Updated May 2026. Written by the Upwell Health Collective clinical team. Clinically reviewed May 2026. Next review due November 2026. For educational purposes only.
Shin splints. Every runner knows them. The dull, achy, sometimes sharp pain along the inside of the lower leg that arrives without warning, worsens during a run, and hangs around for days afterward. Rest for a week, feel better, go back to training, and there they are again. For some runners, this cycle repeats for months.
It repeats because the management is wrong. Not deliberately wrong — just incomplete. Rest without load modification, return without building the structures that tolerate load, and the cycle continues indefinitely because the underlying cause is never addressed.
Shin splints — medial tibial stress syndrome (MTSS) — affect between 13.6 and 20% of recreational runners and up to 35% of new runners (StatPearls, 2025). It is one of the most common running injuries in Australia, particularly in novice runners, those who have recently increased training loads, and military personnel. And the evidence on how to treat it effectively — and how to prevent it from recurring — is clearer than most runners appreciate.
Medial tibial stress syndrome is an overuse injury characterised by exercise-induced pain along the medial border of the tibia — the inner shin. It involves repetitive microtrauma to muscles and tendons in the anterior and medial compartments and irritation of the tibial periosteum (the outer layer of bone), producing localised inflammation and pain.
Recent research has increasingly identified MTSS as primarily a bone stress injury rather than a pure soft tissue condition. A 2025 scoping review (Saad et al., PMC11958822) confirmed that recent investigations in athletes with persistent MTSS have demonstrated it is primarily a bone stress response — cortical bone stress at the distal tibia — with periosteal inflammation at the bone’s surface as the central feature. This places MTSS on a continuum with tibial stress fractures, which are the most serious consequence of unmanaged MTSS and occur when cumulative bone stress exceeds the bone’s ability to remodel.
JOSPT published a 2025 editorial proposing renaming MTSS as “Load Induced Medial-Leg Pain” (LIMP) — a name that removes the anatomically imprecise “tibial stress” label (which patients frequently misinterpret as a stress fracture) and centres the underlying mechanism: load exceeding bone adaptation capacity. The name change is not yet standard, but the underlying concept — that MTSS is a load management problem at its core — is now well supported.
MTSS is not a stress fracture. But it is a warning that bone stress is accumulating faster than the bone can adapt. Ignored or mismanaged, it can progress to a stress fracture — a much more serious and longer-sidelining injury.
MTSS is fundamentally a problem of too much load, too soon, on a system that hasn’t adapted sufficiently. The most consistently identified risk factors across the literature are:
Rapid increases in training load: The most common precipitant. A novice runner going from couch to daily running, a returning runner coming back from a break and jumping straight to previous volume, or an experienced runner significantly increasing weekly mileage or intensity in a short period. Bone adapts slowly. Muscle and cardiovascular fitness improve much faster than bone density and periosteal strength. The runner who feels cardiovascular fit may have bone that is significantly behind in its adaptation.
Previous history of MTSS: One of the strongest predictors of MTSS. Bone that has previously been stressed to the point of periosteal inflammation is more susceptible to recurrence when overloaded again.
Female sex: Female athletes show higher rates of MTSS and bone stress injuries, related in part to lower bone density, potentially lower energy availability, and hormonal factors. Female runners with MTSS warrant specific assessment of energy availability and menstrual function alongside biomechanical evaluation.
Navicular drop and foot pronation: Excessive pronation increases tibial rotation and loading on the medial tibial structures. A foot that rolls inward excessively transmits rotational stress to the lower leg with every footstrike.
Reduced ankle dorsiflexion: Limited ankle mobility increases compensatory tibial loading patterns during running. Tight calves and reduced ankle range are consistently associated with MTSS risk.
Muscle weakness and fatigue: Weakness in the calf complex (particularly the soleus), tibialis posterior, and hip muscles leads to compensatory loading patterns that increase tibial stress. Muscle fatigue — particularly later in runs or training sessions — reduces the muscle’s protective role, leaving the bone to absorb more of the impact force.
Running surface: Hard, unforgiving surfaces (concrete in particular) increase impact forces compared to softer surfaces. Camber running creates asymmetric loading.
Footwear: Worn-out running shoes that have lost their cushioning and support significantly increase impact transmission. Runners who replace shoes irregularly or run in inappropriate footwear are at elevated MTSS risk.
This is the most clinically important distinction in lower leg pain management for runners. MTSS and tibial stress fractures lie on the same continuum of bone stress injury — but stress fractures require immediate modification of weight-bearing activity and a significantly longer timeline before return to running.
Features that raise the index of suspicion for a stress fracture rather than MTSS:
If any of these features are present, imaging is warranted. MRI is the gold standard for bone stress injuries and will identify both stress reactions and stress fractures. X-ray is insensitive in early stress fractures and will frequently appear normal. If a stress fracture is suspected clinically, management should be protective until imaging clarifies the diagnosis.
The primary goals of MTSS management are pain relief, bone healing, and a graduated return to running that builds the bone’s load tolerance progressively rather than exceeding it again.
The distinction between load modification and complete rest is clinically significant. Complete rest removes the very stimulus that bone needs for adaptation and remodelling. Load modification reduces the provocative load while maintaining some bone stress stimulus. The goal is to stay below the threshold at which symptoms are provoked while the bone remodels and strengthens.
In practice: runners with MTSS should reduce running volume, pace, and impact (moving to softer surfaces) to the level at which symptoms are not provoked during or within 24 hours of exercise. Cross-training with low-impact activities — cycling, pool running, swimming — maintains cardiovascular fitness while offloading the tibia.
The most evidence-supported return-to-running framework for MTSS is a progressive walk-run programme that increases tibial load in a controlled, stepwise fashion. The bone needs to progressively adapt to impact — which means it needs to experience impact, but at a level it can manage.
General framework:
The running literature is clear that muscle weakness — particularly of the calf, tibialis posterior, and hip complex — increases tibial loading and MTSS risk. Strengthening these structures during the load modification period both protects the bone and builds the capacity needed to tolerate higher training loads on return to running.
Key exercises: calf raises (bilateral and single-leg), tibialis posterior strengthening (resisted foot inversion), hip abductor strengthening (side-lying hip abduction, clamshells, single-leg squats), and gluteus maximus loading (bridges, deadlifts). Neuromuscular training programmes have shown a protective effect against MTSS in youth female track and field athletes (J Sport Rehabil, 2021).
For runners with excessive pronation and navicular drop, foot orthoses may reduce tibial stress by modifying the loading pattern at the foot. A podiatry assessment with gait analysis is valuable where pronation is identified as a contributing factor. Running shoe assessment — ensuring appropriate cushioning and support for the runner’s biomechanics and mileage — should be part of the management plan.
Running cadence modification (increasing step rate by 5 to 10%) reduces vertical ground reaction forces and tibial loading by shortening stride length. This is a low-cost, evidence-supported modification that can be introduced during the return-to-running phase.
Ice application for 15 to 20 minutes after activity is appropriate for acute symptom management. NSAIDs may be used for short-term pain relief, though their role in modifying bone healing is debated — prolonged NSAID use should be avoided as there is some evidence of impaired bone remodelling with chronic use.
MTSS prevention is built on understanding the bone adaptation timeline. Bone is slower to adapt to load than muscle and cardiovascular systems. A runner who builds fitness rapidly — because they can — may be outpacing their bone’s ability to adapt.
Practical prevention principles:
At Upwell, every shin pain presentation in a runner triggers a structured assessment that distinguishes MTSS from stress fracture, identifies the modifiable contributing factors, and builds a graduated return-to-running plan alongside the strengthening programme.
If your shin splints keep coming back, or you’re not sure whether your shin pain is MTSS or something more serious, contact our team or book a running assessment. Getting the diagnosis right, and the management right, is what breaks the cycle.
This article is for educational purposes only. Information last reviewed May 2026.