Stress Fractures

Shin Splints



What are shin splints?

Shin splints is a general term used to describe pain in the shin (usually the front or inside) and is a common problem in runners. Physiotherapists refer to shin splints as medial tibial stress syndrome (MTSS) as the pain most commonly occurs along the inside border of the shin bone (tibia) and is the result of overuse which causes inflammation of the bone and/or muscle in that region.

Diagnosis of shin splints

The severity of MTSS is quite variable. A low grade injury usually means that the main problem is muscle tightness or inflammation and this should settle relatively quickly with the appropriate treatment.

  1. Key signs and symptoms of a low grade injury are:
  • A history of impact loading (e.g. running) and usually a rapid increase
  • Tenderness along a large portion the shin bone or muscle
  • Pain improves after warming up (e.g. a few minutes into a run)
  • Pain generally does not return after cooling down
  1. A high grade injury refers to the presence of a stress fracture (a small crack or severe bruising in the bone) and in this case, rest from high impact exercise is essential (usually for several months). Whilst uncommon, if MTSS continues to be abused, it is possible for the stress fracture to turn into a complete fracture! It is therefore crucial to consult a qualified physiotherapist early to get an accurate diagnosis as this will dictate what the appropriate treatment is and stop your injury from progressing to a stress fracture.
  1. Key signs and symptoms of a higher grade injury are:
  • Tenderness over smaller, specific point/s of the shin and possibly a lump
  • Night pain e.g. throbbing or aching of the shin when in bed
  • Pain at rest or with simple weight bearing and poor tolerance to light impact activity


The cause of MTSS can be many things, but the most common factor is overload of the muscles/shin through training errors. For example, training for a marathon and increasing running distance and frequency too quickly which does not allow enough time for recovery and adaptation of the bone and muscle to the training stimulus. Training speed, frequency, duration, surface (e.g. grass vs concrete), and footwear, all contribute to the amount of load experienced by the bone and muscles around your shin. It’s a sensible idea to talk to an experienced physiotherapist or running coach about how to plan out and manage your training loads so as to avoid overloading your legs, particularly if you are new to running. Another good idea is to have your running screened. This involves a series of tests of your strength, endurance, balance and flexibility, as well as filming your running technique. Based on the findings of the screening, corrective exercises can be prescribed to minimise the risk of you developing problems from running.

Are radiological investigations necessary?

Patients often ask about whether an X-ray or scan is appropriate to investigate the severity of their MTSS. I generally do not recommend getting scans in the early stage as it normally settles with appropriate physiotherapy management and the results of scans do not change the treatment approach if you have been assessed by an experienced physiotherapist. The best way to manage MTSS is based on signs and symptoms anyway. However, in cases where the diagnosis is unclear or in patients who are very anxious or time constrained (e.g. building up to a Marathon), I often recommend an MRI as this does not expose the patient to any radiation and is quite sensitive for picking up the problem.

I think I have MTSS, what should I do!?

Treatment of MTSS depends on the underlying causes identified by your physiotherapist. For example, it may be determined that muscles around the hip are weak and causing the calf to overload. Therefore, strengthening and stability exercises would be the most important rehabilitation strategy. Another person may have excessive calf muscle tightness (from increasing their running distance too quickly) and this is causing compression and inflammation of the bone and tendons in the shin. In this case, loosening the muscles around the calf will relieve the tension and therefore the patient’s pain. This could be achieved through massage but I find dry needling to be far more effective.



So in summary, MTSS refers to pain in the front or inside of the shin and is the result of overloading of the bone or muscles in that region. Catching it early is important to prevent it progressing to a more serious grading of injury which requires complete rest from high impact activity such as running. A graduated running program and screening for biomechanical deficiencies (e.g. weakness, joint or muscle tightness) are good ways to reduce the risk of developing this common problem.

However, if you do suffer from MTSS, there are treatment options available to settle your condition and keep or return you back to running as soon as possible. For more advice or information, contact an experienced physiotherapist.