Medial Tibial Stress Syndrome

It is a common belief that, as athletes and physically active individuals, we are made more susceptible to injuries, specifically those due to overuse. And while at times this may be an accurate reflection, the underlying reason may not be due to the nature of the sport itself, but rather how it is performed. Despite this, it is true – many overuse injuries may be more prevalent in sporting populations. However, with correct management and early intervention, these injuries can be avoided, or their severity and duration may well be reduced.

Have you ever been stopped short during your morning run, unable to keep going because of the pain in your shin, made worse each time your foot strikes the ground? Or would firmly running your hand up the middle of your shin be enough to send you jumping off your seat?

10% rule: To help avoid shin splints, progressive overload suggests that increases in training volume should not exceed 10% of the current volume.

Medial Tibial Stress Syndrome (MTSS), commonly known as ‘Shin Splints’ is an overuse injury affecting the muscles and bone in the lower leg. Due to repetitive impact, the tibia (shin bone) and surrounding musculature undergo various stress reactions. These stress reactions are a normal response to activity, and the body recovers to make these structures more resilient for future stressors. However, with MTSS the degree of stress reactions caused outweigh the ability and/or the capacity for a full recovery to occur. MTSS is best categorised by a dull, diffuse pain along the middle of the tibia (shin bone) – this pain is made worse with weight bearing and high impact activity. Often pain may be more notable in the cool down and after each training session, and this is an important warning sign to take note of. As the injury progresses, increased levels of pain may be felt throughout the workout itself. Many intrinsic and extrinsic factors can be attributable to MTSS, and having an appropriate awareness of these factors can be useful for prevention and treatment of the injury.

As athletes, training makes up a major part of our lives, but often-common errors in training can make us more susceptible to overuse injuries such as MTSS. The early signs of MTSS should not be ignored, as this is the body’s way of telling us that the stress/load placed upon it, is too much for it to withstand. Many athletes who are highly driven by their training don’t like to hear the word ‘de-load’. However, for the prevention and management of MTSS, making appropriate alterations to training plans is imperative to ensure the injury is short lived.

MTSS is best categorised by a dull, diffuse pain along the middle of the tibia (shin bone). 

Upon the onset of acute symptoms of MTSS, a decrease of running volume should be made – this does not necessarily mean that training must stop. High training loads are still possible without having to run kilometres on end. As triathlete’s we can reap the benefits of training in other disciplines, both of which are ideal in this scenario due to their non-weightbearing nature. This means decreased running times can be compensated for, by increased hours on the bike or in the pool.

Running is a sport with repetitive high impact, and this needs to be considered when both, designing and executing training plans. Training principles such as ‘progressive overload’ can be applied to ensure increases in training volume are done so, in realistic and manageable increments. Progressive overload suggests that increases in training volume should not exceed 10% of the current volume. This gives a simple guideline to follow when designing training plans to ensure that loads placed upon the body are not exceeding its capabilities from which it can recover from. In conjunction with this, running surfaces should also be a consideration when training. Soft surface running e.g. on grass should form part of training. This is often easy to incorporate into speed/fartlek sessions.

Certain biomechanical factors may also contribute to the likelihood of MTSS. With running, each foot strike produces ground reaction forces, which the body needs to overcome. When assessing running technique and kinematics, this remains one of the main risk factors when considering MTSS. Safe and efficient biomechanics and kinematics are integral to ensure running loads are absorbed harmlessly with less stress placed on structures such as bone and muscle. If we can ascertain running techniques that allow us to reduce the ground reaction forces produced, and absorb these forces in an effective manner, the likelihood of MTSS may, therefore, be reduced. Having said that, to say we should all run the same way and adopt the same movement patterns is unrealistic, and may bring about more harm than good. And although this ‘one size fits all’ approach is not encouraged, some common biomechanical elements, such as differences in hip range of motion, changes in pelvic position and pelvic tilt, and muscle imbalances, may predispose someone to produce greater running forces, thus increasing their likelihood of developing injuries such as MTSS. Video running analysis is a way in which we can slow the speed of running gaits and thoroughly assess any inefficient movement patterns. It can be an effective tool for early identification and intervention.

With running, overstriding remains a common error – this is when the foot contacts the ground at a distance too far from the body. Overstriding implies that the runner’s leg is in full extension when foot strike occurs. Not only does this produce great force due to the lower limb still in its acceleration phase, but also creates an inefficient way of absorbing this increased load. So, how do we deem what is an appropriate distance? And should this be the same for everyone? Rather than measuring the distance from the body to the foot, it is more effective to look at the runner’s knee flexion angle – that is, how much the knee is bent when the foot is striking the ground. Having an increased knee flexion angle will mean that foot strike occurs closer to the body, and during its deceleration phase, therefore producing less ground reaction force. A common and effective cue to decrease stride length and increase knee flexion is to increase running cadence, meaning more steps are made per minute.

Extrinsic factors such as footwear can also affect running loads. Footwear remains a contentious issue among runners, many believing that more material in their shoe means more foot support. I stand on the side that says, highly supportive shoes take away from the natural movement of the foot, and if our foot needs support, why not strengthen the bodily structures that give this support rather than relying on external support?

Typically, the modern shoe is made with an enlarged heel wedge, which makes this an ultra-comfortable striking point when running. Now, I’m not going to get into the debate about rear foot vs. forefoot striking, however, for an excessive heel strike to occur the runner’s leg needs to be in full extension. Having already discussed the implications of overstriding with full leg extension, we should be aware of the implications of this when running. Therefore, in contrast, shoes with a smaller heel wedge may encourage foot strike to occur at a close distance to the body, meaning more knee flexion is seen at this point. Now, everybody has his or her preference of running shoes, myself included. However, when opting for a running shoe, I would advise shopping for those that wouldn’t encourage excessive foot strike and don’t limit the foot’s natural movement. If transitioning between running shoes, it is best to transition gradually, as changes in footwear types may alter running mechanics and loading.

Overstriding remains a common error – this is when the foot contacts the ground at a distance too far from the body.

With acute onset of MTSS, recovery becomes more important than ever. We are consistently told, with good reason, the importance of allowing adequate recovery time, but this tends to be an area, which some athletes oversee. In the acute injury phase, recovery should consist of relative rest (from running), ice and cryotherapy, to allow the opportunity for healing to occur. As the injury starts to improve recovery should progress accordingly. Stretching and strengthening, particularly of the calf, should be incorporated. Developing adequate central strength and stability should also be a consideration of this phase of rehab, this means exercises targeted toward hips and core.

Proprioception is also a highly important factor for controlled and safe running impact. Proprioceptive training should be executed, and if non-weight bearing in nature can be implemented throughout the entire course of rehab.

After discussing recovery and rehab methodologies, it is most important to remember that best injury care is injury prevention. Giving regular attention to strengthening susceptible structures can not only enhance performance but also decrease the likelihood of injuries, including MTSS, from occurring. Having early screening, such as running video analysis, may help in the early identification of predisposing factors to injury.    


Galbraith, M. R., & Lavallee, M. E. (2009). Medial tibial stress syndrome: conservative treatment options. Current Reviews In Musculoskeletal Medicine, 127-133.



Zac Turner

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