Medial tibial stress syndrome (MTSS) is a condition that causes pain on the inside of the shin (the front part of the leg between the knee and ankle). MTSS is commonly referred to as shin splits due to the location of pain over the shin bone. MTSS is one of the most common athletic injuries. It affects both the muscle on the inside of the shin and the bone to which it attaches. MTSS may affect up to 35% of athletes who run and jump, such as distance runners, sprinters, basketball or tennis players, or gymnasts. Military personnel, dancers, and other active people can also develop MTSS. A physical therapist can help you recover from MTSS and teach you exercises and tactics to prevent reinjury.
What is Shin Splints (Medial Tibial Stress Syndrome)?
Medial tibial stress syndrome develops when too much stress is placed on the tibia (main shin bone). The muscles that attach to the tibia can cause an overload of stress on the bone. These muscles include the posterior tibialis muscle, the soleus muscle, and the flexor digitorum longus muscle.
The most common risk factors of MTSS include:
- Flattening of the arch of the foot while standing (over-pronation)
- Being an athlete who participates in repetitive jumping and/or running
- Being female
- Excessive hip range of motion
- Smaller calf girth in males
- A high body mass index (>20.2)
How Does it Feel?
You may have MTSS if you feel pain in the middle or bottom third of the inside of the shin. The pain may be sharp when you touch the tender area, or occur as an ache during or after exercise. When MTSS is developing, the pain may be present during the beginning of exercise and less noticeable as exercise progresses. Over time the condition can worsen and pain may be felt throughout any exercise regimen, and it also may continue after exercise.
How Is It Diagnosed?
Your physical therapist will perform a thorough evaluation and take your health history. Your therapist will assess your overall strength, mobility, flexibility, and your walking and running movements. Your physical therapist will apply gentle pressure to the shin, ankle, and foot areas to diagnose MTSS. The most reliable symptom of MTSS is pain felt when pressure is applied to certain parts of the shin.
How Can a Physical Therapist Help?
Your physical therapist will determine what risk factors have caused your MTSS and will teach you how to address those causes. A treatment plan will be developed that is specific to you and what your body needs to recover and to prevent reinjury.
To relieve pain, your physical therapist may prescribe:
- Rest from the aggravating activity or exercise
- Icing the tender area for 5-10 minutes, 1-3 times a day
- Exercises to gently stretch the muscles around the shin
- Taping the arch of the foot or the affected leg muscles
- Hands-on massage of the injured tissue
To help strengthen weak muscles, your physical therapist may prescribe:
- Exercises that increase hip rotation, abduction (lifting the leg away from the other leg), and extension (lifting the leg behind your body) to decrease stress to the lower leg
- Exercises that increase your arch and shin muscle strength to decrease the overpronation (flattening out) of the arch of the foot
Your physical therapist may also prescribe:
- Calf and foot muscle stretches
- Single-leg exercises including squats, reaching exercises, or heel raises
- Modified take off and landing techniques for jumping athletes
- Modified leg and foot control during walking and running
- New footwear to provide better support when walking or exercising
Your physical therapist may also prescribe orthotics or shoe inserts that support the arch of the foot if your feet flatten out too much, or if your foot muscles are weak.
Can this Injury or Condition be Prevented?
Physical therapists recommend that to prevent MTSS you should:
- Get an annual functional fitness examination, including strength, flexibility, mobility, and sport-specific analyses
- Perform dynamic stretches before exercising and static stretches after exercise
- Perform strength and endurance exercises for the foot, hip, and pelvic muscles
- Perform balance exercises on each leg
- Follow a recommended training program when starting or progressing your exercise program
Your physical therapist can teach you all of these exercises to ensure maximum strength and health, and prevent MTSS.
Real Life Experiences
John is a 35-year-old recreational runner who is training for his third half-marathon. John begins to feel shin pain in both legs during the first mile of his runs, which goes away during the remaining miles. Over the next few days, the pain lasts longer during his run. Concerned that he might be injuring himself, John contacts his physical therapist.
John's physical therapist conducts a thorough examination to assess his pelvic, trunk, hip, leg, foot, and ankle strength. She asks him to try to hold test positions as she applies pressure to different areas. John can't hold his position when she applies pressure to the hip area. During further tests, John demonstrates excessive flattening of each of his feet, and his knees show weakness. John’s physical therapist applies pressure to the muscles surrounding the shins and reproduces pain over the muscles on the lower one-third of the inside of the shin on each leg. She diagnoses MTSS in both legs.
She prescribes massage for the painful area in both shins, and teaches John strengthening exercises for the hip and foot muscles. She shows him how to apply ice to the painful areas for 5-10 minutes, 1-3 times a day. She recommends that he modify his training program to run fewer overall miles, and prescribes a change in footwear for better support and cushioning.
Since John sought help when his symptoms began, after two weeks of treatment his pain is much less, and he is slowly rebuilding his training program back to its former level. He continues his prescribed exercise regimen and his physical therapy treatments. The following month, John competes pain free in the half-marathon, and is proud of his finishing time!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat MTSS. However, you may want to consider:
- A physical therapist who is experienced in treating people with MTSS, or who has experience treating patients who participate in your sport.
- A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you’re looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people who have MTSS.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of MTSS. The articles report recent research and give an overview of the standards of practice for treatment of it both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes: a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:12. Free Article.
Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome: a critical review. Sports Med. 2009;39(7):523-546. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Kari Brown Budde, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.