1. Medial Tibial Stress Syndrome (Shin Splints)

2. 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

3. 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

4. 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

5. 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

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

7. 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)

8. 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

9. Further Investigation
X- ray
Bone Scans
MRI

10. 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)

11. 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

12. Plan B
Extracorporeal shockwave therapy
Surgery rarely indicated

13. 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):
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):
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):