Saudi Journal of Sports Medicine

: 2017  |  Volume : 17  |  Issue : 1  |  Page : 50--52

Medial tibial stress syndrome: A case study

Abhinav Sathe 
 Yog Sadhna and Research Centre, Bhopal, Madhya Pradesh, India

Correspondence Address:
Dr. Abhinav Sathe
Consultant Sports Physiotherapist, Yog Sadhna and Research Centre, 24, Patrakar Colony Bhopal, Madhya Pradesh


Medial tibial stress syndrome (MTSS), commonly known as DQshin splints,DQ is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes. Although often not serious, it can be quite disabling and progress to more serious complications if not treated properly. Often, the cause of MTSS is multifactorial and involves training errors and various biomechanical abnormalities. Few advances have been made in the treatment of MTSS over the last few decades. The current treatment options are mostly based on expert opinion and clinical experience. The purpose of this article is to let the readers know regarding conservative treatment options for MTSS and provide recommendations for sports medicine clinicians for improved treatment and patient outcomes.

How to cite this article:
Sathe A. Medial tibial stress syndrome: A case study.Saudi J Sports Med 2017;17:50-52

How to cite this URL:
Sathe A. Medial tibial stress syndrome: A case study. Saudi J Sports Med [serial online] 2017 [cited 2022 May 22 ];17:50-52
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Full Text

 Definition of Medial Tibial Stress Syndrome

Medial tibial stress syndrome (MTSS) is an overuse injury or repetitive stress injury of the shin area. Various stress reactions of the tibia and surrounding musculature occur when the body is unable to heal properly in response to repetitive muscle contractions and tibial strain.


Many believe the main cause of MTSS involves underlying periostitis of the tibia due to tibial strain when under a load. However, new evidence indicates that a spectrum of tibial stress injuries is likely involved in MTSS, including tendinopathy, periostitis, periosteal remodeling, and stress reaction of the tibia.[1],[2],[3],[4] Dysfunction of the tibialis posterior, tibialis anterior, and soleus muscles is also commonly implicated.[1],[3],[4] These various tibial stress injuries appear to be caused by alterations in tibial loading, as chronic, repetitive loads cause abnormal strain and bending of the tibia.[1] Although sometimes composed of different etiologies, MTSS and tibial stress fractures may be considered on a continuum of bone-stress reactions.[1],[4]


In this case, a 17-year-old male flyweight category taekwondo player was assessed who had a complaint of pain in the lower leg bilaterally and had difficulty to take part in training session and play his game. The patient came to the center with the complaint of pain in both legs; anteromedially, distal 1/3 part of the tibia which had started 20 days ago during a training schedule. As reported by the patient, he had an incidence of ankle sprain (right side) 1 month ago. He took treatment and gradually started his training schedule. He had no history of diabetes, asthma, or hypertension. Moreover, as reported, he was a nonsmoker, nonalcoholic, and nonvegetarian. When his occupational history was taken, he was a state level player with 3½ years of experience. He was training on the hard surface for 5 months with a high intensity, and the duration of training was long (approximately 2:30 h/2 times a day). He performed warm-up and cooldown activities as per session, and when asked about his use of protective gears, the following were his answers: Helmet, mouth piece, forearm guard, and shin guard not in use.

The pain history was onset - gradual, duration - for 15 days, type - dull aching, localized, site - billaterally distal 1/3; anteromedial surface of tibia, aggravating factors - training activities (on the spot jumping and kicking), relieving factors - rest and icing, predisposing factors - practice on rough terrain, sleep disturbances - sometimes, and visual analog scale - on rest: 3/10 and on activity: 6/10. On general examination, the built mesomorphic posture - anteroposterior view: No significant deviation, lateral view: Pes planus b/l, posterior view: b/l over pronation, right >left, and gait - antalgic, and on local examination, there was no swelling, scar, and wound, and shoes used were with no corrective insole and no wear-tear as reported. The range of motion and end feel were checked which was found to be about normal, and his manual muscle testing conducted according to the Oxford grading was found to be above average.The [Figure 1] shows the following finding in the lower extremities.{Figure 1}

The test for proprioception and balance reviled both legs standing: Eyes open: b/l negative and eyes closed: b/l negative and when performed with one leg standing: Eyes open: b/l positive and eyes closed: b/l positive. The test for flexibility, i.e., the Ely test for the rectus femoris muscle: Normal (bilateral) and hamstring: Normal (bilateral), gastrocnemius: b/l tightness. The special tests performed were distal tibiofibular compression test, peroneal tendon dislocation test, anterior drawer test, and Thompson test, and they were found to be negative. A digital X-ray was also performed which did not reveal any chance of stress fracture.

 Differential Diagnosis

A digital X-ray was also performed which did not reveal any chance of stress fracture. The findings reviled and hence it was confirmed that it is not a compartment syndrome (pain throughout the muscle belly), anterior shin splints (lateral border mainly and lump on the edge of the bone), and achilles tendinitis (pain on postmedial margin).

 Treatment Options

A physiotherapy management program was planned with short-term goals such as to reduce pain, to reduce tenderness, to maintain the cardiovascular fitness, to improve the strength, and to improve proprioception and balance with long-term goals such as maintaining proprioception and balance, maintaining the strength, improving sports-specific skills, and return to sports activities.

In the initial phase, rest, ice massage: 3-4 times a day for 10 min, transcutaneous electronic nerve stimulation, whirlpool, ankle pumps, passive stretching to the calf muscles, toe taps, static cycling, and intrinsic muscle exercises were given. And then, the progression included resisted isometrics, resistance band exercises, and active/weight-bearing stretches to the calf muscles, stretching to the tibialis anterior, heel raises, and core-strengthening exercises. The proprioceptive training initially included one leg standing on floor, on foam and wobble board exercises, and the progression was tandem walking and one leg standing: On floor and on foam with the use of Swiss ball. For managing the sports-specific skills, the Figure of 8 walking, jumping on spot, hopping, and advancing to sparring activities gradually were done.

Moreover, a home exercise program included icing, exercises and stretching regimes, proper rest, proper warm-up, and cooldown session, advised for a semirigid medial arch support. A caution was given to not practice on hard surfaces, to wear proper guards as required, and to maintain a balanced diet and adequate hydration.


After following a systematic approach in the management of the case, it led to his willingness to return to practice. On examination, the pain scale; visual analog scale was found to be on rest: 1/10 and on activity: 3/10. He had no sleep disturbances. His range of motion and muscle strength improved. There was a marked decrease in tenderness. He gave a positive feedback regarding the exercise as well as training session.


MTSS is one of the most common lower extremity injuries suffered by athletes and it is a common complaint at primary care and sports medicine setups.

Prompt diagnosis and appropriate management of MTSS is important in helping athletes return to full activity in a timely fashion. To date, there is limited evidence to support our current treatment and interventions for MTSS.[5] However, most studies support rest, ice, and analgesics in the acute phase. Many experts also recommend modifying the training routine, stretching, and strengthening the lower extremity, wearing appropriate footwear, using orthotics and manual therapy to correct biomechanical abnormalities, and gradually return to activity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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