Introduction
Medial tibial stress syndrome (MTSS) is one of the most common causes of exercise related leg pain (Schon et al., 1992). Although runners are most commonly afflicted, individuals involved in jumping activities may also develop this disorder (Clement, 1972). The term “shin splints” is frequently used synonymously with this disorder (Michael and Holder, 1985; Schon et al., 1992). The most common complaint in these patients is a dull aching pain along the middle or distal posteromedial tibia (See Figure below).

Early, in this process, the pain may occur at the beginning of a run, resolve with continued exertion, only to recur toward the end or after a workout (Krivickas, 1997). Alternatively, the pain may also be noted towards the end of the run (Fredericson et al., 1995). At this early stage, the pain typically subsides promptly with rest (Clanton and Solcher, 1994). With continued training the pain may become more severe, sharp, and persistent (Clanton and Solcher, 1994; Krivickas, 1997). Patients may attempt trials of complete rest only to have the pain recur with resumption of training. With increasing chronicity, the pain may be present with ambulation or at rest (Clanton and Solcher, 1994; Krivickas, 1997). Training errors have been reported to be causative in approximately 60% of these cases (Fredericson et al., 1995; Jones and James, 1997). Most commonly symptoms occur after a relatively abrupt increase in the frequency, duration, or intensity of training (e.g., increase of over 30% of initial training mileage within 1 year) (Fredericson et al., 1995; James et al., 1978). Excessive hill training, as well as changes in training surface, or worn out footwear have also been implicated (Fredericson et al., 1995; James et al., 1978; Jones and James, 1997; Krivickas, 1997).

Prevention
Before beginning or substantially modifying a weight bearing training regimen, a history of previous injury should be obtained. Also it should be ensured that old injuries have been fully and appropriately rehabilitated (particularly if the individual has been in a cast for any length of time with resultant reductions in bone and muscle mass). Lower limb alignment should be evaluated and any abnormalities should be corrected via strength straining and/or the use of orthoses (paying particular attention to correcting hyperpronation). Improper running technique should also be corrected (Beck, 1998).

During training, lightweight, activity-specific athletic shoes that provide adequate shock adsorption should be worn. They should be replaced approximately 500-700km of running. Training intensity should be gradually increased over a period of weeks, only introducing hills, interval training, high strain, sport specific activities after approximately 6 weeks of graduated training. Training should begin on surfaces that absorb shock to the greatest extent, such as level asphalt, and progress to synthetic track, then to grass, sand and uneven terrain, thereafter varying the training surface. Athletes are advised to maximize the flexibility of the gastrocnemius and soleus complexes with focused stretching. All athletes should consume adequate calcium, at least 1,000 mg/day; some authors recommend 1,500 mg/day for active females (Beck, 1998).  

Finally there are several psychological variables which are important in considering the prevention of injury (Sarason et al., 1990).  These are:

1. The level of stress the athlete is experiencing.
2. The personality of the athlete.
3. The coping style and resources of the athlete.
4. The athlete’s social support network. 

TABLE 1 Strategies for Long-Term Management
and Prevention of Medial Tibial Stress Syndrome

Avoid training errors ('start low and go slow')
Introduce gradual changes in intensity, activity, and terrain
Maintain calf flexibility
Develop adequate anterior tibial (dorsiflexor) strength
Replace worn-out footwear
Correct hyperpronation with orthoses
Ensure adequate calcium intake
Address menstrual dysfunction, if applicable