Have you ever laced up your trainers, eager for a run, only to be stopped mid‑stride by a deep, nagging pain along the inside of your shin? If you have, you are not alone—and you are not weak, unfit, or doing something “wrong.” You may be dealing with Medial Tibial Stress Syndrome (MTSS), more commonly known as shin splints.

I still remember a young amateur footballer I treated during my clinical rotations who insisted the pain was “just soreness.” Two weeks later, he could barely jog. What struck me most was not the injury itself—but how preventable its progression was with the right physiotherapy approach at the right time. That experience shaped how I now explain and manage MTSS: not as a minor inconvenience, but as a warning signal from the musculoskeletal system that deserves attention.

This article provides a clinically grounded, evidence‑based, and patient‑centred guide to Medial Tibial Stress Syndrome and its physiotherapy management. It draws on peer‑reviewed research, real clinical practice, and expert consensus to help you understand what MTSS is, why it happens, and how physiotherapy treats it effectively—not just temporarily, but for long‑term recovery and recurrence prevention.

What Is Medial Tibial Stress Syndrome?

Medial Tibial Stress Syndrome is an overuse injury characterised by diffuse pain along the posteromedial border of the tibia (the inner edge of the shin bone). It is most common in runners, footballers, military recruits, dancers, and anyone exposed to repetitive impact loading.

Unlike stress fractures—which produce localised, pinpoint pain—MTSS presents as a broad, aching discomfort that often worsens during activity and eases with rest, at least in the early stages.

A Simple Way to Understand MTSS

Think of your tibia as a beam repeatedly bent by ground‑reaction forces. Each foot strike sends vibrations through the bone and surrounding soft tissues. When load exceeds the body’s capacity to adapt, the periosteum (the bone’s outer lining) becomes irritated. Over time, this micro‑trauma accumulates, resulting in MTSS.

Professor Michael Fredericson, a leading sports medicine physician at Stanford University, describes MTSS as “a failure of the bone‑remodelling process under repetitive stress.” In other words, the problem is not movement itself—but unmanaged load.

Why MTSS Should Not Be Ignored

MTSS is often dismissed as a minor injury. This is a mistake.

Research published in Sports Medicine shows that up to 20% of MTSS cases can progress to tibial stress fractures if loading continues without appropriate intervention. What begins as discomfort can evolve into months of enforced rest.

From a physiotherapy perspective, MTSS is valuable because it highlights faulty biomechanics, training errors, or strength deficits that—if left unaddressed—may lead to more serious injuries higher up the kinetic chain, including knee, hip, or lower back pain.

Key Causes and Risk Factors (What Actually Leads to Shin Splints)

MTSS rarely has a single cause. It is typically the result of multiple interacting factors.

Training‑Related Factors

• Sudden increase in running volume or intensity
• Transition from treadmill to road or trail running
• Inadequate recovery between sessions
• High‑impact sports on hard surfaces

Biomechanical Factors

• Excessive foot pronation
• Reduced ankle dorsiflexion
• Weak calf musculature (especially soleus)
• Poor hip and core control

A 2014 systematic review in British Journal of Sports Medicine identified navicular drop (a marker of pronation) and higher body mass index as consistent risk factors for MTSS.

Equipment and Environmental Factors

• Worn‑out footwear with reduced shock absorption
• Inappropriate shoe type for foot mechanics
• Hard or cambered running surfaces

How Physiotherapists Clinically Diagnose MTSS

MTSS is primarily a clinical diagnosis, not a radiological one.

A physiotherapist will typically assess:

• Pain distribution along the medial tibia (usually >5 cm in length)
• Pain reproduced with hopping or running
• Palpation tenderness along the posteromedial border
• Movement screening of the ankle, knee, hip, and trunk

Imaging such as MRI is reserved for ruling out stress fractures, particularly when pain becomes localised or persists at rest.

Evidence‑Based Physiotherapy Treatment for MTSS

Physiotherapy management of MTSS is not about a single exercise or modality. It is a progressive, load‑guided rehabilitation process.

Phase 1: Pain Reduction and Load Management

The first step is not complete rest—but relative rest.

In practice, this means:

• Reducing running mileage rather than stopping abruptly
• Substituting with low‑impact cross‑training (cycling, swimming)
• Temporary avoidance of painful surfaces

Clinical experience and systematic reviews agree that absolute rest alone does not resolve MTSS. Controlled loading is essential for bone adaptation.

Modalities such as cryotherapy may help symptom relief, but they are adjuncts—not treatments.

Phase 2: Restoring Mobility and Tissue Capacity

Restricted ankle dorsiflexion is one of the most overlooked contributors to MTSS.

Physiotherapy interventions include:

• Ankle joint mobilisation
• Soft tissue techniques targeting soleus and tibialis posterior
• Calf stretching with knee‑bent emphasis (to bias soleus)

A randomised trial in Journal of Orthopaedic & Sports Physical Therapy demonstrated that addressing ankle mobility significantly reduced symptom recurrence in runners with MTSS.

Phase 3: Strengthening (The Most Critical Component)

This is where many generic programmes fail.

Physiotherapy focuses on progressive loading, not just isolated exercises.

Key strengthening targets include:

• Soleus muscle (slow, heavy calf raises)
• Tibialis posterior (controlled inversion and plantarflexion)
• Hip abductors and external rotators (to control lower‑limb alignment)
• Intrinsic foot muscles (short‑foot exercises)

Dr Rich Willy, a renowned running biomechanics researcher, emphasises that “tissue tolerance improves when muscles are loaded slowly and progressively—not when they are avoided.”

Phase 4: Gait Retraining and Functional Return

Once pain is controlled and strength improves, physiotherapy shifts toward movement re‑education.

This may include:

• Increasing running cadence to reduce tibial loading
• Addressing over‑striding
• Gradual exposure to impact through plyometrics

A 2019 study in Medicine & Science in Sports & Exercise showed that small gait modifications can reduce tibial stress by up to 20%, making this phase crucial for long‑term success.

Do Orthotics Help in MTSS?

Orthotics are not a universal solution, but they can be useful in selected cases.

Evidence suggests that prefabricated orthoses may reduce pain in individuals with excessive pronation, particularly when combined with exercise therapy. However, orthotics should be viewed as a temporary load‑management tool, not a replacement for rehabilitation.

How Long Does Recovery Take?

With structured physiotherapy, most individuals recover within 6–12 weeks.

Delays occur when:

• Pain is repeatedly ignored
• Training errors are not corrected
• Strength deficits are left unaddressed

The earlier MTSS is treated, the faster and more complete the recovery.

Actionable Takeaways You Can Apply Today

• Do not run through persistent shin pain
• Reduce load, not movement entirely
• Strengthen calves slowly and progressively
• Check your footwear age and suitability
• Seek physiotherapy early—not after months of pain

How We Treat MTSS at Cure On Call

At Cure On Call, we manage Medial Tibial Stress Syndrome through individualised, evidence‑based physiotherapy, delivered both in‑clinic and via guided tele‑rehabilitation. Our approach focuses on precise clinical assessment, progressive load management, and long‑term injury prevention rather than short‑term pain relief. Whether you are an athlete, recreational runner, or someone whose work demands prolonged standing, our physiotherapists design recovery plans that fit your lifestyle—so you return stronger, not just symptom‑free.

Frequently Asked Questions (FAQs)

Is MTSS the same as a stress fracture?

No. MTSS involves diffuse periosteal irritation, whereas stress fractures produce localised bone damage. However, untreated MTSS can progress to stress fractures.

Can I keep running with shin splints?

Modified running may be possible in early stages, but this should be guided by a physiotherapist to avoid worsening the condition.

Do compression sleeves help?

They may provide short‑term comfort but do not address the underlying causes of MTSS.

Is physiotherapy necessary?

Evidence strongly supports physiotherapy for faster recovery and reduced recurrence compared to rest alone.

Final Thoughts

Medial Tibial Stress Syndrome is not a sign of weakness—it is a signal. When managed early and correctly through physiotherapy, it becomes an opportunity to rebuild stronger movement patterns, improve performance, and prevent future injury.

If you have experienced shin pain, I invite you to share your experience. What triggered it—and what helped? Your insight may help someone else take action before pain turns into injury.

Read Also: Exercises for the Treatment of Tennis Elbow