Medial Tibial Stress Syndrome (Shin Splints)

Normal Anatomy Bone is constantly remodelling Remodelling is based on the force and load placed through the bone Remodelling occurs quickly in cancellous bone Remodelling occurs slowly in cortical bone The tibia has a slight bow Soleus, Tibialis posterior and flexor hallucis longus all attach onto the tibia

Pathology Overuse injury resulting in stress reaction of the tibia and surrounding musculature Periostitis of the tibia most commonly in acute phases Develops into bone remodelling MTSS can be considered on the bone stress continuum with stress fractures

Mechanism of Injury Insidious Soft Tissue Traction Tibial Bowing Change in training, change in environment of activity or changes in footwear all alter the stress through the tibia Typically runners Soft Tissue Traction Soleus, flexor halluces longus and potentially tibialis posterior tension increases, causing strain on tibial fascia and periosteum Tibial Bowing Calf muscles cause repeated bending or bowing of the tibia at its narrowest point Causes a stress reaction and periosteal reaction

Mechanism of Injury Insidious Soft Tissue Traction Tibial Bowing Change in training, change in environment of activity or changes in footwear all alter the stress through the tibia Typically runners Soft Tissue Traction Soleus, flexor halluces longus and potentially tibialis posterior tension increases, causing strain on tibial fascia and periosteum Tibial Bowing Calf muscles cause repeated bending or bowing of the tibia at its narrowest point Causes a stress reaction and periosteal reaction

Classification Grade 1 Grades 2 -3 Grade 4 Periosteal edema Progressive periosteal and bone marrow edema Grade 4 Cortical stress fracture

Subjective Examination Vague diffuse pain along the posteromedial border of the middle distal tibia with exertion Pain worse at the beginning of exercise and then subsides As injury progresses pain can be present throughout activity or even rest Reports a change in Training methods (load, intensity, pace, mileage, routine) Training environment (terrain) Training equipment (shoes)

Objective Examination Pain on hopping Tenderness on palpation of the medial ridge of the tibia (tibialis posterior and soleus muscle origins) Nil neurological signs Increased pronation of the subtalar joint Kinetic chain abnormalities (tibial torsion, femoral anteversion, leg-length discrepancy, knee varus/valgUS) Tightness triceps surae Weakness lower limb and proximal control Abnormal gait – forefoot running Uneven wearing on shoes

Further Investigation X- ray Bone Scans MRI

Management Multimodal Focus on controlling the load and stress that goes through the tibia Decrease running distance/time Increase recovery time Change running style Change running footwear Change biomechanics (orthotics, increasing ROM, increasing Strength)

Conservative Reduce pain and inflammation Massage Ice NSAID’s Orthotics Appropriate loading Reduce stride length Restore Normal Range of Movement Ankle, Knee and Foot Soft tissue massage Foam rolling Stretching Dry needling Joint mobilisations Joint manipulations Restore Normal Muscle Activation Tibialis Anterior Flexor Hallucis Longus Plantarflexors Invertors Hip External Rotators and abductors Restore Dynamic Stability Proprioceptive work Return to sport/activity specific exercise Gait re-education Gradually increasing running time/distance Reduce stride length

Plan B Extracorporeal shockwave therapy Surgery rarely indicated

References Franklyn, M. and B. Oakes (2015). "Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments." World J Orthop 6(8): 577-589. Galbraith, R. M. and M. E. Lavallee (2009). "Medial Tibial Stress Syndrome: Conservative Treatment Options." Curr Rev Musculoskelet Med 2. Hamstra-Wright, K. L., K. C. Huxel Bliven and C. Bay (2014). "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. Reshef, N. and D. R. Guelich (2012). "Medial tibial stress syndrome." Clin Sports Med 31(2): 273-290. Winters, M., M. Eskes, A. Weir, M. H. Moen, F. J. Backx and E. W. Bakker (2013). "Treatment of medial tibial stress syndrome: a systematic review." Sports Med 43(12): 1315-1333.