Medial tibial stress syndrome (MTSS) develops when too much stress is placed on the tibia (main shin bone). The muscles that attach to the tibia can cause an overload of stress on the bone, and strain themselves at their insertion onto the bone as well. These muscles include the posterior tibialis muscle, the soleus muscle, and the flexor digitorum longus muscle.
The most common risk factors of MTSS include:
Flattening of the arch of the foot (overpronation) while standing and walking/running
Participation in a sport that requires repetitive jumping and/or running
Excessive hip motion (moving the hip through a greater range than is typical)
A high body mass index (>20.2 BMI)
A previous running injury
How Does it Feel?
If you have developed MTSS, you may feel pain in the middle or bottom third of the inside of the shin. The pain may be sharp when you touch the tender area, or occur as an ache during or after exercise. Generally, however, the pain is initially provoked with activity and lessens with rest. When MTSS is developing, the pain may be present during the beginning of exercise and less noticeable as exercise progresses. Over time, the condition can worsen and pain may be felt throughout any exercise regimen and continue after exercise.
How Is It Diagnosed?
Your physical therapist will perform a thorough examination that will include taking a full health history and observing you as you walk and perform the activity that causes your symptoms, such as running or jumping.
Your physical therapist will further perform a series of tests and measures of your musculoskeletal system that assess your strength, mobility, flexibility, and pain response. The most reliable symptom of MTSS is pain felt when pressure is applied to specific locations on the shin.
If the results of the examination suggest MTSS, your physical therapist will discuss with you the goals of treatment and develop a specialized rehabilitation program for you. If a more serious condition could be contributing to your pain, you may be referred to a physician for further tests.
How Can a Physical Therapist Help?
Your physical therapist will determine what risk factors have caused your MTSS and will teach you how to address those causes. A treatment plan will be developed that is specific to you and what your body needs to recover and to prevent reinjury.
To relieve pain, your physical therapist may prescribe:
Rest from the aggravating activity or exercise
Icing the tender area for 5 to 10 minutes, 1 to 3 times a day
Exercises to gently stretch the muscles around the shin
Taping the arch of the foot or the affected leg muscles
Hands-on massage of the injured tissue
To help strengthen weak muscles, your physical therapist may teach you:
Exercises that increase the strength of hip rotation, hip abduction (lifting the leg away from the other leg), and hip extension (lifting the leg behind your body) to decrease stress to the lower leg
Exercises that increase your arch and shin muscle strength to decrease the overpronation (flattening out) of the arch of the foot
Your treatment also may include:
Calf and foot muscle stretches
Single-leg exercises including squats, reaching exercises, or heel raises
Modified take-off and landing techniques for jumping athletes
Modified leg and foot control during walking and running
Suggestions for footwear that provides better support when walking or exercising
Your physical therapist also may prescribe orthotics or shoe inserts that support the arch of the foot if your feet flatten out too much, or if your foot muscles are weak.
Physical therapists help athletes with MTSS alter their training schedules to safely return to sport, and offer specific guidance for reducing the possibility of reinjury.
Can this Injury or Condition be Prevented?
To prevent MTSS, physical therapists recommend that you:
Get an annual functional fitness examination, including strength, flexibility, mobility, and sport-specific analyses.
Perform dynamic stretches before exercising and static stretches after exercising.
Perform strength and endurance exercises for the foot, hip, and pelvic muscles.
Perform balance exercises on each leg.
Follow a recommended training program when starting or increasing an exercise program. MTSS is commonly seen in the early part of a person’s training or the beginning of an athlete’s season. All exercise programs should begin gently and progress slowly.
Choose appropriate footwear for the activity that is being performed.
Choose appropriate cross-training activities to condition the core and leg muscles.
Exercise on a softer, more pliable surface whenever possible.
Your physical therapist can teach you exercises to ensure maximum strength and health, and prevent MTSS.
Real Life Experiences
John is a 35-year-old high school teacher who is training for his third half marathon. Recently, John began to feel shin pain in both legs during the first mile of his runs, which went away during the remaining miles. Over the next few days, the pain lasted longer during his run. John had been to physical therapy before for treatment of a knee problem. Concerned that he might be causing a new injury, John contacted his physical therapist.
John’s physical therapist begins his session with a detailed interview concerning his shin pain. She also asks John about his general health to rule out any other condition that could be a contributing factor to his pain.
John's physical therapist conducts a thorough examination to assess his pelvic, trunk, hip, leg, foot, and ankle strength. She asks him to try to hold test positions as she applies pressure to his legs and hips. John can't hold his position when she applies pressure to the hip area. During further tests, John demonstrates excessive flattening of each of his feet, and his knees show weakness. John’s physical therapist applies pressure to the muscles surrounding the shins and reproduces pain over the muscles on the lower one-third of the inside of the shin on each leg. She diagnoses MTSS in both legs.
John’s physical therapist begins his treatment by applying gentle massage to the painful area in both shins. She shows John how to apply ice to the painful areas for 5 to 10 minutes, 1 to 3 times a day. She teaches him gentle strengthening exercises for the hip and foot muscles. She also recommends that he temporarily modify his training program to run fewer overall miles, and to stop when his symptoms reappear. She offers John suggestions for specific footwear that will provide better support and cushioning, and educates him about choosing safer surfaces to run on when he resumes his full marathon training.
Because John sought help as soon as his symptoms began, after 2 weeks of treatment, his pain is much less. He slowly rebuilds his marathon training program with the advice of his physical therapist. He continues his prescribed exercise regimen and his physical therapy treatments for a few more weeks.
The following month, feeling stronger than he has in years, John competes pain free in the half marathon, and is proud to report a personal-best finishing time!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat MTSS. However, you may want to consider:
A physical therapist who is experienced in treating people with MTSS, or who has experience treating patients who participate in your sport.
A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopaedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you’re looking for a physical therapist (or any other health care provider):
Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience helping people who have MTSS.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of MTSS. The articles report recent research and give an overview of the standards of practice for treatment of it both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Newman P, Witchalls J, Waddington G, Adams R. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013;4:229–241. Free Article.
Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes: a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:12. Free Article.
Moen MH, Bongers T, Bakker EW, et al. Risk factors and prognostic indicators for medial tibial stress syndrome. Scand J Med Sci Sports. 2012;22(1):34–39. Article Summary on PubMed.
Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome: a critical review. Sports Med. 2009;39(7):523-546. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Stephen Reischl, PT, DPT. He is a board-certified orthopaedic clinical specialist. Authored by Kari Brown Budde, PT, DPT. She is a board-certified sports clinical specialist. Reviewed by the MoveForwardPT.com editorial board.