Medial Tibial Stress Syndrome: A Novel Approach?

Medial tibial stress syndrome (MTSS - commonly known as shin splints) is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes and other active individuals. Studies suggest that the incidence of MTSS among physically active soldiers is 7.9%, while among athletes it varies between 4% and 35%^{(1, 2)}. Although often not serious, it can be quite disabling, and progress to more serious complications if not treated properly. To further complicate matters, the rate of relapse in MTSS is high.

Causes of MTSS

The precipitating factors leading to MTSS are thought to be multi-factorial, involving training errors and various biomechanical abnormalities (these factors are discussed at length by Alicia Filley here). Many believe the main cause of MTSS involves underlying periostitis of the tibia due to tibial strain when under load. However, the associated lower leg anatomy makes this unlikely (see Figure 1). Also, other evidence indicates it is likely that a whole spectrum of tibial stress injuries are involved in MTSS, including tendinopathy, periostitis, periosteal remodeling, and stress reaction of the tibia^(3-6).

Dysfunction of the tibialis posterior, tibialis anterior, and soleus muscles are also commonly implicated^{(5, 6)}. These various tibial stress injuries appear to be caused by alterations in tibial loading, as chronic, repetitive loads cause abnormal strain, bending of and micro-damage to the tibia. In other words, while MTSS is sometimes composed of different etiologies, MTSS and tibial stress fractures may be considered on a continuum of bone–stress reactions. One thing that is unarguable is that over the last few decades, comparatively few advances have been made in the treatment of MTSS. Current treatment options are mostly based on expert opinion and clinical experience rather than peer-reviewed comparative studies⁽⁷⁾.