As we come up on the start of winter sports for our high school and college athletes a common topic of conversation is in regards to Medial Tibial Stress Syndrome (MTSS) commonly known as “Shin Splints”. Despite an abundance of studies performed on the causes and factors leading to MTSS there is still conflicting evidence and thus no definitive answer on what causes MTSS. When observing the many reported cases of MTSS it is evident there are many different factors that may lead to the onset of injury. Causative factors include: playing surface, footwear, gait or running mechanics, sudden increases in training volume and thus number of impacts, gender, athlete age and current stage of growth, lower body strength deficits, prior injury, joint mobility, bone mineral density, rest or recovery protocol, dehydration, increased BMI or an increase in body weight, etc. It’s also quite hard to accurately screen for MTSS without MRI or CT scanning, so there are times when pain in the lower leg such as stress fractures, compartment syndrome, nerve entrapment and popliteal artery entrapment syndrome can all be inaccurately diagnosed and treated as MTSS. We recommend a thorough screen from a qualified physio as soon as symptoms start.
In my review of some of the literature I concluded that MTSS is typically the result of overuse in “impact activity” caused by a sudden increase in volume or a lack of recovery time between training sessions or competitions. Simply speaking MTSS can typically be linked to athletes being physically unprepared for sport, or unfit, and then starting their season and/or practice as if they are prepared or fit enough. An athlete who starts an athletic season physically unprepared will also be at a much higher risk for soft tissue injuries outside of MTSS or Shin Splints.
What can you do to prevent it?
1) “Gradual” increases in impact activity prior to the start of a new season are vital to minimizing injury. Sudden increases in volume of impact activity is linked to greater increases in MTSS injury. Prepare for your sport prior to the season.
2) Review your gait mechanics and determine if changes can be made to help minimize unnecessary heel strike in running or sprinting activities. If you have access to a qualified performance coach this can be an invaluable asset for improving mechanics.
3) Work to develop adequate strength in the lower body muscles and tendons through resistance training and plyometrics. The long term athletic development (LTAD) model should be adhered to here.
4) Get adequate recovery between practices and games. Sport coaches need to be aware of the current level of fitness of their athletes and program practices accordingly. Unfortunately, if athletes start a season physically unprepared this means that the coach will have to cut back on volume and intensities of impact activity if they want to minimize injuries such as MTSS. This sucks for a coach who has a great plan in place at the start of the season, but it won’t suck nearly as much as having injuries up and down their roster because they didn’t make healthy changes to those plans.
5) Footwear should be supportive and functional. An old worn out pair of shoes or cleats can be all it takes to start an athlete down the path towards a bigger problem such as MTSS. Using athletic insoles and wearing quality footwear that fits properly will help support the foot and improve the positioning of the foot and ankle upon impact.
6) Having adequate ankle dorsiflexion range of motion (ROM) will allow the foot and ankle to more effectively distribute the impact forces found in running, jumping and cutting.
7) Lose the weight. Athletes who are overweight will be placing greater stress on the tissues involved in withstanding impact forces found in sport and are a much higher risk of developing an overuse injury such as MTSS.
8) Physical Readiness Testing. Testing at the start of a season will allow coaches and trainers to observe trends in fitness for their teams and athletes and make adjustments to their practice intensity and volume accordingly.
9) Utilizing running programs prior to a season designed by a professional coach can be extremely beneficial in preparing athletes for an upcoming season. "Slow cooking" vs jumping in all guns a blazing is the healthiest approach.
10) Sleep and hydration. Do not overlook the value and performance enhancing impact of getting enough sleep every night and being adequately hydrated each day. These two things alone will keep athletes more durable and physically prepared for the stressors of sport than anything else. Chronic and acute dehydration and sleep deprivation have both been linked to increased incidence of soft tissue injury.
For the Geeks out there here’s a bit more...
Below I have included some of my findings and topics of consideration on MTSS.
Overweight, Biomechanics of Ankle and Foot, and Hip ROM.
In this review “The primary factors that appeared to put a physically active individual at risk for MTSS were increased BMI, increased navicular drop, greater ankle plantar-flexion ROM, and greater hip external-rotation ROM. These primary risk factors can guide health care professionals in the prevention and treatment of MTSS.”
Which is first the Chicken or the Egg??
One question I found was in regards to the onset of microtrauma to the bone in cases of MTSS, and which comes first, the trauma in the bone or trauma to the muscle fibers of the lower leg? In review it was determined that microtrauma to the bone actually occurs first as this can be found in the very early stages of impact training such as a new running program, hard playing surfaces such as basketball
courts, dense turf or a track. Trauma to bone tissue will always occur in these activities and can be favorably adapted to, much the same as trauma to muscle tissue can lead to increased levels of strength. The devil is of course in the details, and as I stated before the devil lives mostly in the volume of training of the impact activity being applied. Too much too soon, or too much without adequate rest and recovery between sessions is typically the cause of MTSS and thus strength and conditioning and sport coaches must use caution when creating practice and training programs for their athletes.
Other research pointed to over pronation caused by strength deficits in the legs and gluteals as a factor that in turn lead to increased ground reaction forces to the bones of the lower leg. What this means is that inadequate strength “could” lead to improper running mechanics or compensations in how the athlete navigates running, jumping and landing. Thus, the forces found each time the foot or feet hit the ground are not being “shared” effectively throughout the kinetic chain, muscles and tendons, and in turn the bones of the lower leg must do more than its fair share. An example of this would be with a “heel striker” who makes contact more in front of
their center of mass with impact on the heel first as opposed to the ball of the foot making contact more underneath their body. A strike more under the body will allow the Achilles tendon as well as the structures and fascia of the foot to help dampen and distribute the forces of impact more effectively. Studies have been performed on Step Rate and Shin/Knee Injury in High School Runners where correlations were found with a shorter stride and decreased incidence of injury. Typically, a higher step rate will occur with a shorter stride and be accompanied by foot contact more under the body vs a longer stride which will bias a heel contact more in front of the body.
In closing the most effective approach to avoiding any soft tissue or overuse injury is to be prepared for your sport(s) prior to the season beginning. The gradual ramp up in volume prior to the season will not only help athletes be more resilient to injury but it will also yield a more physically capable athlete for sport and better performance on the field of play. Athletes who neglect the preparation period should be prepared for injuries to follow.
As the saying goes,
“It is easier to stay fit and healthy than to get fit and healthy.”
Athletes who adopt this mindset will see far fewer soft tissue injuries such as MTSS as a result.
This article was written by Coach Adrian Guyer, Owner, Founder, CSCS, RSCC, USAW 2, CSAC
(1) Winkelmann, Z. K., Anderson, D., Games, K. E., & Eberman, L. E. (2016). Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. Journal of athletic training, 51(12), 1049–1052. doi:10.4085/1062-6050-51.12.13
(2) Franklyn, M., & Oakes, B. (2015). Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. World journal of orthopedics, 6(8), 577–589. doi:10.5312/wjo.v6.i8.577
(3) Influence of Step Rate on Shin Injury and Anterior Knee Pain in High School Runners.Luedke LE1, Heiderscheit BC, Williams DS, Rauh MJ.
(4) Brewer, R. B., & Gregory, A. J. (2012). Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports health, 4(2), 121–127. doi:10.1177/1941738111426115
(5) Craig D. I. (2008). Medial tibial stress syndrome: evidence-based prevention. Journal of athletic training, 43(3), 316–318. doi:10.4085/1062-6050-43.3.316