Shin Splints (Medial Tibial Stress Syndrome)

Also known as: Medial tibial stress syndrome, MTSS (medial tibial stress syndrome), Shin splints, Tibial periostitis, Medial shin splints, Posteromedial tibial pain syndrome, Tibial stress syndrome

Last updated: December 18, 2024

Shin splints, also called medial tibial stress syndrome (MTSS), is exercise-related pain along the inner, posteromedial edge of the tibia from repetitive loading, often linked to traction on the bone lining from nearby muscles during running or jumping. Pain is usually diffuse over several centimeters in the lower two-thirds of the shin, can worsen with activity and ease with rest early on, and is often broadly tender to touch. Symptoms often improve when tibial loading is reduced and reconditioning is gradual.

Key Facts

•Shin splints, also termed medial tibial stress syndrome (MTSS), describes exercise-related pain along the posteromedial border of the tibia that occurs with repetitive loading
•Diffuse pain along the inner (medial) shin that span several centimeters and localizes to the distal two-thirds of the tibia
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

Shin splints, also termed medial tibial stress syndrome (MTSS), typically describes exercise-related pain along the posteromedial border of the tibia that can occur with repetitive loading. The condition may reflect a spectrum of tibial bone stress and periosteal irritation, often associated with traction from adjacent musculature and fascia during running or jumping activities. Symptoms generally develop gradually with training changes and can overlap clinically with tibial stress fracture and chronic exertional compartment syndrome. MTSS often represents an overuse injury in which tissue capacity may be exceeded by training volume, intensity, or biomechanical factors.

Affected Anatomy

This condition affects several structures in and around the joint:

•Posteromedial border of the tibial diaphysis (medial tibial cortex)
•Tibial periosteum along the distal-to-mid tibial shaft
•Cortical bone of the tibia (bone stress response region)
•Soleus muscle (origin and fascial connections adjacent to the tibia)
•Tibialis posterior muscle and tendon (deep posterior compartment structures with traction forces)
•Flexor digitorum longus muscle (deep posterior compartment attachment region)
•Deep crural fascia and fascial septa of the lower leg
•Neurovascular structures of the deep posterior compartment (regional structures considered during differential diagnosis)

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Diffuse pain along the inner (medial) shin that may span several centimeters and typically localizes to the distal two-thirds of the tibia
•Pain that often worsens with running, jumping, or prolonged walking and can ease with rest early in the course
•Tenderness to palpation along the posteromedial tibial border that may feel broad rather than pinpoint
•Aching or burning discomfort that can begin at the onset of activity and may intensify as activity continues
•Mild localized swelling or a sense of tightness along the medial shin that can accompany activity
•Pain that may persist after exercise and can occur at rest in more advanced presentations
•Altered gait mechanics (limping or reduced push-off) that may occur due to discomfort
•Symptoms that can be bilateral, particularly in runners with training-load changes or biomechanical contributors

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Repetitive tibial loading that may exceed bone remodeling capacity, producing a tibial stress response along the medial cortex
•Traction-related irritation of the tibial periosteum that can occur from repetitive pull of the soleus and deep posterior compartment musculature
•Training errors such as rapid increases in mileage, intensity, hill work, or plyometrics that can raise cumulative impact forces
•Biomechanical contributors such as overpronation or altered foot/ankle mechanics that may increase medial tibial strain during stance phase
•Running on hard, uneven, or cambered surfaces that can concentrate stress along the medial tibia
•Footwear factors (worn shoes or inadequate shock attenuation) that may increase impact transmission to the tibia

Risk Factors

•Recent increase in training volume, frequency, or intensity, which can raise cumulative tibial load
•Participation in running, jumping, or military-style training with repetitive impact and limited recovery time
•History of prior MTSS or other lower-extremity overuse injuries, which can indicate reduced tissue tolerance
•Foot biomechanics such as excessive pronation or reduced arch support needs, which may increase medial tibial stress
•Reduced calf and ankle flexibility or strength imbalances that can alter load distribution across the tibia
•Higher body mass or rapid weight changes that can increase ground-reaction forces during impact activities
•Training on hard surfaces or frequent downhill running, which can increase eccentric loading demands
•Potential low energy availability or nutritional factors that may be associated with impaired bone stress adaptation in some athletes

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical history focusing on training changes, activity-related pain pattern, surface/footwear factors, and symptom progression to help distinguish MTSS from stress fracture or compartment syndromes
•Physical examination including inspection for swelling, palpation for diffuse posteromedial tibial tenderness, and assessment of ankle/foot range of motion and calf flexibility
•Functional assessment such as gait evaluation and single-leg hop or heel-raise tolerance, which can help characterize load sensitivity and identify biomechanical contributors
•Evaluation for focal point tenderness and pain with percussion or hopping, which can raise concern for tibial stress fracture when symptoms are more localized
•Imaging when indicated by severity, persistence, or diagnostic uncertainty; plain radiographs may be used to evaluate for fracture or other bony pathology, although early stress injury can appear normal
•MRI, which can often characterize tibial bone stress injury and periosteal edema and can help differentiate MTSS from stress fracture along a continuum of bone stress
•Consideration of alternative diagnoses such as chronic exertional compartment syndrome or vascular/nerve conditions; compartment pressure testing or vascular studies may be used in selected cases based on clinical features

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Relative rest and activity modification, which can reduce repetitive tibial loading while maintaining general conditioning through lower-impact cross-training when tolerated
•Gradual return-to-activity programming that typically emphasizes progressive loading, monitoring of symptom response, and avoidance of abrupt training spikes
•Gait retraining and running-form adjustments, which may reduce tibial loading in some individuals depending on mechanics and training context
•Footwear review and possible orthotics or arch-support interventions, which can help address excessive pronation or shock attenuation needs in selected patients
•Surface and training-environment modifications, such as reducing hard-surface running or cambered routes, which may lower repetitive medial tibial stress
•Evaluation and management of contributing health factors (for example, low energy availability or bone health concerns) when clinical history suggests increased bone stress risk

Physical Therapy and Exercise

•Ice or other symptom-modulating modalities that may help with short-term discomfort after activity
•Physical therapy approaches that can include calf/ankle flexibility work, strengthening of the calf and intrinsic foot musculature, and proximal hip/core strengthening to address kinetic-chain contributors

Medications

•Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for symptom relief in some cases, although use can be individualized and may be discussed with a clinician given potential risks and the bone-stress context

Surgery

•Surgical intervention is generally uncommon for MTSS; specialist referral may be considered when symptoms are persistent, diagnosis is uncertain, or alternative conditions such as stress fracture or compartment syndrome are suspected

Prognosis and Recovery

The course of this condition varies between individuals:

•Symptoms often improve with load reduction and gradual reconditioning, particularly when training errors and biomechanical contributors are addressed
•Recovery time can vary and may span weeks to months depending on symptom duration, severity, and ongoing exposure to impact loading
•Recurrence can occur if rapid training progression resumes or if contributing factors such as footwear, surface, or biomechanics remain unaddressed
•Persistent or worsening pain, especially when focal or present at rest, can indicate a higher-grade bone stress injury and may require further evaluation
•Long-term outcomes are generally favorable when the condition is recognized early and managed with progressive load tolerance strategies

Physical Therapy (Physiotherapy)(Procedure)
Stress Fracture (Overuse Fracture)(Condition)
Iliotibial Band Syndrome (IT Band Syndrome)(Condition)

Frequently Asked Questions

Common symptoms include: Diffuse pain along the inner (medial) shin that may span several centimeters and typically localizes to the distal two-thirds of the tibia; Pain that often worsens with running, jumping, or prolonged walking and can ease with rest early in the course; Tenderness to palpation along the posteromedial tibial border that may feel broad rather than pinpoint; Aching or burning discomfort that can begin at the onset of activity and may intensify as activity continues; Mild localized swelling or a sense of tightness along the medial shin that can accompany activity.

Diagnosis typically involves: Clinical history focusing on training changes, activity-related pain pattern, surface/footwear factors, and symptom progression to help distinguish MTSS from stress fracture or compartment syndromes; Physical examination including inspection for swelling, palpation for diffuse posteromedial tibial tenderness, and assessment of ankle/foot range of motion and calf flexibility; Functional assessment such as gait evaluation and single-leg hop or heel-raise tolerance, which can help characterize load sensitivity and identify biomechanical contributors; Evaluation for focal point tenderness and pain with percussion or hopping, which can raise concern for tibial stress fracture when symptoms are more localized.

Treatment options range from conservative measures to surgical interventions, including: Relative rest and activity modification, which can reduce repetitive tibial loading while maintaining general conditioning through lower-impact cross-training when tolerated; Gradual return-to-activity programming that typically emphasizes progressive loading, monitoring of symptom response, and avoidance of abrupt training spikes; Ice or other symptom-modulating modalities that may help with short-term discomfort after activity; Physical therapy approaches that can include calf/ankle flexibility work, strengthening of the calf and intrinsic foot musculature, and proximal hip/core strengthening to address kinetic-chain contributors; Gait retraining and running-form adjustments, which may reduce tibial loading in some individuals depending on mechanics and training context.