Shin Splints or if you want to be technical, it’s MTSS, which is easier to say than Medial Tibial Stress Syndrome
what is MTSS
Medial tibial stress syndrome (MTSS) is one of the most common lower limb injuries in the active population, affecting up to 35% of runners. MTSS is due to non-optimal healing in response to repetitive load on the tibia from ground impact and muscle contractions. MTSS should be differentiated from exertional compartment syndrome, stress fractures and referred nerve pain. Symptoms of MTSS will usually start with vague pain over the far one-two thirds of the tibia, made worse with impact activities. However as the condition continues pain may become more consistent and even be present at rest. MTSS will often begin after a sudden increase in activity duration and/or intensity
the cause of MTSS
In the past, a large range of hypothesis have been suggested for the cause and there was even debate over the specific anatomical structure producing the pain. Previous proposals for the source of pain have included inflammation of the outer lining of the tibial bone (periostitis), muscle dysfunction of the calf or bone stress reaction.
Very few studies have identified any inflammatory markers within the periosteum, which rules periostitis out as a likely cause of pain in MTSS.
Although muscle tenderness is a common finding with tibial pain, there is no direct attachment of these associated muscles to the tibia where the pain is focused. The deep crural fascia, which is a thick connective tissue, links the muscles of the deep calf to the tibia. Increased muscle tension of the deep calf muscles can create a strong pull from this fascial tissue at the site of pain. But, the jury is out to wether this muscle tension & tenderness is the cause or effect of MTSS.
Recently however, with new imaging techniques, it has been suggested that bone stress is the most likely cause of symptoms in MTSS. Advances in CT scanning and MRI have enabled researches to identify bone oedema (swelling) consistently in people suffering from MTSS. Bone oedema is a sign of bone overload.
risk factors for developing MTSS
Several risk factors have been identified across a large number of studies, some we can do something about, while others we are stuck with:
1. being female – females have a higher incidence of reduced bone mineral density (due to delayed menstruation or nutritional deficiencies. You can’t change being female, but you can ensure you have good nutrition to limit this risk.
2. fewer years of running experience – this is largely due to muscle conditioning, which means building up slowly to prevent a sudden overload with fatigue.
3. prior orthotic use – this could be due to a lack of muscle strength and endurance from relying on orthotics for a prolonged period, or that the orthotic changes the shock absorption effect of the foot, essentially increasing the load on the tibia upon impact.
4. increased functional pronation during weight bearing- a reduction of control of your foot’s arch during ground contact, potentially increases the load on the tibia on impact
treatment of MTSS
Recovery times in MTSS are variable, but it can be a lengthy rehabilitation. This relates to the activity you are getting back to, the duration & severity of symptoms. Studies on military recruits, found that recovery from MTSS took an average of 12-15 weeks.
For a complete recovery, physiotherapy management needs to address three main issues:
1. the load on the tibia (amount of activity vs rest)
2. whole body movement patterns (stability)
3. running technique
load- Initially you need to reduce the load on the bone and soft tissue, to allow pain to settle. However, you don’t want to reduce activity so much that deconditioning occurs. In the short term you can help to unload these structures with taping or flexible orthotics, that aid in muscle control but do not make the foot rigid. As symptoms settle, you can gradually re-introduce activity load and wean off the supportive tape or orthotic.
movement patterns- So why has your bone been stressed? Instability or poor joint control can occur in any part of the body & have a knock on effect at any other part of the body. We always perform a whole body assessment to look at any areas in the body that fail to transfer load optimally for efficient movement patterns. Ultimately you need to optimise stability for your task of running, which may start with activating support muscles in single leg standing positions, before being progressed to more complex tasks.
running technique- Once stability has been trained we may also need to address any running technique issues. Some key features in an efficient running technique is a light or quiet landing at a cadence of around 180 steps per minute. This has been found to be an efficient rate for running long distances.
With these three components well managed, you should expect a durable recovery from MTSS to have you running again with flow & freedom.
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