Shin splints: a review of medial tibial stress syndrome.



Medial tibial stress syndrome (MTSS) is caused by a traction periostitis of the tibialis anterior. MTSS is typically due to a sudden increase in training volume, improper footwear, or over-pronation.

Predisposing factors include nutritional deficiency, female gender, obesity, and hyper pronation. Hyper pronation of the subtalar joint is one of the most common and well-document risk factors for MTSS (2).

Pathogenesis: unrepaired microdamage accumulates in the cortical tibia and there is usually an overlying periostitis. Patients are typically overly active which makes it difficult for the cortical damage to heal properly due to repetitive stress and muscle contraction.

Patients present with pain along the distal 2/3 of the medial tibia that is provoked by exercise and relieved with rest. The pain may be reproducible with palpation to the posteromedial tibial border. Swelling, neuropathy, and erythema are absent in this condition.

Tibial stress fractures can be difficult to distinguish from MTSS, radiographs may show the "dreaded black line" if a stress fracture is present. An MRI can help determine the severity of tibial stress fractures.



A female athlete that presents with amenorrhea and MTSS may be presenting with signs of the "female athlete triad". This triad involves an eating disorder, osteoporosis, and amenorrhea. Amenorrhea and MTSS may both be due to nutritional deficiency (eating disorder).

Treatment for MTSS is conservative and involves activity modification. The goal is to reduce repetitive and load-bearing exercises. In refractory cases, calcium and vitamin D supplementation may be utilized along with gait retraining.

Preventing the development of a tibial stress fracture is imperative, but the main concern in most cases of MTSS is the loss of productivity and functionality, especially among athletes and military recruits.

Conclusion:
MTTS (shin splints) are extremely common and can typically be diagnosed by history and physical. Imaging may be necessary if there is concern for a tibial stress fracture. Treatment is conservative and involves activity modification in most cases.

References:
1: https://www.ncbi.nlm.nih.gov/books/NBK538479/
2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848339/

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