Medial tibial stress syndrome

Dr Henry Knipe and Dr Yuranga Weerakkody et al.

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.

Typically occurs in athletes (e.g. runners/jumpers) and is characterised by localised 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 MTSS and a stress fracture: a patient with MTSS can hop at least 10 times on the affected leg where a patient with a stress fracture cannot hop without severe pain reference required.

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

MRI is the most sensitive radiological examination (~88%) 3. It may demonstrate a spectrum of findings ranging from normal to periosteal fluid to marrow oedema to actual stress fracture 5. The anterior cortex (+/- posterior cortex) is most commonly affected 3.

These findings are graded using the Fredericson classification system as follows 7:

  • grade 1: periosteal oedema only
  • grade 2: bone marrow oedema appreciated only on T2-weighted sequences
  • grade 3: bone marrow oedema appreciated on both T1 and T2-weighted sequences
  • grade 4
    • 4a: multiple discrete areas of intracortical signal changes
    • 4b: linear area(s) of intracortical signal change correlating with a frank stress fracture

Bone scintigraphy is relatively sensitive (~74%) 3 and may demonstrate high uptake in the affected region, characteristically along the posterior tibial aspect on lateral views.

Share article

Article information

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

Support Radiopaedia and see fewer ads

Cases and figures

  • Drag
    Figure 1: illustration - Fredericson classification
    Drag here to reorder.
  • Drag
    Case 1
    Drag here to reorder.
  • Drag
    Case 2: MTSS grade 3
    Drag here to reorder.
  • Drag
    Case 3
    Drag here to reorder.
  • Drag
    Delayed bone scan
    Case 4
    Drag here to reorder.
  • Drag
    Case 5
    Drag here to reorder.
  • Drag
    Case 6: ultrasound
    Drag here to reorder.
  • Drag
    Case 7
    Drag here to reorder.
  • Drag
    Case 8: ultrasound
    Drag here to reorder.
  • Updating… Please wait.

    Alert accept

    Error Unable to process the form. Check for errors and try again.

    Alert accept Thank you for updating your details.