'Shin splints' - Medial tibial stress syndrome (MTSS)

Medial tibial stress syndrome (MTSS), commonly called ‘shin splints’, constitutes great number of overuse injuries seen in endurance sports, especially those involving long – distance running. It is one of the most common causes of exercise-induced leg pain. The post will cover current concepts in regards to the causes, history, risk factors, diagnosis and treatment of the MTSS.
It is most probably primarily due to bony overload of the posteromedial tibial border. There is little evidence to support the commonly cited repeated traction-induced periostitis as the primary underlying aetiological factor.MTSS is characterized by exercise-related pain on the posteromedial side of the mid- to distal tibia. Initially symptoms are present on starting activity and subside with continued exercise, but later on pain continues to be present during activity. If symptoms worsen, then the pain can be felt even after the activity ceases.
During physical examination, pain is present on palpation of the distal two-thirds of the posteromedial tibial border. Mild swelling of the tibia can sometimes be present. The differential diagnosis includes true tibial stress fracture, chronic exertional compartment syndrome, and to a lesser extent popliteal artery entrapment and nerve entrapment.
Imaging may include x-ray (typically normal, seldom callus formation), MRI (periosteal oedema and bone marrow oedema can be seen) and CT (osteopenic changes, cortical osteopenia).
Risk factors include excessive foot pronation and female sex (level I) as well as increased internal and external hip ranges of motion, higher BMI, previous history of MTSS and leaner calf girth (level II). Risk factors such as increased running intensity, running distance, change in terrain, change of shoes and running with old shoes are often mentioned but no evidence exists to support.
Treatment includes activity modification, stretching, icing, NSAIDs, massage, acupuncture and attention to biomechanical factors that might be correctable with insoles, orthotics, or antagonistic muscle strengthening. Nevertheless, at present there is no evidence that any treatment is superior to rest alone. There is level I evidence that shock absorbing insoles may help in the prevention of MTSS.