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The Problem

Medial tibial stress syndrome (MTSS), aka Medial Tibial Traction Periostitis, describes exercise-induced pain along the posteromedial border of the tibia.  The condition is commonly referred to as “Shin splints” and is prevalent in pediatric populations and is also a familiar malady in athletes and soldiers where it affects up to 1/3 of those populations.

The condition affects the vulnerable insertion points of the tibial fascia and deep ankle flexors along the medial tibial crest. MTSS is believed to result from repetitive eccentric contraction of the deep flexors during running, jumping, or impact loading. Repetitive traction on the medial tibial crest results in myofascial strain, periosteal inflammation, and bony stress reaction.

Is it Just Growing Pains? 

A systematic review of 56 studies on the relationship between adolescent growth and pain “generally indicated no association between maturation, growth and musculoskeletal conditions. While the relationship remains plausible, the available evidence is not supportive.” (5)

The Bigger Problem

Early etiological theories focused on myofascial strain, but current evidence shows that a bony stress reaction is the most likely cause of MTSS. Research suggests that traction periostitis may be an inflammatory precursor to a tibial stress fracture. The stress of exercise can temporarily weaken bone.  Healthy bone responds to this stress by remodeling itself more densely. Stress reactions occur when the normal adaptive remodeling response cannot keep pace with excessive training loads, i.e., high demands with inadequate recovery times. Prolonged insult may lead to a tibial stress fracture, and many authors now believe that MTSS and stress fracture represent two different points along a continuum of bony stress reaction.

Differentiating the Diagnosis

The clinical presentation of MTSS includes vague, diffuse pain over the middle to distal posteromedial tibia. Symptoms are often worse with exertion – particularly at the beginning of a workout. Initially, symptoms may subside during training, but as the condition progresses (toward stress fracture), symptoms may linger throughout activity or even at rest. Pain that persists more than five minutes post-activity carries a higher suspicion of stress fracture.

Clinical evaluation demonstrates diffuse tenderness over the posteromedial tibial border. Prolonged stress may generate a periosteal reaction detectable as a “rough” or “bumpy” feel upon palpation. Tenderness from MTSS should involve at least 5 cm of the tibial border. More focal tenderness, the presence of anterior tibial tenderness, or any significant swelling suggests stress fracture. Applying a vibrating tuning fork over the tibia may help detect stress fracture with 75% sensitivity. (1) Single leg hopping is painful in about half of MTSS cases (and 70-100% of stress fractures). (2-4) The Talar Bump Test may help differentiate tibial stress fracture from MTSS.


Clinicians should remain vigilant for the possibility of a stress fracture. Radiographs taken within the first 2-3 weeks are not likely to show any signs of tibial stress fracture (periosteal elevation/callus formation or cortical lucency). Unresponsive patients or those with a higher likelihood of stress fracture (runners) may benefit from advanced imaging, including MRI or bone scan. MRI is highly sensitive (74-100%) and is best able to grade the progression of stress reaction.


The successful management of stress-induced tibial injuries requires the removal of risk factors and rest. No intervention has proven more successful than rest for the management of either disorder. Unfortunately, patients are often affected when they are training for a sport or upcoming event.  Continuance of the offending activity will often lead to undue chronicity, frustration for patient and clinician, and decreased performance capabilities. Clinicians must be confident in their diagnosis to speak from a voice of authority when prescribing rest.


The preceding information was taken from ChiroUp’s clinical protocol for MTSS. Visit ChiroUp.com to view the entire protocol (including the 87 supporting references) or any of the other 100+ condition protocols filled with up-to-date, evidence-based assessment and management tools.


1. Lesho EP. Can tuning forks replace bone scans for identification of tibial stress fractures? Mil Med. 1997;162(12):802–803.
2.  Clement DB, Ammann W, Taunton JE, et al. Exercise-induced stress injuries to the femur. Int J Sports Med. 1993;14(6):347–352.
3. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79–84.
4. Batt ME, Ugalde V, Anderson MW, Shelton DK. A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc. 1998;30(11):1564–1571.

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