Shin Pain When Running

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Evidence‐Based Management of Medial Tibial Stress Syndrome in Runners

Kuwabara, A., Dyrek, P., Olson, E.M. and Kraus, E., 2021. Evidence-based management of medial tibial stress syndrome in runners. Current Physical Medicine and Rehabilitation Reports, pp.1-9.

In today’s letter

• How to diagnose & treat medial tibial stress syndrome (shin splints)

• 3 clinical tips

• A fun infographic for you to save and use in the future

• 3 resources to check out to further your knowledge about shin pain

• Meme of the week: Sometimes, we all just want to be a potato 😄 

• Rapid Results =

Medial Tibial Stress Syndrome (MTSS) is best managed with early intervention, biomechanical assessment, and a structured return-to-run program. Rather than just resting, physios should focus on correcting movement patterns, strengthening “weak” muscles, and gradually reloading the tibia to build long-term resilience.

• Professional takeaway =

Assess foot mechanics—excessive pronation and a navicular drop of more than 10 mm significantly increase MTSS risk. Consider orthotics or gait retraining to improve biomechanics and reduce tibial stress during running.

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Aim of the study

To summarise the latest research on the causes and treatment of MTSS

Did you know?

If you’ve worked with runners, you’ve definitely seen Medial Tibial Stress Syndrome (MTSS)—or as your patients probably call it, "shin splints." This pesky overuse injury causes diffused pain along the medial tibial border and sits on the spectrum of tibial bone stress injuries (BSIs), specifically classified as a Fredericson grade I BSI.

In other words, it’s the early warning sign that the tibia isn’t happy with the repetitive impact demands being placed on it.

Why Does MTSS Happen?

MTSS is the body’s way of telling us that something isn’t right. It’s most commonly seen in runners and other athletes that have repetitive, high-impact load. With 13–20% of all running-related musculoskeletal injuries linked to MTSS, it’s clear that this isn’t just an occasional issue—it’s a major problem in the athletic world.

The Science Behind Shin Splints – What’s Really Happening?

Despite how common Medial Tibial Stress Syndrome (MTSS) is, we still don’t fully understand why it happens. However, two main theories dominate the research: the traction theory and the tibial bending theory.

Let’s break them down.

1. Traction Theory

This theory suggests that repetitive stress from muscle attachments along the tibia causes MTSS.

• Tibialis posterior

• Flexor digitorum longus

• Soleus

Since these muscles originate along the medial tibia, it’s logical to think that their repeated pulling could irritate the periosteum.

However, cadaver studies have shown that these muscle origins sit higher than the most common pain site in MTSS, the distal third of the tibia. Instead, research suggests the deep crural fascia may contribute more (excessive fascial tension)

2. Tibial Bending Theory

The second theory focuses on bone stress and remodeling. According to Wolff’s Law, bones adapt to mechanical stress by reinforcing weak areas. The narrowest part of the tibia—the mid-to-distal third—is where MTSS pain is most common. Repetitive loading can cause “microdamage” in this area. Ideally, the bone repairs itself, but if stress outpaces healing, injury occurs.

One study even found microcracks in the tibia of athletes with chronic MTSS who underwent surgery, but no signs of normal bone remodeling—suggesting a possible defect in the repair process.

Clinical Presentation – What You’ll See in Patients

• Pain location: Diffuse pain along the posteromedial mid-to-distal tibia (at least 5 cm in length).

• Pain timing: Worse at the start of exercise, improving as activity continues or with rest.

• Main red flag: If pain persists or worsens with exercise, suspect a higher-grade bone stress injury or fracture.

The Risk Factors

What makes some athletes more prone than others? Research pinpoints several risk factors—some modifiable, some not—that contribute to MTSS.

Let’s break them down.

1. Sex Differences – Why Women Are at Higher Risk

Women tend to be more affected by MTSS, due to:

• Biomechanics: Shorter stride length and greater pelvic drop increase tibial stress.

• Muscle Attachments: The soleus muscle attaches to the tibia more extensively in women (72.5%) compared to men (33.3%).

• Female Athlete Triad/RED-S: Energy deficiency, menstrual irregularities, and low bone mineral density put female athletes at a significantly higher risk of bone stress injuries (BSIs), MTSS included.

2. BMI – Too High or Too Low, Both Are Risky

• High BMI → Increased mechanical load on the tibia, leading to stress.

• Low BMI → Reduced bone density (especially in the Female Athlete), making bones more vulnerable to stress fractures.

3. History of MTSS – The Best Predictor of Future Injury

If an athlete has had shin pain before, they’re at major risk for recurrence. Novice runners and those who ramp up training too quickly are also prime candidates for MTSS.

4. Biomechanics – How Movement Contributes

• Overpronation & Rearfoot Eversion: Excessive motion increases tibial stress.

• Weak Hip Abductors & “Tight” IT Bands: Altered running mechanics lead to compensations that overload the tibia.

• Foot Strike Pattern: Heel strikers are twice as likely to develop MTSS than forefoot runners.

5. Footwear – The Right Fit

• Traditional cushioned shoes encourage a rearfoot strike, increasing tibial loading.

• Minimalist shoes promote forefoot striking, but increase load dramatically. A very bad idea when just starting out

• Tip: Runners should replace shoes every 250–500 miles to maintain good support.

6. Other Contributing Factors

• Smoking: Delays tissue repair and increases MTSS risk when combined with poor biomechanics.

• Calcium & Vitamin D: Low intake weakens bones and heightens the risk of BSIs.

MTSS is a multifactorial condition, meaning no single risk factor is to blame.

Diagnosing MTSS – What to Look for & When to Dig Deeper

Medial Tibial Stress Syndrome (MTSS) is a clinical diagnosis—meaning that a good history and physical exam are usually all you need to identify it. But how can you be sure it's shin splints and not something more serious?

The Signs of MTSS

To diagnose MTSS with confidence, look for:

1. Exercise-induced pain along the distal two-thirds of the medial tibial border.

2. Tenderness spanning at least 5 cm along the posteromedial tibia.

3. Pain that improves with rest but flares with activity.

A study by Winters et al. found that these signs had near-perfect interrater reliability (k = 0.89, p < 0.000001), meaning that different clinicians could consistently agree on the diagnosis.

When to Investigate Further

If any of these red flags are present, consider a more serious bone stress injury (BSI):
🚩 Tenderness <5 cm → Could indicate a tibial stress fracture.
🚩 Pain at rest or while walking → Higher grade BSI must be ruled out.
🚩 Severe swelling or erythema → Consider other conditions like infection or compartment syndrome.

Exam Findings That Might Explain MTSS

Athletes with MTSS often present with underlying biomechanical issues, such as:

• Weak hip abductors and core stabilisers

• Excessive foot pronation (measured with the navicular drop test; >10 mm drop nearly doubles MTSS risk!)

• “Tight” iliotibial bands

• Leg length discrepancy

Do You Need Imaging?

For straightforward MTSS cases, imaging isn’t necessary. But if you suspect a stress fracture or more severe injury, you can think about the below:

• X-ray: Usually normal, but may show periosteal reactions.

• MRI (Best Choice!): Detects bone stress and periosteal edema, distinguishing MTSS (Grade 1 BSI) from more serious injuries.

• Bone Scan/CT/Ultrasound: Rarely needed—high false positives and low specificity.

Treating Medial Shin Pain

Medial Tibial Stress Syndrome can be a frustrating injury for athletes and a challenging one for clinicians. But fear not—effective management exists!

A mix of rest, rehab, and smart modifications.

Step 1: Address the Root Causes

Before treating MTSS, identify modifiable risk factors like:

• Low energy availability – What is the persons nutrition? Are they a newly transitioned vegan?

• Biomechanics – Excessive pronation, weak hip stabilisers, or poor running mechanics need attention.

• Bone health – If recurrent BSIs occur, assess bone mineral density and hormonal levels.

Step 2: Activity Modification

MTSS doesn’t heal overnight, so reducing load is priority #1.

• Full rest (4–6 weeks) is the gold standard until pain subsides.

• Reduce weekly mileage by 50% if complete rest isn't an option.

• Gradual return-to-run protocol is a must once symptoms improve.

Step 3: Medication – Use Sparingly!

💊 Avoid NSAIDs! They may impair bone healing.
💊 Paracetamol? Might not be much better—use sparingly.

Step 4: Rehab

Rehab is essential to improve muscle endurance and reduce bone strain.

• Neuromuscular training – Plyometrics, core work, and ankle strengthening reduce recurrence.

• Gait retraining – Tweaking step width, foot strike, and tibial rotation can lower MTSS risk.

Step 5: Bracing, Orthotics & Other Tools

• Shock-absorbing insoles can help prevent tibial stress.

• Arch supports? Possibly beneficial, especially for overpronators.

• Kinesiotape? Some evidence suggests it reduces medial loading.

Step 6: What About Shockwave Therapy?

Studies suggest Shockwave Therapy combined with a running program may cut recovery time by 30 days. It promotes healing by stimulating bone cell activity, reducing pain, and altering cellular pathways.

More research is needed, but early results are promising

Gradual Return To Running After MTSS

Phase 1: Rest & Recovery

Before running resumes, the athlete must be:

1. Pain-free in daily activities

2. Nontender to palpation along the tibia

3. Comfortable with low-impact exercise

During this phase, focus on:

• Strengthening of the hip, calf and lumbopelvic co-ordination to improve stability

• Mobility work to ensure good biomechanics

Phase 2: Cross-Training – Keep Moving Without Impact

Since MTSS is an overuse injury, athletes must maintain fitness without stressing the tibia. 

Great low-impact options include:
🏊 Swimming
🚴 Stationary cycling
🏃‍♂️ Deep water running
🏋️ Elliptical training
💪 Upper body ergometry

Phase 3: The Return-to-Run Plan

Once pain-free, a structured running program begins. 

• Start on soft, uniform surfaces (e.g., treadmill or track)

• Prioritise duration before intensity – increase weekly volume by ≤10%

• Monitor symptoms closely – pain means scaling back, not pushing through

Final Transition: Back to Sport-Specific Training

As tolerance improves, athletes can gradually increase speed, intensity, and sport-specific drills.

3 Clinical Tips

1. Palpation – Check the 5 cm Rule
   One of the main diagnostic clues for MTSS is tenderness along at least 5 cm of the posteromedial tibia. If the tenderness is more localised (less than 5 cm), consider a stress fracture instead.

   Additionally, if the athlete experiences pain outside of exercise (e.g., during walking or at rest) or presents with severe swelling or redness, further investigation is needed to rule out a bone stress injury (BSI) or other underlying conditions.

2. Fix the Foundations – Identify & Address Risk Factors
   MTSS often develops due to biomechanical imbalances. Look for excessive foot pronation, weak hip abductors or core, leg length discrepancy, or tight iliotibial bands. 

   Assessing foot mechanics using the Navicular Drop Test is helpful, as a drop of more than 10 mm significantly increases MTSS risk. 

   Additionally, nutritional screening is importnat—athletes with low energy availability are at higher risk of bone-related injuries. If you suspect poor dietary intake, referring the athlete to a sports dietitian can be beneficial.

3. Modify Activity, But Keep Moving
   While rest is essential, complete inactivity isn't always necessary. Cross-training with low-impact activities such as deep water running, cycling, or elliptical training can help maintain cardiovascular fitness while reducing tibial stress.

   Some studies suggest that reducing weekly running distance by 50% can improve symptoms.

Top 3 Resources to Check Out

And learn more about shin pain

1. MTSS Rehab guidelines (PDF - LINK 🦵

2. Rehab framework - Shin pain (Article) - LINK 💪

3. Short possible explanation of shin pain 🤓

Meme of The Week

When You’re Ready to Learn More

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1. Killer Articles —> Literally everything you need to know about a specific injury

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