How to Treat Medial Tibial Stress Syndrome

Shin splints. Ask a runner about the injury, and they will tell you that they, or someone they know, has spent countless training sessions hindered by the injury.

But what exactly are shin splints, and what is the best treatment option for them?


As an ex-athlete and biomedical engineer, I have written this article as a reflection of my current understanding based on my interactions with 100s of clinics, reviewing literature and monitoring the use of the Solushin in the Australian athletic populations. My strengths are the athlete and biomedical engineer perspective. 


The purpose of this article is to discuss my current understanding of MTSS, how to best use the Solushin medical device, and to stimulate discussions with other health professionals to build on my clinical perspective.

So, what are shin splints?

As highlighted in an earlier article on anterior shin pain, shin splints isn't really a diagnosis. Dr Nat Padhiar, the British Lead Clinician and Team Leader for Podiatry at the London 20112 Olympic and Paralympic games said: 'It's a meaningless non-specific broad term used by clinicians, athletes and coaches to describe pain in the lower leg and it may prevent patients getting a correct diagnosis and could lead to long-term damage as a result."


Tom Goom, the physiotherapist and author of Running Physio, has broken the colloquial term down into four distinctive categories:

  1. Bony pain - a bone stress response
  2. Chronic Exertional Compartment Syndrome (CECS) - in one of four compartments of the lower leg
  3. Tendinopathy - commonly affecting the tibialis posterior, Achilles tendon or peroneal tendons
  4. Neural Pain

For the sake of clarity in this article, I will primarily be referring to medial tibial stress syndrome (MTSS), which falls under the Bony Pain category.

Medial Tibial Stress Syndrome

Medial tibial stress syndrome (MTSS), or more commonly referred to as "shin splints" is an injury of the lower leg that is common in runners. An often poorly understood injury, MTSS can be an extremely frustrating injury to treat for both the sufferer and the clinician.


Thinking back to Anatomy and Physiology 101, we can also understand how bone responds to stress. Wolff's law tells us that by placing the bone under increased load, the bone remodels itself over time to withstand this increase. Achieved by mechanotransduction, the mechanical stresses are converted to biomechanical signals in cellular signalling. However, if the increased too fast, the bone is unable to remodel and strengthen at a rate suitable enough to withstand the load. As a result, a stress reaction occurs that may develop into a stress fracture if appropriate treatment options are not utilised.


In response to stress, the periosteum along the posteromedial border gets inflamed (periostitis), creating the "periosteal tenting" effect seen with MRI imaging [1-3]. With a good nerve and blood supply, the angry periosteum is very capable of inflicting pain that has been described as both a "dull ache" or "burn" by sufferers.

Risk Factors

Multiple risk factors have been identified in the literature, including the increase in load and running volume mentioned above; muscle imbalances and inflexibility, particularly of the triceps surae (gastrocnemius and soleus) and plantaris muscles; poor running form and biomechanics; old shoes; and, general health (particularly in females) with some conditions affecting bone density [1,4,5].

Treatment

As highlighted by Jackson Tisdell, an enthusiastic young Australian podiatrist and former athlete who suffered from the injury, "As a syndrome, it is essential to understand that the causes and symptoms are likely to be multi-factorial." In addition to this, I have personally seen the syndrome broken down into four stages in clinics: 


Stage 1 – discomfort that appears during warm-up. Early intervention to avoid further deterioration is advised.


Stage 2 – discomfort that may disappear during warm-up but reappears at the end of the activity. A load management protocol is advised to avoid further progression of the injury.


Stage 3 - discomfort that gets worse during the activity. It is essential to confirm the condition may have progressed to a stress fracture. Immediate rest is recommended before undertaking a load management protocol.


Stage 4 – pain or discomfort all the time. Likely due to a stress fracture. All activity must immediately cease. Professional guidance is essential to exclude stress fractures or more significant tibia fractures.


The complex nature of the syndrome, and the varying severity, means that the treatment approach also changes. However, thinking back once again to our Anatomy and Physiology 101, it's starting to become clear why rest and a load management protocol, are the most reliable treatment options cited in the literature [1,3,5,6].


As a clinician, you can identify other factors associated with the injury; however, the best results are achieved when used in conjunction with a load management protocol (or program).Orthotics and appropriate footwear have been shown to reduce the incidence of MTSS and can prevent repeat episodes [1,3,6,7].


But here is the thing, as a former athlete, I can tell you that being told to rest and slowly and methodically rebuild your volume is one of the worst things you can hear. And, because of the fact you, the clinician, are dealing with a population who live to work hard, poor compliance is often associated with load management protocols particularly, as symptoms begin to subside.


The Australian idiom, she'll be right, can be seen in full swing as the pain severity begins to decline.

Solushin team member, William McNamara MD

How can we minimise the time at reduced load for athletes?

A question my team and I asked back in 2015 was, "how do we minimise time at reduced load?"


All of us athletes with access to high-quality treatment, we were smart enough to understand that load management does generally work for MTSS and a variety of other overuse injuries. But, it was also incredibly frustrating. We also worked with and trusted our clinicians, whether they were physiotherapists, podiatrists or sports physicians.


Could we invent an adjunct medical device that, alongside a load management program and other prescribed therapies, solve this immense frustration?

The Hypothesis

After reviewing the literature, talking to clinicians and 100s of runners (amateur through to professional), we settled on the following hypothesis for an adjunct therapy to load management:

1. Compress the periostitis along the posteromedial tibial border

2. Reducing tension in the soleus muscle

We believed that compressing the periostitis may offer pain relief and aid in addressing the inflammation while reducing tension in the soleus muscle would help address the muscle imbalances often associated with MTSS.


It is also important to highlight that this wasn't to take away from current treatment methodologies. But, to see how we could add value to the treatment by quickening the return to pain-free running.


The Solushin

The Solushin applies counter traction to the distal one-third of the posteromedial tibial border with a compressive rod - the first half of the hypothesis.


Counter traction is also applied to the three origin sites of the soleus muscle: posterior to head of the fibula, mid-diaphysis and at the musculotendinous junction with the Achilles tendon. These counter traction nodes are similar to your thumbs performing trigger point therapy. The three origin sites of the soleus are known for their high tension, and as seen in clinical practice, by massaging these sites, we can cause a reduction in tension in the soleus - the second half of our hypothesis.

Compressive rod along tibial border

Node posterior to head of fibula

Node at mid-diaphysis

Node at Achilles tendonitis

While the strapping is attached to a black sleeve, the sleeve offers no compression. Let's have a quick thought experiment:
  1. You pull a sheet taut and try to push your finger down through the sheet - the sheet resists the applied pressure
  2. The same sheet is now loose, and you try to push your finger down through - there is little to no resistance
The tighter the sleeve gets, the lesser the amount of counter traction is successfully applied.

In the RCT, participants wore the Solushin for ~ 3 times per week with an average wear time of 100 minutes. After compiling this research and keeping an open feedback loop with clinics using the Solushin, we recommend 1-hour per day before or after exercise.

Clinical Evidence

Double-blinded randomised controlled trial (pending publication)

To reiterate, the big question for us was, "how do we minimise time at reduced load?"


We worked alongside two Sydney sports medicine practices to conduct a double-blinded randomised controlled trial (RCT) using the Solushin as an investigational device. Participants in both groups were given load management protocols and recorded all other therapies they undertook during the RCT. The placebo group received a Solushin with no counter traction nodes or compression rod - effectively a sleeve with graded compression in the form of horizontal strapping. The key measurements were pain severity and time returned to full-load.


The investigational device demonstrated a significant reduction in MTSS symptoms from 5 weeks that were sustained over 6-months compared to the placebo. Clinically, it has the potential to benefit patients with MTSS as a useful adjunct to current treatment modalities. We were pretty happy with the promising results that demonstrated that faster return to sport.


As the study is pending publication, I couldn't go into too much detail (it's still confidential). However, happy to chat through it with anyone. Just reach out.

ANkle range of motion study (pending publication)

We also did a small study that demonstrated the Solushin's ability to improve knee-to-wall measures by 21% after an hour of wear. We did this at the request of numerous clinicians who saw the additional benefits of reducing the tension in the soleus. This small study has it's obvious limitations (what are the long term outcomes?); however, it shows promising data that we hope to build on in the future.

So, when to use the Solushin for MTSS?

It's essential now to lay the foundations of when to and when not to use the Solushin. And, what can be expected from using it. We did not set out to make a gimmick that solves everything, including headaches.


Thinking back to the four stages

Part of the exclusion criteria for the RCT was a stress fracture, as seen earlier in stage 4 MTSS. While the Solushin may help in the medium to long-term, we do not recommend its use. However, for stages 1-3 MTSS, the Solushin is an adjunct you might want to consider for your patient alongside a load management program. 


What to expect when using the Solushin

As an overuse injury, patients with MTSS often present with symptoms earlier in the season. However, that isn't always the case. Sometimes the she'll be right approach has let them down, and they haven't been able to shake the symptoms. Or sometimes, a sudden increase in volume at the end of the season (finals) has enveloped them with the painful symptoms. Is an athlete going to reduce their load at the end of the season?


This gives us two scenarios to consider:

  1. An athlete who can undertake a load management protocol
  2. An athlete who cannot
The expectations of these scenarios are different and should be an essential consideration. 

Load management is possible.

If the athlete can unload and manage the reloading methodically, we highly recommend the Solushin be used as an adjunct. In the short-term, the athlete can expect a reduction in pain during and immediately after wearing the Solushin. Their shin pain will (very) likely return during exertion; however, with consistent usage, they will typically run with no shin pain within 5-weeks.


We also don't recommend you throw other treatment methodologies out the door. In addition to load management, if you believe other treatments can be utilised (form training, dry needling, etc.), we think you should continue to use them.


We have designed a return to full activity protocol based on the methods and results from the RCT that can be provided with all Solushin's. However, it lacks the personalisation you can give to a patient as an educated clinician. 

Load management not possible

For an athlete who cannot rest and reload, the Solushin can also provide results. A key satisfaction for users is the reduction in pain in the short-term; this is with or without load management. If you have an athlete who is in pain but needs to make it through the next two weeks (for example), the Solushin can provide the safety net they need to get through.


We have also had athletes successfully treated MTSS without a load management protocol, but the data isn't there to say this reflects typical use yet. It is also worth highlighting that we don't have the data to suggest that the Solushin will prevent a stress fracture if the athlete continues to over-exert themselves. As a result, we recommend you keep them under observation during this period.

Please reach out!

If you are interested in hearing more, please contact me directly via my email at the bottom of this article.


If you are hesitant, I understand- there have been plenty of products introduced to the market that did not do what they promised to do. But here is where we differ, we were also victims of those gimmicky products so, while we make no claims to this being the magic Wham! And the pain is gone; we have built our foundations on clinical evidence only claim what we have demonstrated.


We also work with clinics so we can continue to develop our clinical perspectives and make you a device that improves the quality of treatment you can provide, rather than making it obsolete.


If you've made it this far down, thank you for giving it a read! Don't forget to contact me. It'd be great to chat and hear your thoughts.


- Ben Lindsay

ben@solushin.com


About the author:

Ben Lindsay is the Managing Director and engineer behind the Solushin medical device. A former national medalist swimmer, Ben aspires to learn from physicians, physiotherapists and podiatrists so he can develop tools to improve the quality of care for their patients.

References

  1. Beck, B. (1998). Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med, 26(4), 265-79.
  2. Detmer, D. (1986). Classification and management of medial tibial stress syndrome Sports Med, 3(6), 436-46.
  3. Fredericson, M., Bergman, G., Hoffman, K. & Dillingham, M. (1995). Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med,23, 427-81.
  4. Fredericson, M. (1996). Common injuries in runners. Diagnosis, rehabilitation and prevention. Sports Med, 21, 49-72.
  5. Wilder, R. & Seth, S. (2004). Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med, 23, 55-81.
  6. Couture, C. & Karlson, K. (2002). Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints’. Phys Sportsmed, 30(6), 29-36.
  7. Thacker, S., Gilchrist, J., Stroup, D. & Kimsey, C. (2002). The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc, 34(1), 32-40.

1 comment

  • Cherylene Anderson

    Hi, my 14 year old daughter is having major problems with shin splints in both legs and it is hampering her ability to train and play sport. At the moment she is playing rugby league and touch football. We have tried different shoes and physio but not really helping. Do you think the Solushin would be suitable for her to use.

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