Shin splints (MTSS) in runners 2026 update

Clinical synthesis based on the most recent meta-analyses and international consensus statements: Winters 2018, Hamstra-Wright 2015, Warden 2014, Bezerra 2025 and the LIMP 2025 debate.

What are the fundamentals to know about shin splints (MTSS) in runners?🔗 Copy

Shin splints, more rigorously called medial tibial stress syndrome (MTSS) in the scientific literature, is one of the most common overload conditions in runners and military personnel.¹ The historical term “periostitis” is misleading, because the pathophysiology is not dominated by periosteal inflammation but by a bone stress reaction within the tibia, set within the continuum of bone stress injuries (BSI).²

How is this condition defined, who does it affect and what are the risk factors?

MTSS is defined as exercise-induced pain along the posteromedial border of the tibia.¹ The consensus diagnostic criterion, prospectively validated by Winters and colleagues (BJSM 2018), requires the pain to be reproducible on palpation over at least 5 continuous cm.³ This “diffuse” character is essential in distinguishing it from a stress fracture, whose pain is focal.

The epidemiology has been refined by several recent systematic reviews 🏃 :

• In recreational and competitive runners, MTSS incidence ranges from 5 to 19 % depending on the cohort (Lopes 2012, Hamstra-Wright 2015).⁴,⁵
• In military recruits, incidence reaches 35 to 56 % according to the narrative review by Alessa et al. 2024 (Cureus), with a landmark study by Yates & White 2004 (AJSM, n = 124 naval recruits) reporting 35 % incidence over 10 weeks of training.⁶,⁷
• MTSS accounts for 13 to 17 % of all running-related injuries (Lopes 2012).⁴
• The Saad 2025 scoping review confirms wide geographical heterogeneity: prevalence from 5.4 % (USA) to 69.5 % (India) depending on the practice setting.⁸

The landmark meta-analysis by Hamstra-Wright et al. (BJSM 2015), pooling data from prospective cohorts of runners and military personnel, identified five risk factors with a significant pooled effect and low statistical heterogeneity :⁵

• Female sex , with an increased relative risk that is particularly marked in military cohorts (Yates 2004: 53 % of women vs 28 % of men).⁵,⁷
• Higher body mass index (BMI).
• Increased navicular drop (navicular drop), a marker of excessive pronation.
• Previous running injury.
• Increased hip external rotation range with the hip flexed.

A previous episode of MTSS is itself one of the strongest predictors of recurrence (Newman 2013 in Open Access J Sports Med, which independently confirmed three of these factors).⁹

What happens in the body and how does the condition evolve naturally?

The modern pathophysiology of MTSS, supported by the critical reviews of Moen 2009, Beck 1998 and Warden 2014, places the condition on a continuum of bone overload of the tibial cortex, not as simple periosteal inflammation.¹⁰,¹¹,² The central mechanism is repeated mechanical overload that exceeds the capacity of bone to adapt and remodel. 🦴

The process unfolds in several stages:

1. Cumulative load : the repeated impacts of running drive accelerated bone remodelling.
2. Resorption / formation imbalance : if volume or intensity outstrips adaptation, the rate of osteoclastic resorption exceeds osteoblastic formation.
3. Microdamage and cortical porosity : the negative balance leads to an accumulation of microfractures, increased porosity of the tibial cortex and reduced bone stiffness.²,¹¹
4. Diffuse pain : this stress reaction shows itself clinically as the characteristic pain over ≥ 5 cm.

Histological analysis (Johnell 1982, cited by Beck 1998) showed that the lesion involves not only the periosteum but also the bony cortex and the marrow, definitively reorienting management towards mechanical load management rather than towards anti-inflammatories.¹¹

The natural course can be unfavourable if load is not modified. Warden et al. (2014) describe a clinico-radiological spectrum running from normal adaptive remodelling all the way to complete fracture, by way of stress reaction (MRI bone oedema, Fredericson grade 1-3) and incomplete stress fracture (Fredericson grade 4).²,¹² Training on despite the pain encourages microdamage to coalesce.

How do you assess and diagnose shin splints (MTSS) with certainty?🔗 Copy

The diagnosis of MTSS rests essentially on the clinical examination, with sensitivity and reliability validated prospectively by Winters 2018 in 46 patients (high inter-examiner kappa for palpation of the painful length).¹ Imaging is not required first line, except where the diagnosis is in doubt or a stress fracture is suspected. 🏃

Which questions should you ask to understand the patient and their history?

History-taking aims to reconstruct the story of the injury and to identify training errors, the main triggering factor.² The lines of questioning:

• Pain characteristics : dull, diffuse pain along the distal third of the posteromedial border of the tibia, appearing during exercise, sometimes easing initially after the warm-up, then returning with greater intensity as activity continues or once it stops.²,³
• Training history : any rapid increase in volume, in intensity, in frequency or any change of surface (moving from track to road) or of footwear in the 4 to 6 weeks preceding symptoms is suspicious.⁴
• Past history : a previous episode of MTSS or of running injury is one of the strongest predictors of recurrence.⁵
• Systemic factors : systematically ask about energy intake, the menstrual cycle in women, a history of stress fractures and glucocorticoid use (flags for RED-S and high-risk BSI).
• Biomechanical factors and equipment : type of footwear, wear, insoles, foot type (more pronated = increased risk, with RR 1.7 in Yates 2004).⁶

Which clinical tests should you perform and which other conditions should you rule out?

The central clinical test is the “Shin Palpation Test” : palpation reproduces the pain over a continuous length of at least 5 cm along the posteromedial border of the tibia, usually in its distal third. Inter-examiner reliability has been shown to be good to excellent (Winters 2018, kappa 0.76).¹ 🔬

Other tests are useful:

• Hop test (10 single-leg hops on the spot) : sharp, focal pain should raise the suspicion of a stress fracture rather than MTSS.⁷
• Fulcrum test : bimanual pressure on the tibia; positive if localised pain suggests a fracture (Milgrom 2021).⁷
• Functional tests : single-leg heel raises (the ability to perform 20-30 repetitions without pain is a progression criterion), single-leg squat (looking for pelvic drop and dynamic valgus).

The critical differential diagnosis is the tibial stress fracture, which sits on the same continuum (Warden 2014).⁸ Signs pointing towards a fracture:

• Very localised pain (< 5 cm) over an exquisite point.
• Pain at rest, or even at night (red flag).
• Positive hop test.
• Persistence despite properly applied relative rest.

In chronic exertional compartment syndrome (CECS) the pain is cramping and predictable, building during exercise and resolving within a few minutes of stopping. The reference standard for diagnosis remains measurement of intra-compartmental pressure, as confirmed by the recent systematic review Dean 2023 (J ISAKOS, 25 surgical studies, 1018 patients; fasciotomy gives a return to sport of 26 to 100 %).⁹,¹⁰

More rarely, popliteal artery entrapmentcan mimic MTSS: look for loss of the dorsalis pedis pulse on resisted plantarflexion and confirm with dynamic duplex ultrasound.

Should patients with MTSS be classified, and what are the benefits?

Yes: classifying MTSS helps to assess severity, set a prognosis and guide the rehabilitation strategy, particularly the return to running.

A clinical classification into 4 grades, derived from Galbraith & Lavallee (2009) and widely used:¹¹

This grading has clear prognostic value : grade 1 allows modified activity to continue, whereas grade 4 requires withdrawal from sport and thorough reassessment (suspicion of an associated stress fracture).

For suspected BSI, the Fredericson MRI classification (1995) remains the reference standard:¹²

• Grade 1 : isolated periosteal oedema.
• Grade 2 : marrow oedema visible on T2 sequences.
• Grade 3 : marrow oedema on both T1 and T2 sequences.
• Grade 4a : multiple areas of intracortical signal.
• Grade 4b : visible fracture line (significantly longer recovery time).

Validation of this MRI classification by Nattiv 2013, confirmed by paediatric studies (Stein 2020), shows that grade 4b significantly lengthens the time to return to sport.

Critique and controversy: the “MTSS → LIMP” debate (Anderson 2025)

🤔 The nomenclature itself has been debated for a long time. The term “periostitis” is anachronistic, because the histological data do not support predominant periosteal inflammation.¹¹ More recently, Anderson & Beck (JOSPT 2025) propose renaming MTSS as LIMP (Load Induced Medial-Leg Pain).¹³ Their argument:

• The term “tibial stress” is confused with “bone stress injury” (BSI), leading to excessive and unjustified rest.
• The exact pathophysiology of MTSS remains debated : bone overload, traction on the deep crural fascia by soleus/tibialis posterior, or both?
• “LIMP” steers management towards load management without presupposing the underlying pathology.

This proposal has yet to reach consensus, but it reflects an important conceptual shift: clinically distinguishing MTSS (diffuse pain, low risk of rapid progression) from BSI (focal pain, potentially high risk) matters more than a purely etymological debate.

Which treatment strategies are the most effective?🔗 Copy

The effectiveness of MTSS treatment rests on rigorous management of mechanical stress and on progressively increasing the capacity of the tissue to tolerate it.¹ Exercise and education are far better supported by evidence than passive therapies.

Where do you start? What is the recommended hierarchy of interventions?

The first and most crucial intervention is load management.¹,² This is not complete rest, which deconditions the tissue, but a reduction of activity to a level that provokes no pain during, after or the day following exercise. The therapeutic hierarchy:

What is the place of exercise, and is there a superior approach?

Therapeutic exercise is a central pillar. 🏃 It aims to improve the capacity of the lower leg complex to absorb and transmit forces. Effective programmes share the principle of progressive loading (Warden 2014).¹

Priority muscle targets:

• Soleus and tibialis posterior : major pivots in controlling pronation and absorbing impact when running (Verrelst 2014).³
• Hip abductors and external rotators : a recent RCT by Atalla et al. (J Orthop Surg Res 2024, n = 40 runners with MTSS) shows that 8 weeks of functional hip abductor strengthening, combined with a standard PT programme, significantly reduce pelvic drop and dynamic knee valgus when running.⁴ This effect is consistent with the kinetic-chain pathomechanics identified by Bramah 2018 (AJSM).⁵
• Foot intrinsics : useful for medial longitudinal stability.

Progression follows a classic model: isometric → concentric → eccentric → plyometric, always within a tolerable pain threshold (≤ 2/10 according to Crowell-Davis 2011).⁶

For prevention, the reference meta-analysis is now that of Bezerra et al. (Gait Posture 2025, 12 RCTs, 8197 participants, GRADE assessment) :⁷

• The use of neuromuscular training (4 studies, 3887 participants) is recommended for prevention in young female athletes and military recruits.
• Likewise, anti-pronation orthoses (overpronation insoles) (4 studies, 1047 participants) are recommended for prevention in military recruits.
• This conclusion converges with the landmark RCT by Bonanno 2018 (BJSM, n = 306 Australian naval recruits), which showed a 34 % reduction in the combined risk of MTSS / patellofemoral pain / Achilles tendinopathy / plantar fasciitis with prefabricated orthoses.⁸

Manual therapies, shockwave: how effective are they really?

Passive therapies are often used, but the evidence is heterogeneous:

Focused extracorporeal shockwave therapy (ESWT) has been the subject of encouraging studies (Bagherzadeh-Cham 2022 systematic review, and the Moen 2012 pilot RCT) showing a reduction in pain and in time to return to sport in chronic MTSS.⁹ Methodological heterogeneity nevertheless remains high, and shockwave must never replace active treatment.

Passive manual therapies (massage, dry needling, mobilisations) have not shown robust efficacy on the underlying pathology. They can bring short-term symptomatic relief but do not change the bone continuum.

Beyond the physical: education and psychological factors

Therapeutic education is probably the best-value intervention. 🧠 It covers:

• The nature of the injury : MTSS is a bone overload on a continuum, not a simple inflammation. Understanding this defuses the fear and underpins load management.
• Modifiable training errors : volume, intensity, surface, cadence, footwear.
• Interpreting the pain : pain ≤ 2/10 that disappears within 24 h = tolerable overload; residual pain = overload to be corrected.
• Optimising systemic factors : sleep, nutrition (calcium, vitamin D), stress management, RED-S screening (see chapter 6).¹⁰

How do you secure lasting recovery and prevent recurrence?🔗 Copy

Preventing recurrence is a central concern: without appropriate management, the recurrence rate is high. It rests on two pillars: making the patient autonomous and planning a criteria-based return to running, not a fixed calendar.¹

How do you make the patient an active participant in their recovery through self-management?

Therapeutic education is the cornerstone of prevention. 🏃‍♂️ Making the patient competent turns their role from passive to active, which is a major prognostic factor.²

Self-management is built around three levers:

1. Understanding the mechanism : the patient must take on board that MTSS is the result of a load exceeding the capacity of bone to adapt, not a matter of bad luck.³
2. A daily monitoring tool : a training log (on paper or in an app such as Strava/TrainingPeaks) recording distance, duration, perceived intensity (RPE), pain 0-10 makes the cause-and-effect relationship objective.⁴
3. A simple “traffic light” rule : described by Moen 2009 and widely adopted:¹

Adherence to the home exercise programme is just as central. Progressive strengthening of the soleus, the tibialis posterior and the hip abductors must become a long-term maintenance routine , even in the absence of pain.⁵

When and how should a safe return to running be planned?

Return to running is a process that is progressive, individualised and criteria-based. 📈 Rushing the return is one of the main causes of recurrence.

Functional prerequisites before resuming running:

• Brisk walking for 45 minutes with no pain at all.¹
• The ability to perform 20 to 30 single-leg heel raises without pain.
• Negative hop test bilaterally.
• No pain on palpation at rest.

The graded Moen 2009 protocol remains the reference, a progressive walk/run alternation over several weeks, respecting the tolerable pain threshold. One guideline (not validated by RCT, but widely adopted) is not to increase the total running volume by more than 10 % per week.⁶

During this phase, three parameters must be monitored:

1. Pain : ≤ 2/10 during and after, resolving within 24 h.
2. Running technique : this is the ideal moment for gait retraining. A cadence increase of 5 to 10 % significantly reduces tibial impact forces (Crowell-Davis 2011, Luedke 2016).⁷,⁸
3. Strengthening : continue and intensify in parallel, introducing plyometrics once tolerated.

Critique and controversy: the “10 % rule” and pronation

💡 The famous “10 % rule” for weekly increases is a clinical heuristic, not a rule validated by a high-quality controlled trial. Some trained runners tolerate more; novices and post-injury patients may need an even slower progression.Individualisation guided by pain takes priority.

Meanwhile, excessive pronation (increased navicular drop) is a robust risk factor (Hamstra-Wright 2015), but routinely prescribing orthoses is not universally beneficial. The Bezerra 2025 meta-analysis (GRADE) recommends anti-pronation orthoses only for prevention in military recruits ; in recreational runners, their place remains to be individualised according to the biomechanical profile.⁵

What do real clinical cases teach us?🔗 Copy

Clinical cases shed valuable light on how evidence-based principles are applied in practice, provided they are placed correctly in the hierarchy of evidence (level 5 on the Oxford CEBM scale). 🧐

A real case: novice runner (Ramteke 2024)

The case report by Ramteke & Jaiswal (Cureus 2024, PMC 11417438) illustrates the typical management of MTSS in a novice runner.¹ Presentation:

• Patient : a 22-year-old man, a novice runner who had rapidly increased his weekly volume.
• Symptom : severe pain along the medial border of the tibia, worse during running.
• Examination : palpation reproducing the pain over a diffuse posteromedial area (consistent with the Winters 2018 criteria).

The multifaceted management over 6 weeks :

• Phase 1: pain relief, relative rest (not complete rest).
• Phase 2: progressive strengthening and stretching of the lower limbs (soleus, tibialis posterior, hip abductors).
• Phase 3: progressive loading programme (progressive loading) to promote tissue healing and reduce recurrence.
• Phase 4: proprioceptive work and mobilisation techniques.

Outcome : considerable improvement in symptoms and function, a progressive return to running, and documented gains in lower-limb strength and flexibility.¹ This case shows that the fundamental principles (load management + progressive exercise + education) are enough in the great majority of uncomplicated MTSS.

Another recent RCT (Atalla 2024, n = 40 runners with MTSS) clinically confirms the added value of functional hip abductor strengthening over 8 weeks, with significant improvement in pelvic drop and in dynamic knee valgus compared with the PT programme alone.²

The diagnostic challenge: when MTSS mimics another condition

Three major mimics must be ruled out systematically:

• 🔍 Tibial stress fracture : the shift from diffuse pain to focal pain is a warning signal. Milgrom 2021 (n = 429 elite recruits) prospectively validated that the combination “pain + focal tenderness over < 1/3 of the tibial length + a positive hop or fulcrum test” identifies fractures effectively.³ MRI (Fredericson grading) remains the reference imaging.⁴
• 🔍 Chronic exertional compartment syndrome (CECS) : predictable cramping pain appearing after a few minutes of running and disappearing quickly on stopping. The systematic review Dean 2023 (J ISAKOS, 25 surgical studies, 1018 operated patients) confirms that measuring intra-compartmental pressure remains the reference diagnostic test; the return-to-sport rate after fasciotomy ranges from 26 to 100 %.⁵,⁶
• 🔍 Popliteal artery entrapment : rare, but to be considered where there are vascular symptoms (paraesthesia, a dead-leg sensation); the key sign is loss of the dorsalis pedis pulse on resisted plantarflexion, confirmed by dynamic duplex ultrasound.

Complex case studies

Some MTSS presentations prove recalcitrant despite well-conducted rehabilitation. The recent literature (Tenforde, Warden) highlights three avenues to explore in these cases:

1. Systemic factors: RED-S : energy intake that is insufficient for expenditure (Relative Energy Deficiency in Sport) compromises bone health and recovery.⁷ See the dedicated chapter below.
2. Psychological factors : kinesiophobia, catastrophising and performance anxiety can slow the return to sport; a cognitive-behavioural approach coupled with therapeutic education is then indicated.
3. Imaging to stratify : faced with chronic or bilateral MTSS, MRI (high-resolution T1/T2 sequences) locates the patient on the Fredericson continuum and distinguishes pure MTSS from low-grade BSI.⁴

The major systemic factor: RED-S and the BSI continuum🔗 Copy

Any recalcitrant, recurrent or bilateral MTSS should lead the clinician to assess the patient’s systemic background . The best-documented factor, and the most frequently under-diagnosed, is RED-S (Relative Energy Deficiency in Sport), recognised by the IOC since 2014 and substantially updated in 2023.¹,²

What is RED-S and when should you think of it?

RED-S describes a multi-system syndrome resulting from insufficient energy availability (low energy availability, LEA) , that is, a calorie intake too low for the demands of sport, independently of any formal eating disorder.² It replaces and broadens the older concept of the “female athlete triad” (Nattiv 2007) by recognising that:

• It affects both sexes, despite a higher prevalence in female athletes.
• The consequences reach far beyond bone health: cardiovascular, immune, endocrine, psychological and performance-related.
• The IOC 2023 introduces the CARE score (Clinical Assessment of Risk in REDs), a three-level stratification tool (green / amber / red) that guides the decision to continue or stop sport and the need for multidisciplinary referral.²

The link with MTSS is direct: chronic LEA impairs bone healing, lowers mineral density and increases the risk of every bone stress injury (BSI), from moderate MTSS to high-risk stress fracture.³,⁴ A key study by Tenforde et al. (BJSM 2018) in 156 male middle-distance runners showed that athletes with a high “Triad cumulative risk” score have a multiplied BSI rate , demonstrating that the phenomenon is not exclusively female.⁵

BSI risk stratification: from MTSS to high-risk fractures

MTSS is the “benign” end of the continuum of bone stress injuries (BSI), which is divided into sites at low risk and high risk of complications (slow union, non-union, complete fracture).⁴,⁶

This stratification is crucial, because it determines:

• Imaging : MRI (Fredericson grading, more sensitive than scintigraphy) is the investigation of choice to confirm and stratify a suspected BSI.
• The mode of offloading : walking remains allowed for low-risk BSI; complete offloading is required for high-risk BSI (in particular the anterior tibial cortex “dreaded black line”).⁴
• Referral : any suspicion of high-risk BSI must lead to a prompt specialist medical consultation.

The recent international consensus (BJSM 2024) stresses that low-grade BSI can progress to severe grades if neglected, and that optimal management combines activity modification, nutritional optimisation and addressing the risk factors (including RED-S).⁶

Critique and controversy: is RED-S over-diagnosed or under-diagnosed?

🤔 The diagnosis of RED-S remains debated. The main criticisms:

• The precise biological markers of chronic LEA (LH pulsatility, T3, IGF-1) are hard to obtain routinely; the CARE-2023 score is still recent and needs large-scale external validation studies.²
• Causal attribution between LEA and an individual BSI remains probabilistic, not deterministic.
• But under-diagnosis is probably the greater problem : most runners with recurrent BSI are never assessed for their energy status.⁵

The recommended pragmatic stance: systematic clinical screening in every patient with recurrent or bilateral MTSS, or MTSS occurring in an at-risk athlete (gravity-restricted sport, dietary restriction, amenorrhoea). Where there is any doubt, refer promptly to a sports physician or a multidisciplinary team (doctor, nutritionist, psychologist where relevant).

How do you apply these recommendations concretely in your practice?🔗 Copy

Turning evidence into daily practice takes clinical skill, interprofessional communication and objective outcome measurement. 🧑‍⚕️ This section provides a pragmatic framework.

When and to which other health professionals should you refer?

Referral is a key skill of the modern physiotherapist. It rests on identifying the situations that exceed their scope of practice or that call for multidisciplinary management.

To the sports physician or the GP :

• The presence of a red flag suggesting a stress fracture, a systemic condition or RED-S.
• Failure of well-conducted conservative treatment over 3 to 6 months, to consider imaging (Fredericson MRI) and a specialist opinion.
• Any suspicion of high-risk BSI (anterior tibia, femoral neck, sacrum).

To the sports physician or the sports nutritionist : any patient with RED-S flags (see the previous chapter), recurrent MTSS, a young amenorrhoeic athlete, weight loss or dietary restriction.

To the podiatrist : for detailed biomechanical assessment and prescription of anti-pronation orthoses (recommended for prevention in military recruits according to Bezerra 2025).¹

To the pain psychologist : where yellow flags are present (catastrophising, kinesiophobia, performance anxiety) that slow rehabilitation down.²

Interprofessional collaboration improves outcomes and the efficiency of the care pathway (Cochrane review, Reeves 2017).³ Three keys: clear communication, shared goals, mutual respect for each other’s skills.

How do you measure outcomes and overcome barriers to implementation?

The systematic use of PROMs (Patient-Reported Outcome Measures) is the modern standard for quantifying outcomes. 📈 For MTSS:

• MTSS Score (Winters 2018, BJSM 52:1108-15) : the only PROM specific to MTSS, 15 items measuring pain and limitation (standing, walking, sport).⁴ The reference tool, to be used systematically.
• Lower Extremity Functional Scale (LEFS) : a generic lower-limb tool, with a validated French version.
• NPRS (Numerical Pain Rating Scale 0-10) : for day-to-day pain (training log).
• UWRS scale (University of Wisconsin Running Scale) or VISA-A depending on the context (multi-injury runners).

Assessing PROMs at the start, middle and end of treatment makes progress objective, supports shared medical decision-making and demonstrates the value of physiotherapy interventions.⁵

Implementing evidence-based practice runs into documented barriers: lack of time, lack of critical appraisal skills, and access to the scientific literature.⁶ Concrete solutions:

• Synthesised resources : clinical practice guidelines, Cochrane reviews, the PEDro database (free, with methodological scoring), JOSPT Insights, BJSM/JOSPT podcasts.
• Journal clubs or monthly reading groups, demonstrably effective for building an EBP culture.
• PROM calculation apps and digital logs for the patient (reducing the administrative burden).
• A culture of mentoring between clinicians.

Critique and controversy: from rigid protocol to shared decision-making

🤔 Three tensions persist in applying the evidence:

• The “PROM paradox” : their usefulness is demonstrated but their uptake remains low (administrative burden, difficulty of interpretation).⁷ The challenge is to turn a numerical score into a relevant clinical decision, without falling into a purely “accounting” approach.
• The “tyranny of red flags” : their individual predictive value is low, and excessive focus can generate unnecessary imaging. Better to use probabilistic clinical reasoning, weighing the cluster of findings against the patient’s overall profile.
• Standardisation vs personalisation : guidelines rest on population averages; the clinician treats unique individuals. The art of EBP is to combine high-level evidence, clinical expertise and patient preferences.⁵