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. It is considered a low risk stress fracture.

Typically occurs in athletes (e.g. runners/jumpers) and is characterized by localized 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 2.

CT is not particularly sensitive (~40%) 3. It may reveal mild osteopenia 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 edema to actual stress fracture 5. The medial cortex (+/- posterior cortex) is most commonly affected 3

These findings are graded using the modified Fredericson classification system which allows grading of the MRI findings with a good correlation with clinical severity and outcome. It allows an estimate to a safe return to activity in athletes. It is as follows 7,8:

  • grade 1: periosteal edema only
  • grade 2: bone marrow edema appreciated only on T2-weighted sequences
  • grade 3: bone marrow edema 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 (~75%) 3 and may demonstrate high uptake in the affected region, characteristically along the posterior tibial aspect on lateral views.

  • tibial stress fracture: there can be some overlap depending on the definition.
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Article information

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

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Cases and figures

  • Figure 1: illustration - Fredericson classification
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  • Case 1
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  • Case 2: MTSS grade 3
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  • Case 3
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  • Delayed bone scan
    Case 4
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  • Case 5
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  • Case 6: ultrasound
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  • Case 7
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  • Case 8: ultrasound
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  • Case 9
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  • Case 10
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