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Medial Tibial Stress Syndrome

Medial Tibial Stress Syndrome (MTSS) is a common injury suffered by runners and triathletes. Known to most athletes as ‘shin splints’, MTSS refers to pain along the medial (inside) aspect of the tibia.  It is typically either an inflammation of the lining of the bone or tendinopathy of the muscles inserting into the medial tibia (tibialis posterior, soleus and flexor digitorum longus).  While MTSS is very common and plagues numerous athletes, it is also often easily prevented.

As with many overuse injuries, MTSS results from the inability of muscles and tendons to continually support repetitive forces which may break down over time and/or transfer the load to the bone. Triathletes are particularly susceptible to the condition since both running and cycling are highly repetitive.  The same forces are being applied to the same tissue over and over, making a preventative approach especially important for these athletes.

MTSS is diagnosed when there is tenderness or an ache continuing several centimetres along the inside of the calf or shin bone that is worse following running. A smaller area of sharp or acute pain on the bone may indicate a local stress reaction or even a stress fracture. As always, athletes are best to seek advice from an experienced therapist for an accurate diagnosis and also help to facilitate a safe return to training as soon as possible.

Over the years of treating runners and triathletes, I have noticed a number of factors that appear to contribute to the development of MTSS:

• Quick changes in volume and or intensity of running
• Tight, weak and/or overactive calf muscles
• Running on hard surfaces, which increases maximum peak forces
• Excessive pronation (flat feet)
• Poor running technique; particularly over striding/low cadence form or a pronounced forefoot or toe running technique, which can include poor technique on hills
• Off camber surfaces
• Poor or inappropriate footwear
• Running when fatigued – thus reducing the muscle’s ability to absorb force, making any injury more likely

Treatment & Prevention of MTSS

A few basic rules to follow are:

• Increase mileage slowly and consistently, no quick changes!
• Avoid running on hard surfaces where at all possible – grass, trail and other softer surfaces greatly reduce impact forces of the lower limb
• Improve your run technique, especially:
  • Increase your cadence
  • Reduce any tension you carry in your feet – many people carry tension in the area unconsciously
  • Allow your feet to engage with the ground to use your natural shock absorber, which is the arch of your foot and plantar fascia
• Ice the area, particularly after running
• Dynamic calf stretches such as ‘curb marching’ and activation exercises before running (see video)
• Calf strengthening (see video)
• Wear footwear that are suited to you
• Massage or self-massage areas of muscular tightness but not where bone is painful
• Bike riders, make sure cleat position is suitable on bike, as this can add to loading
• During runs, take thirty seconds every five to ten minutes for a brief period of walking followed by some calf dynamic stretches.  This helps to reduce tension and maintain run form, especially when you are getting tired!

Most importantly, remember that MTSS is something that you don’t have to put up with.  By taking a consistent and proactive approach you will be able to do away with the dreaded shin splints once and for all!

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Last updated on March 2nd, 2021.