Michael W.

Heaslet, DPM, MS
4950 Barranca Parkway, Ste 308
Irvine, CA 92604
949-651-1202
Email address: michaelheasletdpm@sbcglobal.net

Private practice, Irvine, CA for 33 years

Masters Degree in Medical Education, Pepperdine University
Diplomate, American Board of Podiatric Surgery
Fellow American College of Foot and Ankle Surgeons
Fellow American Academy of Podiatric Sports Medicine
Past President American Academy of Podiatric Sports Medicine
Director of Sports Medicine Fellowship Training, Irvine
Distance runner for over 35 years
Marathons completed 15 (including Boston and New York)
Personal best marathon 2 hrs 51 min (World Masters Irvine Marathon 1981)

MEDIAL TIBIAL STRESS SYNDROME

IN RUNNERS

DEFINITION: Medial tibial stress syndrome (MTSS) is defined as a soft tissue injury
most probably to the deep covering (fascia) of the tibia or leg bone, although the exact
cause is still not clearly understood. Most likely it is the origin of attachments of the
lower calf muscle (Soleus) and of the long flexors (Flexor Digitorum Longus) as they tug
and pull excessively on the fascia creating micro-injury and inflammation. The location
of the pain is generally in the central and lower one third of the inside or medial aspect of
the leg. This injury should not be confused with pain along the front or anterior shin as
this is a distinctly different injury with distinctly different causes.

Medial tibial stress syndrome or MTSS has previously been nicknamed “Shin Splints”
which has led to much confusion especially when describing in the medical literature.
Medial shin and anterior shin pain was often lumped together resulting in additional
confusion and misinformation. This article will focus only on MTSS.

According to the literature, incidence of MTSS comprises anywhere from 4-35% of

running injuries. An article published by the American Journal of Sports Medicine in
2004 revealed a 35% incidence of MTSS in naval military recruits. There was a 2:1 ratio
of female to male incidence which gives rise to the question of muscle strength and size
of the tibia of males compared to females possibly contributing to the cause.
A Journal study (JBJS) in 1994 reported the dissection of 12 cadaver legs to identify the
structures attaching to the tibia precisely in the area or location of MTSS. The conclusion
was that the soleus muscle (part of the calf muscle) at its origin of attachment was
probably the major contributor to the injury.

DIAGNOSIS: pain is usually described as sharp or dull ache in the medial lower leg and
is experienced either during or following running activity. Usually the pain significantly
subsides following a running workout, however pain and tenderness is persistent when
palpating or pressing against the inside portion of the tibia or lower leg bone.

CONTRIBUTING FACTORS: In most cases some type of overuse has occurred,

however multiple factors are often involved. Common factors contributing to MTSS
include:
1. Excessive running mileage.
2. Insufficient recovery, (e.g., adding more days of running per week).
3. Increasing pace of run (i.e. faster!).
4. Improper running shoe (e.g., too soft or too stiff a midsole can cause).
5. Terrain, such as running on a harder surface such as asphalt or cement, or transition
from a relatively softer surface such as trail or grass to a harder surface such as asphalt or
cement.
6. Inflexibility of muscles/tendons predispose to injury.
7. Biomechanical weakness such as flat feet, excessively pronated feet, etc. An
excessively pronated foot reduces the natural shock absorbing ability of the foot which
can put more demand upon the lower leg muscles that stabilize the lower extremities.

Overuse syndrome, the overwhelming cause of MTSS, is vaguely defined as too much
too soon too fast, however its subtleties often make it easy to overlook. For example, if
one runs 5 miles three times per week (15 miles/wk) and merely adds one more 5 mile
run per week (20 miles/wk) this equates to more than a 30% increase in weekly mileage!
It's easy to see why it is so easy to inadvertently become injured by increasing one's
mileage. Adding one more running day per week is generally easily accommodated and
at least initially no negative effect is felt. Even more subtle than this would be if
someone adds a hike or additional walking (e.g. vacation, tourist, shopping, etc.) in
addition to their weekly mileage. This could be enough to bring them to the brink of the
injury. These examples may seem silly or unimportant but in my experience with over 33
years of treating runners, they are a common occurrence.

EXAMINATION: generally speaking, there is a linear area of 6-8 centimeters along the
inside shin that is tender with palpation. The patient will often reach down and try to stop
the examiner from pressing along this very sensitive area. The injury may only involve
one leg but often times both are involved with one side usually worse than the other. A
more localized area of pain involving approximately only 2-3 centimeters may be
indicative of something else such as a stress fracture of the leg bone (tibia). X-rays of the
leg are helpful in ruling out bone lesions/tumors and one can often visualize a stress
fracture during its healing phase. If the x-ray is negative which may be the
case,(approximately 40-70% of the time) it may be desirable to get more definitive
imaging via a bone scan or an MRI. More simplistic techniques have been used to
diagnose a stress fracture such as therapeutic (not diagnostic ultrasound) ultrasound or a
tuning fork but they are highly un-reliable, in my experience.

TREATMENT: treatment that is most effective usually revolves around determining the
cause in the first place and then attempting to eliminate that cause. For example,
correcting or modify training errors, terrain, or inappropriate running shoe. Rest or
"relative rest" is imperative. It is not uncommon for it to take weeks, months, or a year or
more until the inflammatory process from the injury has sufficiently diminished. While
this is occurring, the objective here is to keep the athlete fit when possible by offering
cross-training options that don't impact the shin injury. Any full weight-bearing activity
such as excessive walking, running or jumping will usually exacerbate the shin
symptoms. With severe cases complete rest from lower extremity workouts is necessary.
Generally speaking, in all but severe cases "semi-weight-bearing" activities will not
negatively impact a shin injury. Examples of this would be stationary cycling, elliptical
trainer, cross-country ski machine, swimming/pool running, etc.

MTSS is an inflammatory injury and therefore ice application is very helpful in reducing
that inflammation. Circumstances can very, however in most cases I recommend 10-15
minute applications of ice along the inside shin 2-3 times daily during any acute phase,
and immediate ice application (10-15 min) following cross-training activity.

Anti-inflammatory medication (NSAI medications) can be used but most appropriately

they should not be taken on a consistent basis for more than two weeks at a time. They
afford pain relief as well as anti-inflammatory effect. The anti-inflammatory effect is
significantly reduced if they are not taken on a consistent basis (i.e., consistently during a
2 week period in this case). If they are taken sporadically they basically are providing
pain relief with minimal anti-inflammatory effect. In my opinion, unless pain is not
tolerable it is best to not use them strictly for pain relief as this will mask symptoms and
therefore make it difficult to assess how the injury is progressing. It should also be noted
that any type of anti-inflammatory medication is not without risk of side effects, some
minimal and some potentially serious. The most commonly used non-prescription anti-
inflammatory medications are aspirin, ibuprofen (e.g. Advil, Motrin), and naproxen (e.g.,
Naprosyn, Aleve). Acetaminophen (e.g. Tylenol) is a pain reliever only and possesses no
anti-inflammatory ability. This medication should not be taken indiscriminately either as
it can have significant side effects.

It is sometimes helpful to wrap the lower shins with a neoprene compressive sleeve
during workout activity. One may apply adhesive tape in a spiral direction in order to
deemphasize the amount of pull of the musculature in the leg during exercise. A similar
option is to tape the foot to restrict pronation which can oftentimes be of benefit.
Shock wave therapy (ESWT, or Extra Corporal Shockwave Therapy) has been
popularized during the past several years for treating soft tissue injuries. Low energy
ESWT has been used since the 1980s, however to treat such injuries.

Various physical therapy modalities such as electrical stimulation, ultrasound, or laser

therapy can be helpful adjuncts to treatment, as can deep tissue massage, strengthening
and stretching.

Platelet Rich Plasma (PRP) historically has been described for several years in the
veterinary literature which reported enhancing and stimulating healing following surgery
or injury by injecting a concentrated platelet mixture taken from the animals own blood
that had previously been centrifuged. This same application is being used in humans and
thought to have merit. Currently literature however show conflicting results as to its
effectiveness.

Orthotic inserts are commonly used to treat this injury and range from over-the-counter
cushioned inserts, or arch supports commonly found in sporting goods stores, to a
prescriptive orthotic device that is prescribed by a doctor. All have been known to help.
In more difficult case however, a prescriptive orthotic device usually is most effective
because an in depth evaluation of an athlete’s biomechanics/structure is noted and the
foot is casted with the foot and leg in anatomical alignment. The orthotic device is then
made via a prescription by a specialty orthotic lab.

The American Academy of Podiatric Sports Medicine has endorsed a treatment protocol
for MTSS through the help of Richard Bouche DPM, a Past President. The following is
an abridged outline of this treatment protocol:

Phase I (Acute Phase)

Decrease pain and inflammation. Sometimes absolute rest is necessary (e.g. non-weight-
bearing/crutches).
"Relative rest", can ambulate in a cast boot.
I.C.E.
NSAIDS

Phase II (Rehabilitation Phase)

Further decrease pain and inflammation.

Ultrasound, electrical stimulation, laser therapy, phonophoresis, hot/cold contrast,
massage therapy, etc.
increased flexibility (active/passive range of motion, stretching)
strengthening (open/closed kinetic chain, e.g. isometric, isotonic, iso-kinetic)
*when patient can perform these exercises WITHOUT PAIN, may proceed to next phase.
Phase III (Functional Phase)

Continue with open kinetic chain then on to closed kinetic chain therapeutic exercises.
Plyometric training (e.g., Trampoline, then to cautious jump roping, then to "Vertical
Jumps".
Protect during functional activity with taping leg, neoprene shin sleeve, air cast leg brace,
orthotic device (non-custom, custom), proper shoe, etc.

Phase IV (Return to activity)

continue functional activities.
Proper shoe
orthotic devices
correct training method error.

SUMMARY: The easiest and most effective way to treat MTSS is to PREVENT THE
INJURY IN THE FIRST PLACE. This amounts to learning to read your body and be
able to interpret what your body is telling you. Pain in any part of your body experienced
either during or following a running workout should demand your attention. Early
detection or/or identification of pain and appropriate modification of your workout
usually results in relatively quick recovery.