Shin Splints or Medial Tibial Stress Syndrome (MTSS)

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Published: December 30, 2013
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Last reviewed: September 4, 2017

What are shin splints: definition and medical term

A lay term shin splints usually refers to pain along the inner (medial) side of the shins during and after running.

A medical term for shin splints is medial tibial stress syndrome (MTSS).

Causes

  • Sudden increase in training activity
  • Heel striking with forefoot slapping, especially when running downhill

Treatment

Rest, icing, compression sleeves, elevation.

Prevention

No method, including muscle stretches, has been scientifically proven effective so far 34.

Anatomy of the Lower Leg

The shin is the front part of the lower leg between the knee and the ankle.

The shinbone, with a Latin name tibia, is the large, weight-bearing bone in the lower leg.

The soleus muscle–the muscle in the calf, which, together with gastrocnemius forms triceps surae–is most commonly mentioned muscle involved in the mechanism of shin splints 8,59.

Types

There are 2 types of shin splints:

  • Posteromedial or posterior shin splints or medial tibial stress syndrome (MTSS) — pain in the inner (medial) side of the shins 9
  • Anterolateral or anterior shin splints or anterior exertional compartment syndrome — pain and numbness in the upper outer shin just below the knee extending for 2-3 inches (5-8 centimeters) longitudinally; pain, numbness and weakness in the foot (foot drop) 8,9,33

Medial Tibial Stress Syndrome (MTSS)

Medial tibial stress syndrome is an exercise-induced injury of the shin area with pain along the inner (medial) edge of the shinbone (tibia) 3,25.

Shin-Splints-Medial-Tibial-Stress-Syndrome-MTSS-Image

Picture 1. Shin splints on the inner side of the right shin (red area)

Synonyms

  • Medial shin splints
  • Tibial pain syndrome
  • Tibial bone stress reaction
  • Tibial fasciitis
  • Soleus syndrome 38
  • Soleus enthesopathy
  • Tibial traction periostitis

Pathophysiology of MTSS

Acute MTSS is probably caused by a bone stress injury resulting in periostalgia (periosteal pain), which is not the same as periostitis (inflammation of the periosteum) 25. A likely underlying mechanism of MTSS is a mismatch between the bone resorption and formation resulting in the overload of the shinbone during running 61,62.

Muscles most likely involved in MTSS 56,63:

A) Plantar flexors, which move forefoot downwards:

  • Soleus muscle (origin: the upper back side of the tibia; insertion: back side of the heel [calcaneus]; function: plantar [downward] flexion of the foot) 38,43
  • Flexor digitorum longus (origin: the middle medial side of the tibia; insertion: the bottom side of the toes 2-5; function: plantar flexion of the toes 2-5) 1
  • and, maybe, tibialis posterior muscle (origin: the upper medial side of the tibia, interosseous membrane; insertion: the bottom side of the foot; function: plantar flexion and inversion [supination] of the foot) 69

B) Dorsiflexors, which move forefoot upwards and control slapping of the forefoot:

  • Tibialis anterior (origin: the outer side of upper 2/3 of the tibia, interosseous membrane; insertion: the inner side of the foot; function: foot dorsiflexion and inversion) 67
  • Extensor digitorum longus (origin: the upper outer side of the tibia, upper 3/4 of the front side of fibula; interosseous margin; insertion: digits 2-5; function: foot dorsiflexion) 55

Other possible but yet unproven mechanisms involved in shin splints:

  • Traction of the soleus fascia by overworked and therefore tight soleus muscle 33,38
  • Traction of the tibial fascia (deep fascia in the front of the lower leg) by the soleus muscle, flexor digitorum longus and tibialis posterior muscle, and subsequent traction of the fascia to the lower tibia at the site of the shin pain 3,15,48,56,63,68
  • Bending of the tibia 56
  • Injury of the periosteum beneath the origin of the posterior tibial muscle resulting in periosteum inflammation (traction periostitis) 38,48,61,62
  • Injury of the tendon of the tibialis posterior muscle (tendinopathy) or its inflammation (tendinitis) 3,15
  • Muscle adhesions (abnormal formation of bands of connective tissue within the muscle)

Symptoms and Signs

Symptoms of shin splints include 3,4,15:

  • Dull, sharp, burning or throbbing pain in the medial (inner) side of the lower two-thirds of one or both shins shortly after the onset of the exercise, which decreases with the exercise and subsides with rest (in 15 minutes of exercise cessation) 3,8,10
  • Pain, which tends to be worse in the morning and can become severe enough to cause limping 11
  • Tenderness over the inner side of the shin muscles where they are attached  to the shinbone; not tenderness over the shinbone itself
  • Mild swelling (edema) along the shinbone (sometimes)

Chronic pain can develop gradually after repeated exercise and can persist during rest 3,4.

Symptoms NOT typical for shin splints: pain limited to an inch of the shin, bruising, numbness and tingling, leg weakness, swollen or painful ankles or knees.

Causes and Risk Factors

1. Types of Activity

  • Jumping: long and high jumpers, basketball, volleyball players, gymnasts, training with a jumping rope
  • Running: cross-country, marathon and triathlon runners, sprinters, soccer, football, tennis and other racket sports players, field hockey athletes
  • Dancing: ballet and aerobic dancers 40
  • Long-distance walking: soldiers, hikers 41, marching band musicians, brisk walking
  • Other: weight lifting, bodybuilding, mountain biking

Road cycling and swimming less likely cause shin splints, since there is no heel striking.

2. Training Factors

  • Recent increase in exercise intensity or duration, running more than 20 miles per week
  • Running on hard (concrete) or uneven surfaces, running downhill or uphill
  • Heel striking with forefeet slapping
  • Slow gait velocity 64
  • Cycling: dropping the heels too far, pulling too much
  • References: 3,13

3. Athlete’s Characteristics

  • Beginner (<5 years of training) 25
  • Young (children, adolescents, young adults) 48
  • Overweight 25,41
  • Female (female: male ratio = up to 3 : 1) 41,50; osteoporosis, amenorrhea and eating disorders 26
  • Weakness of the leg, gluteal and hip muscles 50,59, increased plantar (downward) flexion of the foot 61
  • Increased hip rotation 25,62
  • Large calf girth 25,62
  • Gait abnormalities due to anatomical anomalies:
    • The knees: knock knee (genu valgus); bowed legs (genu varus)
    • Tibial torsion
    • Leg-length discrepancy
    • Foot deformities (NOT proven to cause shin splints) 41:
      • Rearfoot varus deformity (overpronation) 62 resulting in an excessive load on the inner foot edge
      • Flat feet (pes planus)
      • High arch (pes cavus)
      • Decreased upward bending (dorsiflexion) of the foot 12
  • Injuries of the spine or sacroiliac joint
  • History of orthotics use or stress fracture 25
  • Calcium deficiency, low bone mineral density, hormonal imbalances 50
  • References: 3,13

4. Running Shoes

Shoes that do not absorb shock well or are worn out or wet increase the risk of shin splints.

Diagnosis

A doctor can usually make a diagnosis of medial tibial stress syndrome solely from the injury history and physical examination.

Physical Examination

Tenderness is present behind the medial (inner) ridge of the shinbone (at the site of muscle fascia attachment, but not over the shinbone itself), starting at 1.5 inches (2 cm) above the inner ankle and extending upwards for 2-5 inches (5-12 cm) 33,48,,59,62.

Pain in the shin can be triggered by downward or upward movement of the foot against pressure (resisted plantar flexion or dorsiflexion) or by inward flexion of the ankle (supination) 48.

Physical examination alone, including the hop test (jumping on one leg), is NOT a reliable test to distinguish between shin splints and stress fracture, for which imaging investigations are required:

X-Ray

In acute MTSS, X-ray does not show any changes; in chronic MTSS, thickened periosteum (periosteal reaction) over the lower 2/3 of the tibia may be observed 3,6,59.

A tibial stress fracture may not be detectable in the first 2-3 weeks by an X-ray; later it can appear as a dreaded black line 3,51.

Bone Scan (Scintigraphy)

A bone scan involves an injection of the radioactive substance into the arm vein and scanning the leg with the gamma camera.

  • MTSS appears as diffusely increased longitudinal uptake of the radioactive substance along the tibia only in the third phase of the scan 3,4,5,41.
  • A tibial stress fracture appears as an intense focally increased uptake in the first phase 41.

Magnetic Resonance Imaging (MRI)

MRI can most accurately reveal tibial stress syndrome and related changes in the shin: soft tissue injuries, periosteal edema, bone marrow edema, bone resorption cavities, striation; it can also reveal stress fractures 4,5. The extent of the injury in MTSS is described with grades 1-4 (Table 1).

Table 1

Table 1. (source: PubMedCentral, Creative Commons license)

Computed Tomography (CT)

Computer tomography is less accurate in diagnosing MTSS or stress fractures than MRI or scintigraphy 5.

Differential Diagnosis of the Exercise-Induced Pain in the Lower Leg

Table 2. Exercise Related Shin Pain
CONDITION SYMPTOMS and SIGNS TEST TO CONFIRM DIAGNOSIS
Medial tibial stress syndrome (MTSS) or posteromedial or true shin splints 3,15 Pain along the inner side of the lower 2/3 of the shin, above the inner ankle, decreases with running, relieved by rest within 15 minutes; normal pulses at ankles Physical examination
Anterolateral shin splints 9 Pain along the outer (lateral) side of the shins when the heel hits the ground; relieved by rest Physical examination
Osgood-Schlatters disease (inflammation of the patellar tendon; in adolescent athletes) 45 Pain in the upper 1/3 of the shin in the front, just below the kneecap; triggered by exercise, relieved by rest Physical examination
Tibial stress fracture (an incomplete crack; may follow MTSS)11,13,15,17,41 Sharp, sudden, localized pain that can be pinpointed by a finger in the middle of the shinbone or below the knee during exercise; pain at rest, possibly at night, aggravates with exercise, tenderness and edema only at the point of fracture X-ray: often negative in the first 2-3 weeks; bone scan positive within 2 days; MRI
Acute exertional compartment syndrome 15 Severe pain on outer side of shins that increases with running, obvious swelling, numbness or tingling in shins and foot, foot slapping; ceases within 30 minutes of exercise cessation Compartment pressure testing, MRI
Chronic anterior exertional compartment syndrome 18,23 Pain, fullness, tightness, cramps and numbness in the outer side of the shin and upper side of the foot, usually bilaterally, within 15-30 minutes of onset of exercise at a predictable time and worsening with exercise; pain goes away within 15 minutes of exercise cessation; reduced pulse at the front of the ankle, muscle knots and hernias; no pain at rest Compartment pressure testing, MRI
Tibialis anterior tendinopathy or tendonitis (microtears in the muscle tendon) 19 Pain and swelling in the front of the ankle, caused by running or excessive tightening of shoelaces; aggravated by standing or walking (in middle-aged or older individuals) MRI
Tibialis anterior muscle strain (pull) 27 Sudden, focal pain and swelling during running; pain aggravated by a muscle stretch MRI
Tear of tibialis anterior muscle 22 Extreme pain in the front of the shin (for example, after hard hitting the ball with the foot), foot drop, foot slapping during walking Ultrasound, surgery
Tenosynovitis (inflammation of the tendon sheaths) 24 Pain in front or around the inner or outer ankle; aggravated by walking Ultrasound
Subperiosteal hematoma (direct blow) Tender bump, bluish/yellowish skin discoloration of the skin Physical examination, X-ray
Peroneal nerve entrapment on the lateral side of the knee at the fibular head 16 Burning pain, tingling or numbness on the lateral part of the lower leg and top of the foot, worse by walking and squatting; foot drop Neurological examination, EMG
Lumbar spinal stenosis (congenital, or due to osteoarthritis in >50 yo) 28,29 Pain in the lower back, buttocks and thighs, pain, numbness and weakness in the thigh, calf and foot (on inner, outer or both sides of legs, often bilaterally) aggravated by standing or walking, relieved by bending forward, squatting, sitting or lying down; normal ankle pulses X-ray, myelogram, CT, MRI

Other (Non-Exercise Related) Causes of Shin Pain

  • Erythema nodosum (painful red lumps in shins, fever, after respiratory infection, in pregnancy) 57
  • Herniated disc in the lumbar spine
  • Fibromyalgia (fatigue, tender points in the shins and all over the body)
  • Osteomyelitis (bone infection; severe pain, fever)
  • Cellulitis (skin infection; painful, red swelling) 58
  • Paget’s disease of the bone 65
  • Sickle-cell anemia (inherited, paleness, bone pains) 58
  • Hyperparathyroidism (muscle fatigue, bone pains) 58
  • Ganglion cyst (in the bone or muscle)
  • Benign bone tumor or cancer 65
  • Sarcoidosis (fatigue, enlarged lymph nodes, persistent cough, rash over the shins) 66
  • Rickets (bone deformities in children) 58
  • Neurosyphilis or tabes dorsalis (unsteady gait, muscle weakness, mental illness) 65

Causes of Exercise-Induced Pain in the CALF

  • Strenuous exercise resulting in sore muscles due to lactic acid accumulation after strenuous exercise
  • Dehydration and mineral deficiencies: hypokalemia (potassium deficiency), hyponatremia, hypocalcemia, hypomagnesemia 54
  • Popliteal artery entrapment — pain in the back of the calf in young male athletes 31
  • Achilles tendonitis — pain 2-3 inches above the heel 21
  • Posterior compartment syndrome
  • Tennis leg — partial rupture of the gastrocnemius muscle
  • Effort-induced venous thrombosis (blood clotting) — pain, redness and swelling in the calf
  • Peripheral artery disease (atherosclerosis in older smokers and diabetics) — pain in one or both calves after walking short distance and relieved by stopping walking for few minutes (intermittent claudication) 28
  • Complex regional pain syndrome (CRPS, reflex sympathetic dystrophy, causalgia) caused by a limb injury — burning pain triggered by a light touch, changes in skin appearance, hair and nail growth 48,52
  • Drugs: simvastatin (a cholesterol-lowering drug) — calf cramps 39.

FOOT Problems Associated With Shin Splints

Athletes with foot overpronation often suffer from plantar fasciitis with pain and tightness on the bottom of the feet during walking.

Treatment

Which doctor to see for shin splints?

  • An orthopedic or sports medicine doctor or chiropractor can perform physical examination and order investigations.
  • A sports physiotherapist can perform massage and teach you exercises.
  • A podiatrist can assess your foot and lower leg biomechanics.

Management of ACUTE Shin Splints

STOP RUNNING IMMEDIATELY after you feel pain in the shins.

RICE protocol for 48-72 hours 3,11,14:

  • Rest from any activity that causes pain for 2-6 weeks; use crutches when walking triggers pain. According to one study, rest was the only effective treatment 62.
  • Ice packs wrapped in cloth (not directly to the skin) over the painful area for 15-20 minutes after the exercise and then every 2 hours during the day. Ice helps to reduce inflammation. DO NOT massage with ice.
  • Compression (neoprene) sleeve(s): this is to prevent traction of the muscles on the shinbone25,48,62
  • Elevation: lift the leg to the hip level while sitting and above heart level while sleeping

No HARM protocol: No heat, alcohol, running (or other exercises) or massage of the shin area, because they increase blood flow and inflammation 11.

Massage of the calf muscles with a foam roll or a tennis or golf ball 3 times for 15-60 seconds on both legs 37.

Analgesics, such as acetaminophen, ibuprofen, naproxen sodium, aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) for 2 weeks 48

Physical Rehabilitation – Insufficient Evidence of Effectiveness

Possibly effective treatments but without sufficient evidence include iontophoresis, phonophoresis, ultrasound therapy, periosteal pecking (medical acupuncture, dry needling), extracorporeal shockwave therapy (ESWT), icing, cold compression therapy (continuous cold wrap), manual therapy (osteopathy) 2,3.

Not proven effective treatments include stretching and strengthening exercises, sports compression socks, circumferential straps, taping, immobilization (lower leg braces, walking cast, pneumatic leg brace), low energy laser treatment, pulsed electromagnetic fields, whirlpool baths, augmented soft tissue mobilization, electrical stimulation, unweighted ambulation, injections: steroids, autologous blood, platelet-rich plasma, prolotherapy (injection of substances that promote cell growth) 2,3,61.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and phenylbutazone did not speed up the healing of MTSS in one study (NSAIDs can reduce pain, though) 61.

Casting or pneumatic braces are recommended only for severe MTSS or stress fractures 3.

Surgery

Surgical release of the deep posterior compartment (soleus sling, posterior fasciotomy, removal of posteromedial tibial periosteum) can cure chronic MTSS in some but not all athletes; complications include hematoma, numbness and stress fracture 3,61.

Healing or Recovery Time

A recovery time for shin splints is time after which an athlete does not feel any shin pain during regular sports activity; it may range from 2 weeks to 3 months or more. In some athletes, shin splints recur after any amount of rest — in this case, the only cure may be giving up the training forever. Some doctors recommend returning to sports activities gradually – by increasing exercise intensity by 10-25% every 3-6 weeks 61.

Long-Term Complications

Acute compartment syndrome with extreme pain and swelling of the lower leg in which the blood supply to the muscles in the lower lateral leg is shut down requires an urgent surgical release of the lower leg, called fasciotomy 8.

Tibial stress fracture needs 6-8 weeks of rehabilitation 8.

Prevention

Shoes, Insoles, Inserts, Arch Supports

According to recent reviews of studies, using custom-made biomechanical insoles (shock-absorbing insoles or inserts, foam or gel heel pads) may help prevent shin splints 3,7,60. General recommendations 3,46:

  • Shoes should have at least a finger wide space in front of your longest toe, and the heel should not move within the shoe during running.
  • Shoes should be light with low rounded heels and soles you can bend with your feet.
  • Change the shoes if they are wet.
  • Change shoes every 250-500 miles.

There is NO EVIDENCE of the effectiveness of the following measures in the prevention of shin splints 60:

  • Gradual increase in training in novice runners
  • Adjusting training regime
  • Stretching and strengthening exercises 30
  • Massage using foam roll or tennis ball
  • Wearing running shoes based on the foot shape
  • Taping
  • Barefoot running (using minimalistic shoes) 10,61

Frequently Asked Questions

1. Do calf stretching and strengthening exercises help prevent shin splints?

There is no scientific evidence about the effectiveness of muscle stretches in preventing shin splints 59. Still, many athletes and coaches believe they help. Do not do any exercise as long you experience shin pain during walking or running 23.

Exercises to strengthen the muscles that move the foot toward the shin (dorsiflexors: tibialis anterior, extensor digitorum longus):

  • Bucket-handle exercise 53
    • Sit on a table and place the bucket handle over the front of a shoe. Slowly raise the front of the foot and then slowly lower it. Repeat 3 x 10 times. To increase resistance, add some water to the bucket–but the exercise should not trigger pain.
  • Tie elastic band over the leg of the drawer, sit in front of it, wrap it around the forefoot and pull as much as you can; repeat 10 times with each leg 50.
  • Toe raises 53
    • Rise on toes and lower slowly; repeat 3 x 10 times.
  • Outward rolls 53
    • Stand up and roll the ankles out, so the inner edge of the foot raises; slowly lower the sole back. Repeat 3 x 10 times.
  • Heel step downs 59
    • Stand upright and make one moderate step forward. When the heel touches the ground, slowly lower the forefoot but not fully to the ground, then raise it and step back. Repeat 3 x 15 times with each leg.
  • Heel walking
    • Walk on heels for 20 meters 37,59
  • Heel jumping for 20 meters (only on soft surfaces) 59
  • Skipping with landing on midfoot for 20 meters 59

Exercises to strengthen muscles that move the foot down (plantar flexors: soleus, gastrocnemius, tibialis posterior):

  • Toe raises 72
  • Toe walking for 20 meters 37
  • Toe jumping for 20 meters 59

Exercises to strengthen foot muscles

  • Towel scrunches 37
    • With the heel on the floor, grab the towel with the toes and move it toward you and then push it away; repeat 10 times 37.

2.What are the best walking or running shoes (sneakers)?

To date, no shoes are scientifically proven to prevent shin splints. Cushioned shock-absorbing shoes may help a bit.

Athletes with normal feet arches may benefit from stability shoes with semi-curved last.

Athletes with pes planus (flat feet), lateral ankle instability (floppy ankle after ankle strain) or varus ankle (overpronated feet with shoes worn at the inner edge) may benefit from motion control shoes with straight lasted (symmetrical) shoes with arch supports, medial heel wedge and medial post beneath forefoot that prevent overpronation 48.

Athletes with high foot arches and rigid “clunk feet” or valgus ankle (underpronation = supination = shoes worn at the outer edge) may benefit from cushioned shoes with curved or semi-curved last, a full slip last (no board inside) and heel cup 44,48. Cushioned shoes reduce tibial loading.

3. What are recommended running techniques?

Not yet proven by scientific trials to prevent shin splints, but often recommended:

Pose tech running includes wearing non-cushioned sneakers to avoid heel striking, leaning forward–so gravitation makes you running–landing on the forefeet, focus on pulling from the ground; at least 180 steps per minute (3 strikes/sec), bent knees in all running phases 47.

Chi running bases on tai chi martial arts and is very much like pose running.

Barefoot running includes wearing minimalistic or zero drop shoes, which supposedly strengthen the foot muscles. If you intend to switch to barefoot running, do this very gradually; otherwise, you may seriously injure your feet and legs. Again, not proven to prevent shin splints.

4. Can massage help?

In individuals with chronic exertional anterior compartment syndrome, massage of the front and back lower leg muscles can improve the upward flexion of the foot, but it may not reduce the pressure in the calf muscles 42. There is no evidence of the effectiveness of massage in the treatment of MTSS, though.

5. Kinesiology Tape Wrapping (Athletic, Kt or Rock Tape), ACE Bandage

Kinesiology tape bandages wrapped around the ankle can prevent overpronation in high jumping with spiked boots 35, walking and jogging 36.

There seems to be a lack of studies of the actual effect of the taping on shin splints.

Circumferential straps did not prevent tension to medial tibial crest 56.

6. Can calf support with compression socks or sleeves or calf guards help?

Many runners claim compressive sleeves helped them prevent shin splints but, so far, there is no scientific evidence to support this 30. According to one study, neoprene compression sleeves or semi-rigid orthotics can help, though 62.

7. Can walking alone without exercising cause shin splints?

Brisk walking, especially downhill, in someone who is not used to walk briskly can cause temporary pain in the shins lasting from 15 minutes to few days.

8. Are there any remedies and supplements available?

Remedies including over the counter (OTC) painkillers and ice packs can help relieve pain, but do not speed the recovery.

Some people recommend calcium, vitamin D, the amino acid taurine, “essential oils,” or other supplements to prevent shin splints but there is no scientific proof of their effectiveness 17.

Painkillers and ice packs may help relieve the pain but not prevent it from recurring within 24 hours.

9. Can I keep running with shin splints?

Do NOT try to run through shin splints. If you have chronic (recurring) shin splints, you will not likely get rid of them if you do not take a rest from all activities that trigger pain in the shins. Running with shin splints may lead to stress fracture.

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