiate between the two conditions, as the management is quite different.
In the early stages of MTSS, you generally feel pain at the beginning of exercise as you warm up, this will often disappear during the main part of the exercise session, only to return once you have cooled down. As MTSS progresses, the pain will remain during exercise and can be present for days after.
During examination, a mild swelling in the painful area may be present as well as tenderness on palpation along the medial tibial border. The front of the tibia, however, is usually nontender, except in cases of stress fracture.
Chiropractic and physiotherapy intervention can conservatively manage your MTSS. A standard treatment plan would involve:
· 2-6 weeks of rest from the aggravating activity, depending on the severity of the symptoms.
· Stretching and eccentric strengthening exercise program for the calf, hip and core after the pain has reduced.
· Ultrasound therapy to assist with swelling and collagen realignment.
· Dry needling and soft tissue therapy to reduce muscle tightness around the lower limb and correct muscle imbalances.
· Pelvis and lower limb re-alignment to address any biomechanical dysfunctions
· If indicated, foot orthotics or exercises, to help restore foot and lower limb alignment.
· Once the pain has subsided and biomechanical abnormalities have been addressed then a progressive (not excessive) return to training can be commenced.
Individuals with MTSS are highly susceptible to re-injury because of its multi-factorial cause. A few tips to minimise the risk include:
· Avoid hills and uneven surfaces during the initial stages of returning to training.
· Use correct footwear during all exercises, and change running shoes every 800-1000km as shoes lose shock absorbing capacity at this distance.
· Maintain flexibility and strength through the pelvis and lower limbs.
· On return to training after a break, follow the progressive, not excessive, overload principle. Begin at 50% of your peak load and don’t increase your training load by more than 10% per week – giving yourself a good 6-week period to acclimatize to training load.
· If you do suffer from recurrent bouts of MTSS, then have a foot posture assessment done to assess if you need an insert in your shoe to allow permanent correction.
So that’s an overview of how MTSS occurs. If you have any questions or comments please e-mail us at firstname.lastname@example.org and we will be happy to answer them for you.
If you suffer with pain through the bottom of the shin, especially before or after exercise, feel free to call us on (08) 9486 8653 and our therapists will be happy to chat with you about the best management plan.