Der Unfallchirurg
Leitthema
Unfallchirurg
https://doi.org/10.1007/s00113-019-0667-z
© Springer Medizin Verlag GmbH, ein Teil von
Springer Nature 2019
Editors
M. Scheltinga, Veldhoven, NL
P. van Eerten, Veldhoven, NL
Introduction
Medial tibial stress syndrome (MTSS) is
one of the most common lower leg syn-
dromes in athletes [1]. A recent study
found that it is the most frequent injury
in runners; 16% of all running injuries
relates to MTSS [2]. The syndrome is de-
fined as exercise-induced pain along the
posteromedial tibial border, and recog-
nisable pain is provoked on palpation
of this posteromedial tibial border over
a length of ≥5 consecutive centimetres
[3].
The pathology underlying MTSS is
equivocal: some reports suggest it to be
due to fasciopathy [4], whereas more re-
cent reports in athletes with prolonged
MTSS point to it being a bone overload
injury. These studies found reduced tib-
ial bone mineral densities at the site of
MTSS, which returned to normal val-
ues after MTSS symptoms had disap-
peared [5, 6]. Another study found mi-
crocracks without a repair response in
biopsies taken from the painful sites in
athletes with MTSS, suggesting impaired
bone repair function [7]. In the absence
of strong evidence for any of the theo-
ries on its pathology, MTSS is considered
a clinical pain syndrome [8, 9].
This article provides an overview of the
evidence and gives recommendations on
the diagnosis and management of athletes
with MTSS.
The German version of this article can be
found under https://doi.org/10.1007/s00113-
019-0666-0.
Marinus Winters1,2
1
Department of Rehabilitation, Physiotherapy Sciences & Sports, University Medical Centre Utrecht,
Utrecht, The Netherlands
2
Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University,
Aalborg Øst, Denmark
The diagnosis and management
of medial tibial stress syndrome
An evidence update
Clinical diagnosis of MTSS:
a reliable and logical approach
History and physical examination are the
cornerstones of the diagnostic process in
clinical pain syndromes. Multiple stud-
ies have shown that imaging modalities
such as X-ray, ultrasound, magnetic res-
onance imaging, computed tomography
and bone scans are unable to differentiate
between athletes with and without clini-
cally diagnosed MTSS [2, 10–12]. As long
as the pathology of MTSS is equivocal, it
does not seem logical to use imaging to
establish or rule out the diagnosis MTSS.
Clinicians making reliable diagnoses
make for a good foundation to discuss
expectations and to plan treatment with
the patient. While making a reliable di-
agnosis, it is also important to reliably
identify co-existing lower leg injuries; the
presence of concomitant injuries may af-
fect prognosis and treatment in practice.
To this end, the author and collegues
recently performed a cross-sectional re-
liability study to investigate whether di-
agnosing MTSS and identifying co-exist-
ing injuries could be done reliably [13].
The study showed that making the diag-
nosis MTSS using history and physical
examination has almost perfect reliabil-
ity between clinicians with backgrounds
in medicine and physiotherapy, as well
as a wide range in years of clinical expe-
rience. The clinicians were also able to
reliably identify those athletes with con-
comitant lower leg injuries. Medial tib-
ial stress syndrome can be diagnosed us-
ing a seven-step standardised history and
physical examination approach (. Fig. 1).
History
The first step is to judge whether there is
exercise-induced pain along the medial
tibial border. If this is the case, the athlete
is asked what worsens and relieves their
pain. Physical activity should provoke
their pain during or after the activity,
otherwise it is unlikely that the patient
has MTSS. The athlete is also asked about
pain in any other adjacent or remote ar-
eas in the lower leg. In the third step the
athlete is specifically asked about cramp-
ing, burning or pressure-like calf pain.
These signs could point to the presence
of chronic exertional compartment syn-
drome (CECS)—this could be present
concurrent to MTSS or as a sole explana-
tion for the pain. CECS is usually present
during exercise and quickly decreases af-
ter exercise. In addition, athletes are also
asked about any pins and needles in the
foot or a cold foot during or after exer-
cise, especially when pain in the area is
reported [13].
Physical examination
When MTSS is suspected on the basis
of the history, one should palpate the
posteromedial tibial border. The ath-
lete is asked for recognisable pain (i. e.
from painful activities) during palpation.
When recognisable pain is absent upon
palpation, or when the recognisable pain
cannot be palpated for at least 5 consecu-
tive centimetres, other lower leg injuries
(e. g. a stress fracture) should be consid-
ered. The diagnosis MTSS can be con-
firmed when recognisable pain is present
Der Unfallchirurg
 Leitthema

Presence of exercise-induced
pain along the distal 2/3 of the
medial tibial border

Yes

Pain provoked by (during or

after) physical activity and
reduced with relative rest
History

Yes

Yes
Cramping, burning pain over the Consider CECS may be
posterior compartment present alone, or additional
to MTSS

No Yes

Numbness, pins and needles in

the foot during exercise

No

No recognisable pain?
Recognisable pain on palpation
of the posteromedial tibial No
border ≥5 cm
Pain <5 cm
Physical Examination

Yes

E.g. visible (severe)

Other symptoms or signs not
typical of MTSS?
No
Medial Tibial Stress Syndrome
Yes
swelling or erythema
along the medial
border / pain not
related to loading Fig. 1 9 History taking and
physical examination tool
for lower leg pain in clinical
sports medicine practice.
Likely not MTSS, consider MTSS medial tibial stress
other lower leg entities syndrome, CECS chronic
exertional compartment
syndrome

upon palpation of the posteromedial tib-
ial border over 5 cm or more. Upon
physical examination, the athlete should
be asked about pain in adjacent structures
and, if present, these structures should be
palpated to verify whether any concur-
rent injuries are present. Recognisable
pain should be provoked upon palpation
of these structures to identify a concur-
rent injury.
Finally, one should ensure that there
are no symptoms or signs present that
suggest severe pathology, e. g. the pres-
ence of severe swelling or erythema [13].
Management: what to do in the
absence of strong evidence?
After making the diagnosis of MTSS,
a management strategy needs to be set up
with the patient. A number of treatment
modalities have been suggested for the
treatment of athletes with MTSS. Gait
retraining, rest, ice massage, shockwave
therapy, stretching and strengthening ex-
ercises, graded running programs, lower
leg braces and injection therapies are
some examples. The authors’ systematic
review showed that none of the inter-
ventions has proven to be effective [14,
15]. In the absence of good evidence, one
should prioritise evidence from observa-

Der Unfallchirurg

tional studies and clinical reasoning [16].
The following recommendations, how-
ever, should be interpreted with caution
as they are based on lower levels of evi-
dence.
Conservative management
strategies
Patient expectations, education
and load management
It is important to discuss expectations
with the patient before treatment is
started. Many athletes are over-opti-
mistic about how long it takes to get
back to their preferred sporting activity.
The duration of the condition is often
prolonged: studies suggest that it can
take up to 90 days to run at moderate
intensity for 20 min with minimal pain
[17, 18]. For most athletes, the preferred
level of activity is much higher. From
clinical experience, 9–12 months for an
athlete having shin pains for ±3 months
is a much more realistic prognosis, de-
pending on the athlete’s personal goals.
Educating the patient about the nature
of MTSS and its relation to (inadequate)
load management is a second key step
before treatment is started. This should
include the fact that MTSS is highly vari-
able; the presence and severity of pain and
disability seem to depend on how well
the athlete balances loading with loading
capacity. Medial tibial stress syndrome
often comes back, or worsens, when this
balance is not achieved. Loading con-
sistently, e. g. changing load by <10%
a week, may be important to avoid flares
and (re-)injuries [19]. While the 10% rule
seems a good and logical guideline to ex-
pose athletes to increasing loads, recent
studies suggest that changing load by up
to 30% from week to week may be safe
[20]. Running or activity apps can help
the athlete to monitor their loading—to
avoid spikes in their sporting activities.
Graded exposure to loading as
a promising management strategy
for athletes with MTSS?
Athletes with MTSS are sensitive to
loading—their symptoms are related to
how well they balance loading with their
loading capacity, and it seems that the
adequacy with which they balance load-
ing and loading capacity is also related
to their prognosis. Therefore, gradual
load exposure seems a logical man-
agement strategy. Moreover, although
MTSS is considered a clinical pain syn-
drome, there is limited evidence that
MTSS is a bony overload injury and/or
a crural fasciopathy. Evidence suggests
that both these pathologies benefit from
graded exposure to loading. Recent trials
suggest that loading activities enhance
bone remodelling [21]. A randomized
controlled trial in patients with plantar
fasciopathy suggested that stimulating
the mechanical properties of the fas-
cia through heavy slow-load exercises
reduces pain [22]. A combination of
graded tibial loading exercises and ankle
plantar flexor strengthening exercises
may, therefore, be the best strategy for
athletes with MTSS.
Loading: a gradual approach
When the athlete with MTSS first
presents, pain is often severe. Reducing
pain and ensuring loading meets loading
capacity is a priority. Pain can be reduced
with ice massage and loading reduction.
Some pain while loading seems to be
more beneficial than reducing the load-
ing to the extent that the patient has
no pain, following a recent review by
Smith et al. (2018) [23]. From clinical
experience, not exceeding a pain score
of 2 on a 0–10 pain scale while engaging
in physical activity is recommended.
A physiotherapist may supervise the
athlete to ensure the athlete manages
their pain appropriately. Instructing the
graded tibial loading program and ankle
plantar flexor exercises form a good start
to the loading program. After a couple
of these sessions, the athlete can con-
tinue to perform this program indepen-
dently with a few follow-up sessions to
check the patient’s progress and make
adjustments to the program according
to progress and how successful they self-
manage their MTSS. The athlete and clin-
ician can use the MTSS score to monitor
the athlete’s progress. The MTSS score
is a validated patient-reported outcome
measure, specifically developed for ath-
Abstract · Zusammenfassung
Unfallchirurg
https://doi.org/10.1007/s00113-019-0667-z
© Springer Medizin Verlag GmbH, ein Teil
von Springer Nature 2019
M. Winters
The diagnosis and
management of medial tibial
stress syndrome. An evidence
update
Abstract
Medial tibial stress syndrome is a common
overuse injury in jumping and running
athletes. It is defined as exercise-induced
pain along the distal posteromedial border
of the tibia and the presence of recognisable
pain on palpation over a length of 5 or more
centimetres. This overview article provides
an evidence update on the diagnosis and
management of athletes with medial tibial
stress syndrome.
Keywords
Medial tibial stress syndrome · Shin splints ·
Diagnosis · Treatment · Management
Diagnostik und Therapie des
Schienbeinkantensyndroms.
Update zur Studienlage
Zusammenfassung
Das Schienbeinkantensyndrom
ist eine häufige Verletzung durch
Überbeanspruchung bei Sportlern, die
springen und laufen. Definiert ist es durch
belastungsinduzierten Schmerz entlang
des distalen posteromedialen Rands
der Tibia und durch das Vorliegen eines
erkennbaren Schmerzes bei Palpation
über eine Länge von mindestens 5 cm. In
der vorliegenden Übersichtsarbeit wird
die aktuelle Studienlage zu Diagnostik
und Management bei Sportlern mit
Schienbeinkantensyndrom beschrieben.
Schlüsselwörter
Schienbeinkantensyndrom · „Shin splints“ ·
Diagnose · Behandlung · Management
letes with MTSS, having good validity,
reliability and responsiveness [24, 25].
It is a simple four-item scale that eval-
uates injury severity from the patient’s
perspective.
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 Leitthema
Surgery for recalcitrant MTSS?
When pain persists despite conserva-
tive management of MTSS, surgery is
sometimes performed. To date, there are
six case series of low-quality [26–31].
Surgery consists of fasciotomy, either
alone [26–28] or in combination with
periosteal stripping [29–31]. Outcomes
in these case series are poorly reported.
Excellent results were reported for pain
in 69%–92% of athletes with MTSS
[30, 31], whereas a return to sport was
achieved in 29%–93% of athletes. High-
quality evidence is lacking to merit
clinical recommendations. Given the
absence of a known pathology in pa-
tients with MTSS, surgery seems an
implausible treatment approach for the
effective management of this condition
and should be avoided as a first-line
treatment.
Conclusion
Medial tibial stress syndrome can be diag-
nosed reliably on the basis of history and
physical examination. There is an over-
all absence of strong evidence to support
the management of Medial tibial stress
syndrome (MTSS). It seems most logical
to manage MTSS conservatively, using
a graded loading program and exercise
therapy. Surgery is not recommended
based on the available evidence.
Practical recommendations
4 Diagnosis:
jMTSS should be diagnosed on
the basis of history and physical
examination.
jImaging for shin pain is only logical
when pathology is suspected, e. g.
tibial stress fracture or osteosar-
coma.
4 Management:
jSet expectations: MTSS is often
a prolonged injury; it can take up
to 9–12 months to heal.
jEducate patients on how to mon-
itor their training workload and
advise them to make only small
changes on a week-by-week basis.
jA graded tibial loading program
and ankle plantar flexor strength-
Der Unfallchirurg
ening exercises seem the most
logical interventions, address-
ing the two possibly affected/
sensitised structures in MTSS: the
tibial bone and the crural fascia.
jSurgery for MTSS is not recom-
mended according to the currently
available evidence.
Corresponding address
Dr. Marinus Winters, MSc, PhD
Research Unit for General Practice in Aalborg,
Department of Clinical Medicine, Aalborg
University
Fyrkildevej 7, 9220 Aalborg Øst, Denmark
marinuswinters@hotmail.com
Compliance with ethical
guidelines
Conflict of interest M. Winters declares that he has
no competing interests.
For this article no studies with human participants
or animals were performed by any of the authors. All
studies performed were in accordance with the ethical
standards indicated in each case.
The supplement containing this article is not spon-
sored by the industry.
References
1. Moen MH, Tol JL, Weir A et al (2009) Medial tibial
stress syndrome: a critical review. Sports Med
39:523–546
2. Mulvad B, Nielsen RO, Lind M, Ramskov D (2018)
Diagnoses and time to recovery among injured
recreational runners in the RUN CLEVER trial. PLoS
ONE 13(10):e204742. https://doi.org/10.1371/
journal.pone.0204742
3. Yates B, White S (2004) The incidence and risk
factors in the development of medial tibial stress
syndrome among naval recruits. Am J Sports Med
32:772–780
4. Johnell O, Rausing A, Wendeberg B et al (1982)
Morphological bone changes in shin splints. Clin
Orthop Relat Res 167:180–184. https://doi.org/10.
1097/00003086-198207000-00027
5. Magnusson HI, Westlin NE, Nyqvist F et al (2001)
Abnormally decreased regional bone density in
athletes with medial tibial stress syndrome. Am J
Sports Med 29(6):712–715
6. Magnusson HI, Ahlborg HG, Karlsson C et al
(2003) Low regional tibial bone density in athletes
normalizes after recovery from symptoms. Am J
Sports Med 31(4):596–600
7. Winters M, Burr DB, van der Hoeven H, Condon
KW, Bellemans J, Moen MH (2018) Microcrack-
associated bone remodeling is rarely observed in
biopsies from athletes with medial tibial stress
syndrome. J Bone Miner Metab. https://doi.org/
10.1007/s00774-018-0945-9
8. Winters M (2017) Medial tibial stress syndrome.
Diagnosis, treatment and outcome assessment.
https://dspace.library.uu.nl/handle/1874/355940
(ISBN 978-90-393-6880-0)
9. Winters M (2018) Medial tibial stress syndrome;
diagnosis, treatment and outcome assessment
(PhD Academy Award). Br J Sports Med
52(18):1213–1214. https://doi.org/10.1136/
bjsports-2017-098907
10. Batt ME, Ugalde V, Anderson MW et al (1998)
A prospective controlled study of diagnostic
imaging for acute shin splints. Med Sci Sports Exerc
30:1564–1571
11. Gaeta M, Minutoli F, Scribano E et al (2005) CT and
MR imaging findings in athletes with early tibial
stress injuries: comparison with bone scintigraphy
findings and emphasis on cortical abnormalities.
Radiology 235:553–561
12. Winters M, Bon P, Bijvoet S, Bakker EWP, Moen MH
(2017) Are ultrasound findings like periosteal and
tendinous edema associated with medial tibial
stress syndrome? A case-control study. J Sci
Med Sport 20:128–133. https://doi.org/10.1016/j.
jsams.2016.07.001
13. Winters M, Bakker EWP, Moen MH, Barten CC,
Teeuwen R, Weir A (2018) Medial tibial stress
syndrome can be diagnosed reliably using history
and physical examination. Br J Sports Med
52(19):1267–1272. https://doi.org/10.1136/
bjsports-2016-097037
14. Winters M, Eskes M, Weir A, Moen MH, Backx
FJ, Bakker EW (2013) Treatment of medial tibial
stress syndrome: a systematic review. Sports Med
43(12):1315–1333
15. Winters M, Eskes M, Weir A, Moen MH, Backx FJ,
Bakker EW (2016) The treatment of medial tibial
stress syndrome: an extensive summary and
update of a systematic literature review. Sport
Geneeskd 2:44–45
16. Winters M (2018) Critically appraising the evidence
to help our patients with overload syndromes:
should we prioritise knowledge from observa-
tional studies and focus on ‘the essentials’? Br J
Sports Med 52(22):1414–1415. https://doi.org/10.
1136/bjsports-2018-099181
17. Moen MH, Schmikli SL, Weir A et al (2014) A
prospective study on MRI findings and prognostic
factors in athletes with MTSS. Scand J Med Sci
Sports 24(1):204–210. https://doi.org/10.1111/j.
1600-0838.2012.01467.x
18. Moen MH, Holtslag L, Bakker EW et al (2012)
The treatment of medial tibial stress syndrome in
athletes; a randomized clinical trial. Sports Med
Arthrosc Rehabil Ther Technol 4(1):12
19. Gabbett TJ (2016) The training-injury prevention
paradox: should athletes be training smarter and
harder? Br J Sports Med 50:273–280
20. Damsted C, Glad S, Nielsen RO, Sørensen H,
Malisoux L (2018) Is there evidence for an
association between changes in training load and
running-related injuries? A systematic review. Int J
Sports Phys Ther 13(6):931–942
21. Vlachopoulos D, Barker AR, Ubago-Guisado E et al
(2018) The effect of 12-month participation in os-
teogenic and non-osteogenic sports on bonede-
velopment in adolescent male athletes. The PRO-
BONE study. J Sci Med Sport 21(4):404–409.
https://doi.org/10.1016/j.jsams.2017.08.018
22. Rathleff MS, Mølgaard CM, Fredberg U et al (2015)
High-load strength training improves outcome
in patients with plantar fasciitis: A randomized
controlled trial with 12-month follow-up. Scand J
Med Sci Sports 25(3):e292–300. https://doi.org/
10.1111/sms.12313
23. SmithBE, HendrickP, SmithTO, BatemanM, Moffatt
F, Rathleff MS, Selfe J, Logan P (2017) Should
exercises be painful in the management of chronic
musculoskeletal pain? A systematic review and
meta-analysis. Br J Sports Med 51(23):1679–1687.
https://doi.org/10.1136/bjsports-2016-097383
24. Winters M, Franklyn M, Moen MH, Weir A, Backx
FJG, Bakker EWP (2016) The medial tibial stress
syndrome score: item generation for a new
patient reported outcome measure. S Afr J Sports
Med 28(1):11–16. https://doi.org/10.17159/2078-
516X/2016/v28i1a426
25. Winters M, Moen MH, Zimmermann WO, Lin-
deboom R, Weir A, Backx FJ, Bakker EW (2016)
The medial tibial stress syndrome score: a new pa-
tient-reported outcome measure. Br J Sports
Med 50(19):1192–1199. https://doi.org/10.1136/
bjsports-2015-095060
26. Järvinnen M, Niittymaki S (1989) Results of the
surgical treatment of the medial tibial stress
syndrome in athletes. Int J Sports Med 10(1):55–57
(Feb)
27. Holen KJ, Engebretsen L, Grondvedt T et al (1995)
Surgical treatment of medial tibial stress syndrome
(shin splints) by fasciotomy of the superficial
posterior compartment of the leg. Scand J Med Sci
Sports 5(1):40–43
28. Wallenstein R (1983) Results of fasciotomy in
patients with medial tibial stress syndrome or
chronic anterior compartment syndrome. J Bone
Joint Surg Am 65(9):1252–1255
29. Abramowitz AJ, Schepsis A, McArthur C (1994) The
medial tibial stress syndrome: the role of surgery.
Orthop Rev 23(11):875–881
30. Yates B, Allen MJ, Barnes MR (2003) Outcome of
surgicaltreatmentofmedialtibialstresssyndrome.
J Bone Joint Surg Am 85(10):1974–1980
31. Detmer DE (1986) Chronic shin splints: classifi-
cation and management of medial tibial stress
syndrome. Sports Med 3(6):436–446

Der Unfallchirurg