As we’ve discussed in previous articles, shin pain can take many forms and be due to many things. Broadly speaking, your condition can be bony, muscular, vascular or neural. This article will focus on bony shin pain, Medial Tibial Stress Syndrome.

What is Medial Tibial Stress Syndrome (MTSS)?

Medial tibial stress syndrome describes a spectrum of overload injuries that can occur to the front of the shin. All of these conditions will come on gradually, and not with a one-off incident.

Stage 1: Periostitis

One of our calf muscles, the soleus, actually inserts into the bony part of our shin bone (tibia). Sometimes, inactive people, this insertion can become overloaded, inflamed, aggravated and painful. The area of pathology is actually at the muscle/bone interface.

This will often present itself as a “niggle” or tightness that is present at the start of an activity, but warms up and goes away. Often the pain is difficult to localize, but will commonly affect the front and inside of the shin.

Stage 2: Bone stress reaction

If early warning signs are ignored, the condition can progress to cause some stress on the bone. Importantly, this stage is a stress reaction, so fractures have often not developed, but instead, there is some swelling within the bone. It is unclear as to whether this stress is caused by the soleus pulling on its bony attachment on the tibia, or by the constant force coming up from the ground each step. It is likely that it is both.

Further to this, the fibula (bone on the outside of the lower leg) and other parts of the tibia can be subject to bone stress.

With bone stress, sometimes the pain will go away with activity but other times it will become worse, and more focal as activity goes on.

Stage 3: Bone stress fractures

As the condition progresses and is left unmanaged, the stress can cause tiny little fractures in the bone, called stress fractures. These fractures are very limiting (difficult to push through the pain) but importantly, they are stable; extremely unlikely to cause a complete bone break and very rarely requiring surgery.

The most common site for stress fractures is in the front and inside of the tibia, but again they can be found in other parts of the tibia and in the fibula.

Stress fractures cause pain that it easy to localize (focal pain) and feel like a deep ache. They will usually cause pain that gets worse with activity, and might even last after activity as you rest. Sometimes, the deep ache will last into the night as well.

How do I know if I have a stress fracture?

If you can:

Hop up and down on one leg without pain

Push on your shin bone without pain

then a stress fracture is very unlikely

** Pain with the test does not mean you have a stress fracture, but you should definitely get it checked out by a physiotherapist or other practitioner with experience and knowledge in sport. **

What else could it be?

There are up to 33 different causes of shin pain that have been identified in the research to date. Other possible causes of shin pain are:

  • Compartment syndrome
  • Tendinopathy
  • Neural pain
  • Referred pain from hip, knee or ankle
  • Infections and tumours (very rare)

If you would like to inquire more or to get a clear and accurate diagnosis along with an appropriate management plan, then call us today.


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