Medial tibial stress syndrome
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Medial tibial stress syndrome (MTSS) – commonly known as ‘‘shin splints” – is a frequent overuse injury or repetitive-stress injury of the lower extremity.

The condition is one of the most common causes of exertional leg pain in athletes, and usually presents as diffuse pain of the lower extremity, along the middle-distal tibia associated with exertion. Early courses of MTSS are characterized by pain that (i) gets worse at the beginning of exercise, (ii) gradually subsides during training, and (iii) stops within minutes after exercise. Later, pain may present with less activity and may even occur at rest.

Diagnosis is based on the clinical features of the disease. Diagnostic imaging should be considered to rule out other causes of exertional leg pain, or to establish the diagnosis of MTSS when in doubt.

Training errors (“too much, too fast”) appear to be the most common factors involved in MTSS. The condition is most often found in runners, soccer and basketball players, and in dancers. Notably MTSS is almost always associated with biomechanical abnormalities of the lower extremity including knee abnormalities, tibial torsion, femoral anteversion, foot arch abnormalities or a leg-length discrepancy. However, improper footwear (including worn-out shoes) can also contribute to shin splints. A variety of tibial stress injuries can be involved in MTSS including tendinopathy, periostitis, and dysfunction of the tibialis posterior, tibialis anterior and soleus muscles. Women appear to be more affected than men, and have an approximately threefold risk for progression to stress fractures.

The treatment of MTTS should start with rest and ice in the acute phase, followed by low-impact and cross-training exercises during rehabilitation and a modified training program (decreased intensity, frequency, and duration, regular stretching and strengthening exercises, wearing proper-fitting shoes with good shock absorption). Orthotics, manual therapy, injections and acupuncture may also help to alleviate the symptoms. Patients not responding to conservative treatment for six months should then be subjected to radial shock wave therapy (RSWT). Surgery should also be considered for recalcitrant cases of MTSS.