There probably is no single cause of MTSS. A variety of factors may contribute to its development, including the running surface; the level of the athlete's conditioning; an increase in activity level; footwear; and abnormal biomechanics, which may include hyperpronation and heel rather than forefoot running.
Clinical features. The primary presenting symptom of MTSS is pain localized to the medial border of the distal third of the tibia. As in other overuse injuries, the pain initially is mild, develops toward the end of exercise, and is relieved with rest. If the athlete continues to exercise, the pain increases in intensity and begins to occur earlier or may occur with walking or at rest.
On physical examination, a diffuse area of tenderness often is found along the medial border of the distal tibia and along the medial gutter.7 Pain may be elicited with dorsiflexion or plantar flexion of the foot against resistance. In more severe cases, mild induration and swelling over the involved area may be noticed; in some chronic cases, thickening or nodularity may be palpated.5,6 The results of neurovasculature assessment are normal.
A diagnosis of MTSS usually is made with a thorough history and physical examination. However, imaging studies are ordered if the diagnosis is unclear and the clinician wants to rule out occult fracture, stress fracture, or bone tumor. Most patients with MTSS have normal radiographic findings.
Triple-phase bone scanning (TPBS) is highly sensitive in detecting bone stress lesions; this study often is the next to be ordered. TPBS usually shows superficial periosteal hyperconcentration or patchy areas of increased uptake along the medial border of the tibia.7,9
MRI may be used in evaluation of shin pain; it is similar to TPBS in its sensitivity and specificity.10 This alternative offers the benefits of having no radiation and providing additional evaluation of soft tissue structures. Therefore, although MRI is not required, it probably is the study of choice to make the diagnosis.
Treatment. Management of MTSS includes the same principles that are involved in management of other overuse injuries. Relative rest eliminates the inciting activity, allowing the inflamed muscle-tendon units or periosteum to heal; the patient also may engage in cross training (eg, bicycling, swimming, and pool running) to maintain fitness. The required duration of rest varies with the severity of the injury; it may be as short as a few days or as long as a few weeks.
During the acute phase, NSAIDs and anti-inflammatory modalities (eg, ice massage and iontophoresis) may help reduce inflammation and pain. Iontophoresis is a therapeutic means of introducing a topically applied corticosteroid, such as dexamethasone, into deeper soft tissue structures via a small electric current. A neoprene sleeve worn on the lower leg also may provide pain relief.
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- Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55-81.
- Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95-101.
- Brukner P, Khan K, Bradshaw C. Shin pain. In: Brukner P, Khan K, eds. Clinical Sports Medicine. 2nd ed. Sydney, Australia: McGraw-Hill; 2001:508-523.
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- Abramowitz AJ, Schepsis A, McArthur C. The medial tibial syndrome: the role of surgery. Orthop Rev. 1994;23:875-881.
- Brukner P. Exercise-related lower leg pain: bone. Med Sci Sports Exerc. 2000;32 (3 suppl):S15-S26.
- Michael RH, Holder LE. The soleus syndrome: a cause of medial tibial stress (shin splints). Am J Sports Med. 1985;13:87-94.
- Shikare S, Samsi AB, Tilve GH. Bone imaging in sports medicine. J Postgrad Med. 1997;43: 71-72.
- Batt ME, Ugalde V, Anderson MW, Shelton DK. A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc. 1998;30:1564-1571.
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- Roebuck JD, Finger DR, Irvin TL. Evaluation of suspected stress fractures. Orthopedics. 2001;24:771-773.
- Boam WD, Miser WF, Yuill SC, et al. Comparison of ultrasound examination with bone scintiscan in the diagnosis of stress fractures. J Am Board Fam Pract. 1996;9:414-417.
- Romani WA, Perrin DH, Dussault RG, et al. Identification of tibial stress fractures using therapeutic continuous ultrasound. J Orthop Sports Phys Ther. 2000;30:444-452.
- Wheeler P, Batt ME. Do non-steroidal antiinflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med. 2005;39:65-69.
- Batt ME, Kemp S, Kerslake R. Delayed union stress fractures of the anterior tibia: conservative management. Br J Sports Med. 2001;35:74-77.
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- Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35-40