Medial tibial stress syndrome

Medial tibial stress syndrome (MTSS), also known as shin splints, describes a spectrum of stress injury that occurs at the medial tibia. This term is often used to indicate any type of tibial stress injury or the earlier manifestations of a tibial stress lesion before a fracture component can be identified 1. It is considered a low-risk stress fracture.

Typically occurs in athletes (e.g. runners/jumpers).

Medial tibial stress syndrome is characterized by localized pain that occurs during exercise at the medial surface of the distal two-thirds of the tibial shaft.

A "one-leg hop test" is a functional test, that can be used to distinguish between medial tibial stress syndrome and a stress fracture: a patient with medial tibial stress syndrome can hop at least 10 times on the affected leg where a patient with a stress fracture cannot hop without severe pain 2.

Considered insensitive. It may, however, demonstrate subtle periosteal reaction or callus around the cortex of the tibia medially 11

CT is not particularly sensitive (~40%) 3. It may reveal mild osteopenia as an early sign of fatigue damage of cortical bone in tibial diaphysis 3,4.

May show focal hyperechoic elevation of the periosteum with irregularity over the distal tibia and increased flow on Doppler interrogation. 

MRI is the most sensitive radiological examination (~88%) 3. It may demonstrate a spectrum of findings ranging from normal to periosteal fluid to marrow edema to a complete stress fracture 5. The medial cortex (+/- posterior cortex) is most commonly affected 3. The axial fluid sensitive, fat-saturated sequences are often the most helpful.  

The Fredericson grading system can be used to grade the MRI findings with a good correlation with clinical severity and outcome 7,8.

Bone scintigraphy is relatively sensitive (~75%) 3 and may demonstrate high uptake in the affected region, characteristically along the posterior tibial aspect on lateral views. On the 3-phase isotope bone scan there will be typically normal appearances on the arterial and blood pool phases but longitudinal uptake on the delayed images. (cf. stress fracture which will show early phase uptake). 

  • tibial stress fracture: there can be some overlap depending on the definition.

Article information

rID: 10776
Section: Syndromes
Synonyms or Alternate Spellings:
  • Shin splints
  • Shin splint syndrome
  • MTSS
  • Medial tibial stress syndrome (MTSS)
  • Shin splint

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Cases and figures

  • Figure 1: illustration - Fredericson classification
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  • Case 1
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  • Case 2: MTSS grade 3
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  • Case 3
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  • Case 4
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  • Case 5
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  • Case 6: ultrasound
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  • Case 7
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  • Case 8: ultrasound
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13: annotated study
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