Running: Medial Tibial Stress Syndrome

I’m sure if you’re an avid runner you have at some point said that you’ve had shin splints. If not you then I’m sure you have heard another runner say it before. Shin splints is the common term for a cluster of injuries involving pain in the shins when running. There are three main causes of pain in the shins; stress fractures, compartment syndrome and medial tibial stress syndrome (MTSS). The latter being the most common cause.

MTSS is classed as a diffuse pain along the inside border of the tibia at variable intensities. The pain tends to be worse in the morning and after exercise, with tenderness over the edge of the tibia and muscular insertions. The pain is made worse with loading/resistance and there may be visible swelling around the muscular insertion points. The pain is most likely caused by an inflammation of the bone (periostitis) which is caused by overuse.

Potential causes of MTSS are flat feet (over-pronation), training errors, shoe design, surface type, muscle dysfunction, fatigue, decreased flexibility, being female (sorry ladies), increased BMI, increased rotation at the hip, increased calf girth, a history of stress fractures and a history of orthotics use. Now that is a lot of variables that could be causing pain in the shins! However, if you have been running for a while then there are certain things you should have done to set yourself up well for running. Such as, getting your gait analysed for training errors, making sure you are wearing the correct footwear for your feet and supplying your feet with the correct support. These are all basic things that getting your gait analysed will assist with.

However, some of the above risk factors will probably only be able to be identified by a professional; muscle dysfunction, decreased flexibility, increased hip rotation, increased calf girth and even a history of stress fractures would need to be assessed before ascertaining the cause.

Now for the technical bit...

During the phase of running when the foot is fully on the floor the foot sometimes falls in towards the arch to assist with shock absorption and to adjust the foot to any variances in the terrain. The soleus helps to resist the foot falling in too much when running, therefore if the other muscles in the foot are not helping with the foot falling in this combined with the repetitive impact when running will cause pain on the insertion point in the middle of the tibia = medial tibial stress syndrome.

Magnusson et al, measured bone density of the tibia in patients with MTSS symptoms and found that there was a lower bone density in the affected region. Fortunately, this bone density was regained after the patient resolved their symptoms. This could point to a higher risk of developing stress fractures shortly after experiencing shin splints.

Treatment for MTSS includes activity modification- taking up lower impact activities such as cycling or swimming whilst the symptoms subside. The usual rest, ice and pain killers as needed. No current treatment has proven to be better than rest alone, but shock absorbing insoles have proved promising. The entire calf area should be assessed for tightness and focal areas of thickening which should be treated with soft tissue techniques. Surgical intervention is a very last resort with a success rate of only 70%. As mentioned in the previous blog, shockwave treatment is looking very promising. Moen et al. (2011) found that shockwave treatment combined with a running program enabled the athletes to recover faster from MTSS than either intervention on their own. Basically, receiving shockwave treatment alongside a graded return to running has proven to be greatly beneficial IN ATHLETES. This must be taken with a pinch of salt as people who do not do sport as their job have other strains on their shins other than just running. This must be taken into account when devising a treatment program and when thinking about returning to sport.

In Summary

This blog has highlighted risk factors and ways to prevent getting shin splints as well as general treatment plans. If you already have shin splints, then getting assessed by a sports therapist would probably be the best option. This is so that they can fully assess you to make sure that a) it is actually shin splints and b) the best treatment options for you.

If you have any questions about any sports injuries do not hesitate to contact me by emailing

Beth Roberts BSc (Hons)

Sports therapist


  1. Magnusson et al. (2001). ‘Abnormally decreased regional bone density in athletes with medial tibial stress syndrome’

  2. Brukner and Khan, ‘Clinical sports medicine’ (2017)

  3. Taunton et al. (2002) ‘A retrospective case-control analysis of 2002 running injuries’

  4. Moen et al. (2011) ‘Shockwave treatment for medial tibial stress syndrome in athletes’


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