Shin Splints (Medial Tibial Stress Syndrome).
What are shin splints?
Shin splints, medically known as medial tibial stress syndrome (MTSS), are a common lower leg condition characterised by pain and inflammation along the shinbone (tibia). They typically occur in individuals engaged in high-impact activities that involve repetitive stress on the lower leg, such as running, jumping, dancing, and sports like basketball and soccer.
MTSS is one of the most common running-related injuries, accounting for approximately 13 to 17% of all running injuries. It is particularly prevalent in new runners, military recruits beginning intensive training, and athletes who significantly increase their training load — the classic "too much too soon" pattern. It is more common in women than men, and more common in individuals with lower bone density.
What actually causes shin splints — and why it matters for treatment
The name "shin splints" is somewhat misleading — nothing splits. MTSS involves stress to the posteromedial cortex of the tibia, produced by the cumulative impact loading of running and jumping. The soleus and flexor digitorum longus muscles attach along the posteromedial tibial border, and their repeated contraction during the stance phase of running generates bending forces on the tibia that, when they exceed the bone's adaptive capacity, produce periosteal inflammation and bone stress reaction.
This places MTSS on the bone stress continuum — a spectrum from periosteal inflammation (MTSS) at one end to complete tibial stress fracture at the other. MTSS is the less severe end of this spectrum and is generally managed conservatively. However distinguishing MTSS from a tibial stress fracture is clinically important because the management differs significantly — a stress fracture requires more aggressive rest and may require imaging to confirm healing before return to activity.
What are the symptoms?
Pain along the posteromedial (inner-lower) border of the tibia — typically in the middle to lower third — that is diffuse (spread over several centimetres rather than sharply localised) is the hallmark. Pain develops during running, initially only at the start of a run and resolving as the muscle warms up, then progressing to pain throughout the run and eventually to pain during daily activities and at rest in more severe presentations.
The diffuse nature of MTSS tenderness — spread across 5cm or more of the tibial border — is clinically important. A sharply localised tender spot suggests a stress fracture rather than MTSS and warrants imaging to exclude it. The hop test — single-leg hopping on the affected leg — reproduces sharp localised pain in stress fractures but is typically less provocative in MTSS.
How is it diagnosed?
Diagnosing shin splints involves a comprehensive evaluation including a thorough medical history review, discussion of physical activities, and physical examination. Diagnostic imaging such as X-rays or MRI scans may be utilised to rule out other potential causes and assess the extent of the injury.
MRI is the most sensitive investigation for distinguishing MTSS from tibial stress fracture — periosteal oedema and superficial cortical signal change on STIR sequences is the characteristic MTSS finding, while a fracture line indicates a more significant stress fracture requiring more conservative management.
How can physiotherapy help?
Physiotherapy plays a central role in MTSS management through load management, graduated return-to-running programming, and addressing the biomechanical contributors that produced excessive tibial bone stress.
Load management in the acute phase involves reducing running volume to below the pain threshold — typically to zero in severe presentations — while maintaining cardiovascular fitness through non-impact alternatives. Pool running, cycling and swimming allow meaningful training stimulus without tibial bone loading. The duration of this relative rest phase depends on symptom severity — mild MTSS may require only one to two weeks of load reduction, while more significant presentations may require four to six weeks.
Graduated return-to-running is the most important component of MTSS management and the most commonly mismanaged. Returning to full training before bone stress has adequately settled — typically indicated by the ability to perform single-leg calf raises and hop without pain — produces immediate recurrence. A structured walk-run progression building volume before speed systematically restores running capacity without provoking bone stress reaction.
Biomechanical assessment identifies the training load, running mechanics and footwear factors that produced excessive tibial bone stress. Increasing running cadence — which reduces tibial peak impact forces and stress fracture risk at each stride — is one of the most evidence-based running mechanics interventions for MTSS. Hip and gluteal strengthening addresses the proximal contributors to tibial loading patterns — weak hip abductors increase medial tibial stress through increased pronation during stance. Foot pronation — whether from flexible flat feet or inadequate footwear — increases the torque applied to the posteromedial tibia during impact and is addressed through orthotics and footwear modification where relevant.
Calf and soleus strengthening builds the muscular shock absorption that reduces the peak forces transmitted to the tibial cortex. A progressive calf strengthening program is both therapeutic and preventive.
Bone health assessment is appropriate for women with MTSS — particularly those with menstrual irregularity, very low body weight or restricted eating — where low bone density and relative energy deficiency in sport (RED-S) are significant risk factors that, if unaddressed, will produce recurrent MTSS and progress to stress fracture. GP referral for DXA scanning and dietary review is appropriate in these cases.
Clinical Pilates provides an excellent non-impact environment for hip, gluteal and calf strengthening during the load reduction phase. Real time ultrasound assists in assessing deep lower leg muscle activation.
Our physiotherapists Eliane Machado and Mauricio Bara both have experience in running-related lower leg conditions and are members of the Australian Physiotherapy Association. Eliane's doctoral research in running biomechanics is directly relevant to the gait analysis and return-to-running programming central to MTSS rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Book your initial physiotherapy appointment
Shin splints, medically known as medial tibial stress syndrome (MTSS), are a common lower leg condition characterised by pain and inflammation along the shinbone (tibia). They typically occur in individuals engaged in high-impact activities that involve repetitive stress on the lower leg, such as running, jumping, dancing, and sports like basketball and soccer.
MTSS is one of the most common running-related injuries, accounting for approximately 13 to 17% of all running injuries. It is particularly prevalent in new runners, military recruits beginning intensive training, and athletes who significantly increase their training load — the classic "too much too soon" pattern. It is more common in women than men, and more common in individuals with lower bone density.
What actually causes shin splints — and why it matters for treatment
The name "shin splints" is somewhat misleading — nothing splits. MTSS involves stress to the posteromedial cortex of the tibia, produced by the cumulative impact loading of running and jumping. The soleus and flexor digitorum longus muscles attach along the posteromedial tibial border, and their repeated contraction during the stance phase of running generates bending forces on the tibia that, when they exceed the bone's adaptive capacity, produce periosteal inflammation and bone stress reaction.
This places MTSS on the bone stress continuum — a spectrum from periosteal inflammation (MTSS) at one end to complete tibial stress fracture at the other. MTSS is the less severe end of this spectrum and is generally managed conservatively. However distinguishing MTSS from a tibial stress fracture is clinically important because the management differs significantly — a stress fracture requires more aggressive rest and may require imaging to confirm healing before return to activity.
What are the symptoms?
Pain along the posteromedial (inner-lower) border of the tibia — typically in the middle to lower third — that is diffuse (spread over several centimetres rather than sharply localised) is the hallmark. Pain develops during running, initially only at the start of a run and resolving as the muscle warms up, then progressing to pain throughout the run and eventually to pain during daily activities and at rest in more severe presentations.
The diffuse nature of MTSS tenderness — spread across 5cm or more of the tibial border — is clinically important. A sharply localised tender spot suggests a stress fracture rather than MTSS and warrants imaging to exclude it. The hop test — single-leg hopping on the affected leg — reproduces sharp localised pain in stress fractures but is typically less provocative in MTSS.
How is it diagnosed?
Diagnosing shin splints involves a comprehensive evaluation including a thorough medical history review, discussion of physical activities, and physical examination. Diagnostic imaging such as X-rays or MRI scans may be utilised to rule out other potential causes and assess the extent of the injury.
MRI is the most sensitive investigation for distinguishing MTSS from tibial stress fracture — periosteal oedema and superficial cortical signal change on STIR sequences is the characteristic MTSS finding, while a fracture line indicates a more significant stress fracture requiring more conservative management.
How can physiotherapy help?
Physiotherapy plays a central role in MTSS management through load management, graduated return-to-running programming, and addressing the biomechanical contributors that produced excessive tibial bone stress.
Load management in the acute phase involves reducing running volume to below the pain threshold — typically to zero in severe presentations — while maintaining cardiovascular fitness through non-impact alternatives. Pool running, cycling and swimming allow meaningful training stimulus without tibial bone loading. The duration of this relative rest phase depends on symptom severity — mild MTSS may require only one to two weeks of load reduction, while more significant presentations may require four to six weeks.
Graduated return-to-running is the most important component of MTSS management and the most commonly mismanaged. Returning to full training before bone stress has adequately settled — typically indicated by the ability to perform single-leg calf raises and hop without pain — produces immediate recurrence. A structured walk-run progression building volume before speed systematically restores running capacity without provoking bone stress reaction.
Biomechanical assessment identifies the training load, running mechanics and footwear factors that produced excessive tibial bone stress. Increasing running cadence — which reduces tibial peak impact forces and stress fracture risk at each stride — is one of the most evidence-based running mechanics interventions for MTSS. Hip and gluteal strengthening addresses the proximal contributors to tibial loading patterns — weak hip abductors increase medial tibial stress through increased pronation during stance. Foot pronation — whether from flexible flat feet or inadequate footwear — increases the torque applied to the posteromedial tibia during impact and is addressed through orthotics and footwear modification where relevant.
Calf and soleus strengthening builds the muscular shock absorption that reduces the peak forces transmitted to the tibial cortex. A progressive calf strengthening program is both therapeutic and preventive.
Bone health assessment is appropriate for women with MTSS — particularly those with menstrual irregularity, very low body weight or restricted eating — where low bone density and relative energy deficiency in sport (RED-S) are significant risk factors that, if unaddressed, will produce recurrent MTSS and progress to stress fracture. GP referral for DXA scanning and dietary review is appropriate in these cases.
Clinical Pilates provides an excellent non-impact environment for hip, gluteal and calf strengthening during the load reduction phase. Real time ultrasound assists in assessing deep lower leg muscle activation.
Our physiotherapists Eliane Machado and Mauricio Bara both have experience in running-related lower leg conditions and are members of the Australian Physiotherapy Association. Eliane's doctoral research in running biomechanics is directly relevant to the gait analysis and return-to-running programming central to MTSS rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Book your initial physiotherapy appointment
