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Medial Tibial Stress Syndrome Cheat Sheet (DRAFT) by

Presentation, Management , AKA Shin splints

This is a draft cheat sheet. It is a work in progress and is not finished yet.

MTSS

- Exercise induced pain along poster­omedial border of the tibia
- Eccentric contra­ction of deep flexors (runni­ng/­jumping on hard surfaces)
- Repetitive traction on medial tibial crest causes muscle pain, periosteal inflam­mation and bony stress
- Inflam­matory precursor to tibial stress f#
- Bone responds to stress by remode­lling itself more densely (occurs when remode­lling cannot keep up with excess­ive­/im­proper training -terrible toos - too much, too fast, too long)

Demogr­aph­ics­/Risk factors

- Females more than males
- Prior Hx
- Increased BMI
- Foot hyperp­ron­ation

Presen­tation

- Vague diffuse pain over middle to distal poster­omedial tibia
- Worse with exertion (increase in activity intens­ity­/du­rat­ion­/be­ginning of a workout)
- Pain >5 mins post activity Consider Stress F#
- Assess for numbne­ss/­par­est­hesia (compa­rtment syndrome)
- Diffuse tenderness over poster­omedial tibial border (at least 5cm)
- Might feel a periosteal reaction of roughn­ess­/bu­mpiness
- Focal & anterior tibial tenderness = Consider stress f# (tuning fork test)
- Single leg hop = painful most of the time
- Tenderness over FDL and tibialis posterior
- Talar bump test (if +ve strong suspicion of stress f#)
- Assess for hypert­onicity of gastro­soleus
- Navicular drop test (hyper­pro­nation)
- Assess for postural risk factors:
Inflex­ability or imbalance of the hamstr­ings, quads
Genu varus/­valgus
Tibial Torsion
Femoral anteve­rsion
Leg length discre­pancies
Hip abductor weakness
Excessive ext rot of the hip
- Assess gait/r­unning patter­ns/­joint mobility of LL

Imaging

Often unnece­ssary unless red flags, focal tender­ness, +ve vibration testing, pain at rest, fail to improve with con care
Radiog­raphs taken >2-3 weeks unlikely to show findings
MRI better than x-ray for stress f# and to grade them as follows:
Grade 1: Periosteal odema
Grade 2-3 Bone marrow oedema
Grade 4: Cortical stress f#
X-ray findings of stress f# = periosteal elevat­ion­/calus format­ion­/co­rtical lucency

DDx

- Stress f#
- External compar­tment syndrome
- Peripheral vascular disease
- Muscle strain
- Occult f#
- Infection
- Neoplasm
- DVT
- Peripheral neuropathy
- Popliteal artery entrapment syndrome
- LS Radicu­lopathy
- Vascular claudi­cation

Management

- Remove risk factors - identify training errors and biomec­hanical risk factors
- Consider non-weight bearing activities (swimming, stationary cycling, pool running)
- Ultras­ound, electrical stimul­ation
- Ice/home ice massage
- Stretching and myofascial release of gastro, soleu, hip ext rots, tibialis posterior and anterior
- Streng­thening of tibialis posterior and hip abductors
- SMT/EMT of Spine, SI , pelvis, LL
- Arch supports for pronation
- Return to activity should start slowly (lower intensity and distance then increasing by 10-15% per week)
- Avoid running on hard/u­neven surfaces
- Wider step width if narrow gait
- Assess running shoes
- Surgery is rarely indicated (posterior fascio­tomy)