Research Review: No Magic Cure For Shin Splints

BLUF (Bottom Line Up Front)

There is no single proven treatment for shin splints (MTSS). Start with rest and reduced running volume, and progress based on soreness. Extracorporeal shockwave therapy (ESWT) and arch-support orthoses show promise in some studies; lasers, braces, and pulsed electromagnetic fields (PEMF) do not. Diagnose clinically (diffuse tenderness >5 cm along the posteromedial tibia), rule out stress fracture, and use MRI if the picture is unclear. For prevention, shock-absorbing insoles have the best randomized evidence; build load gradually and avoid very hard or uneven surfaces early.

Background

Medial tibial stress syndrome (MTSS), commonly called shin splints, is an overuse condition marked by diffuse pain and tenderness along the posteromedial (inner) border of the tibia—typically in the middle-to-distal third—brought on by running or similar impact activity and often relieved by rest (Bhusari & Deshmukh, 2023). It is frequently reported in runners and military trainees (Ciszewski, Drelichowska, & Azierski, 2025). Mechanistically, two overlapping processes are described: traction-related periosteal irritation from repetitive pulling of soft tissues that attach near the painful border (especially soleus and flexor digitorum longus), and a bone-overload stress response in which repetitive tibial bending and impact create microdamage faster than bone remodeling can keep up. These processes are amplified by rapid increases in training, biomechanical factors such as excessive foot pronation, running on firm surfaces, worn or unsuitable footwear, prior MTSS, higher BMI, and female sex; low vitamin D is also discussed in recruit settings (Bhusari & Deshmukh, 2023; Ciszewski et al., 2025).

Purpose

Synthesize findings from scholarly sources on causes/mechanisms, diagnosis, treatment options, and running/activity modifications for MTSS.

Methods

Review of peer-reviewed scholarly resources on MTSS (systematic and narrative reviews, randomized and controlled trials, a meta-analysis, a clinical rehabilitation guideline, and a case report).

Results

Etiology & Pathophysiology

MTSS is described as a load-related spectrum injury involving periosteal irritation at muscle/fascial attachments and bone stress or microdamage from repetitive loading. Anatomically, the symptomatic region aligns with traction from the soleus and flexor digitorum longus; tibialis posterior is not implicated at the classic site (Bhusari & Deshmukh, 2023; Ciszewski et al., 2025).

Risk Factors

Across reviews and higher-level evidence, contributors include female sex, higher BMI, prior MTSS, greater navicular drop (pronation), and training-load errors (Hamstra-Wright, Bliven, & Bay, 2015; Bhusari & Deshmukh, 2023; Ciszewski et al., 2025). A prospective cohort of collegiate runners also found that lower step rate (cadence) is associated with higher bone-stress-injury risk (Kliethermes et al., 2021).

Diagnosis & Imaging

Diagnosis is primarily clinical: diffuse tenderness along the posteromedial tibial border provoked by activity (Bhusari & Deshmukh, 2023). Rehabilitation guidance notes that tenderness over more than 5 cm supports MTSS, whereas less than 5 cm suggests a medial tibial stress fracture; if progress stalls, evaluate for stress fracture (Sanford Health, 2024). When imaging is required to clarify or exclude other causes, a summarized dataset reports MRI sensitivity ≈88% and accuracy ≈90% for early tibial stress injury, higher than CT (≈42%) or bone scintigraphy (≈74%) (Ciszewski et al., 2025).

Treatment Evidence

Foundational care

• Relative rest and graded return. Initial activity reduction with progressive reloading is recommended. The rehabilitation guideline notes a general healing timeline of ~4–12 weeks and an average return around 7–8 weeks for low-risk bone-stress injuries such as MTSS. It recommends restarting running below 50% of prior training volume and using day-to-day “soreness rules” to guide progression (Sanford Health, 2024).
• Symptom-modulating basics. Ice, short courses of NSAIDs, compression bandage, flexibility work, supportive footwear, and—where indicated—orthotics are listed as nonsurgical options (Bhusari & Deshmukh, 2023).
• Short-term immobilization when everyday activities are painful. A cast boot or pneumatic leg splint for 2–4 weeks is allowed when activities of daily living (ADLs; basic daily tasks like routine household walking) are painful (Sanford Health, 2024).

Modalities and specific interventions

• Extracorporeal shockwave therapy (ESWT). A 2013 systematic review concluded that no therapy could be recommended definitively owing to study bias/quality, though ESWT “appears to have the most promise” (Winters et al., 2013). A later double-blind randomized sham-controlled trial tested ESWT specifically for MTSS, offering higher-quality evidence but still with limitations (Gomez-Garcia et al., 2017).
• Laser therapy. Low-energy laser was not proven effective in the 2013 systematic review (Winters et al., 2013).
• Iontophoresis and phonophoresis. In combined analyses of randomized controlled trials (pooled RCTs = statistical combination of RCT results), there was no significant difference between iontophoresis and phonophoresis; lower-quality studies suggested each could be superior to control, but overall evidence was low (Winters et al., 2013).
• Ice massage and therapeutic ultrasound. Reported as potentially effective versus control in lower-quality studies (Winters et al., 2013).
• Periosteal pecking. A needling technique applied to the periosteum (bone lining) reported as potentially effective versus control in lower-quality evidence (Winters et al., 2013).
• Stretching/strengthening as stand-alone. Not proven effective in the systematic review (Winters et al., 2013).
• Strengthening within multimodal care; TENS/needling/electro-dry needling. A dissertation-level systematic review reports moderate evidence for these when used as part of a multimodal program; no single therapy had strong evidence (Crous, 2021).
• Compression stockings, lower-leg braces, pulsed electromagnetic fields (PEMF). Not proven effective for treatment; braces showed no significant treatment effect versus control (Winters et al., 2013).
• Manual therapy and ultrasound as adjuncts. The rehabilitation guideline lists soft-tissue and joint mobilization and ultrasound as “modalities as indicated” within a criterion-based plan (Sanford Health, 2024).
• Foot orthoses as a treatment adjunct. In a randomized controlled trial of female recreational runners with MTSS, adding arch-support foot orthoses to a multimodal program improved pain/recovery versus the same program with sham flat insoles (Naderi, Degens, & Sakinepoor, 2022).
• Cupping, gait change, TENS/cryotherapy (case-level). A single case report documented improvement over two weeks with a program including gait modification to heel-contact running, cupping, stretching/strengthening, and TENS/cryotherapy; this is not generalizable evidence (Deshmukh, Phansopkar, & Wanjari, 2022).

Running & Activity Modifications / Return to Running

Begin return to running at <50% of prior training volume and use “soreness rules” to progress or regress. Suggested shock-attenuation cues include increasing step rate, a slight increase in step width, and a slight forward trunk lean, with avoidance of hills, uneven terrain, and very firm surfaces early. For low-risk bone-stress injuries like MTSS, average return is about 7–8 weeks, with total timelines varying by severity and chronicity (Sanford Health, 2024). In one case report, transitioning from forefoot to heel-contact running coincided with symptom improvement for that athlete (Deshmukh et al., 2022). Recent guidance for tibial bone-stress injuries recommends a criteria-based progression (pain-free impact tests, resolution of tibial tenderness, adequate strength/impact tolerance) rather than rigid percentage rules (George, Sheerin, & Reid, 2024).

Prevention

A systematic review of randomized trials in military trainees found limited evidence overall. Shock-absorbing insoles showed the most encouraging results for reducing overuse injuries and specifically tibial stress syndrome in one trial; heel pads, heel-cord stretching, alternative footwear, and graduated running programs did not show strong support in the reviewed trials, and methodological limitations were substantial (Thacker, Gilchrist, Stroup, & Kimsey, 2002). More recent randomized work in naval recruits evaluated prefabricated foot orthoses for prevention of lower-limb overuse injuries during basic training and informs orthoses’ preventive role beyond older studies (Bonanno et al., 2018).

Key Findings

• Definition & clinical pattern. Diffuse, exercise-provoked pain and tenderness along the posteromedial tibial border; diagnosis is primarily clinical. MRI is the most sensitive imaging modality when needed for early tibial stress injury (Bhusari & Deshmukh, 2023; Ciszewski et al., 2025).
• How MTSS develops. Combined periosteal traction near the symptomatic border and bone-overload stress response from repetitive loading; training spikes and mechanics/surface/footwear factors increase both (Ciszewski et al., 2025; Bhusari & Deshmukh, 2023).
• Risk profile. Female sex, higher BMI, prior MTSS, navicular drop (pronation), and training-load errors; lower step rate is prospectively associated with higher bone-stress-injury risk in runners (Hamstra-Wright et al., 2015; Kliethermes et al., 2021).
• Treatment.
  • ESWT: Signal of benefit but insufficient evidence for a definitive recommendation (systematic review); one sham-controlled RCT supports benefit with caveats (Winters et al., 2013; Gomez-Garcia et al., 2017).
  • Laser: Not proven effective (Winters et al., 2013).
  • Iontophoresis vs phonophoresis: No difference between them in pooled RCTs; each only shows lower-level signals vs control (Winters et al., 2013).
  • Ice massage, therapeutic ultrasound: Lower-level supportive findings vs control (Winters et al., 2013).
  • Periosteal pecking (periosteal needling): Lower-level positive findings (Winters et al., 2013).
  • Stretching/strengthening as stand-alone: Not proven effective (Winters et al., 2013).
  • Strengthening within multimodal care; TENS/needling/electro-dry needling: Moderate evidence as adjuncts (Crous, 2021).
  • Compression stockings, lower-leg braces, PEMF: Not supported; braces showed no significant effect vs control (Winters et al., 2013).
  • Manual therapy and ultrasound as adjuncts: Listed “as indicated” within a criterion-based plan (Sanford Health, 2024).
  • Foot orthoses (treatment adjunct): RCT evidence shows adding arch-support orthoses to a multimodal program improves outcomes vs a comparable program with sham insoles (Naderi et al., 2022).
  • Cupping, gait change to heel-contact, TENS/cryotherapy: Positive outcome in a single case; not generalizable (Deshmukh et al., 2022).
• Return to running. Use a criteria-based progression, manage surfaces/hills, and incorporate shock-attenuation cues; typical return for low-risk bone-stress injuries is about 7–8 weeks (Sanford Health, 2024; George et al., 2024).
• Prevention. Insoles/orthoses show the most encouraging evidence within training populations; heel pads, heel-cord stretching, alternative footwear, and graduated programs lacked strong support in earlier trials (Thacker et al., 2002; Bonanno et al., 2018).

Conclusion

Across peer-reviewed sources, MTSS is a clinical diagnosis of diffuse, exercise-provoked medial tibial pain arising from overlapping periosteal traction and bone-overload responses. Risk reflects training-load errors compounded by biomechanics (pronation), footwear/surface factors, and individual characteristics; meta-analysis and prospective data strengthen these associations. Treatment evidence remains limited and mixed: ESWT shows a promising signal (including one sham-controlled RCT), laser lacks support, iontophoresis/phonophoresis and several other modalities have only lower-level evidence, and braces/PEMF are not supported. An RCT supports arch-support foot orthoses as an adjunctwithin a multimodal program. Return-to-running should be criteria-based with surface and hill management. For prevention, shock-absorbing insoles/orthoses have the clearest supportive evidence in training settings; other popular strategies have not shown strong effects in trials.

References

• Bonanno, D. R., et al. (2018). Effectiveness of prefabricated foot orthoses for prevention of lower-limb overuse injuries in naval recruits: randomized controlled trial. Br J Sports Med, 52(5), 298.
• Bhusari, N., & Deshmukh, M. (2023). Shin Splint: A Review. Cureus, 15(1), e33905.
• Ciszewski, P., Drelichowska, A., & Azierski, M. (2025). Shin Splints—A hidden epidemic among runners and athletes: a review of the current state of knowledge. Medical Science, 29, e79ms3571.
• Crous, Z. (2021). A systematic review of the conservative treatment options and their effectiveness in the treatment of MTSS. Master’s dissertation, Durban University of Technology.
• Deshmukh, N. S., Phansopkar, P., & Wanjari, M. B. (2022). A Novel Physical Therapy Approach in Pain Management and Enhancement of Performance in Shin Splints Athletes: A Case Report. Cureus, 14(7), e26676.
• George, E. M., Sheerin, K., & Reid, D. (2024). Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Medicine, 54(9), 2247–2265.
• Gomez-Garcia, S., et al. (2017). Shockwave treatment for medial tibial stress syndrome: a randomized sham-controlled trial. J Sci Med Sport, 20(11), 992–997.
• Hamstra-Wright, K. L., Huxel Bliven, K. C., & Bay, C. (2015). Risk factors for medial tibial stress syndrome in physically active individuals: systematic review and meta-analysis. Br J Sports Med, 49(6), 362–369.
• Kliethermes, S. A., et al. (2021). Lower step rate is associated with a higher risk of bone stress injury in collegiate cross-country runners. Br J Sports Med, 55(15), 851–858.
• Naderi, A., Degens, H., & Sakinepoor, A. (2022). Foot Orthoses Enhance the Effectiveness of Exercise, Shockwave Therapy, and Ice Massage in the Management of MTSS: Randomized Controlled Trial. Clin J Sport Med, 32(3), e251–e260.
• Sanford Health. (2024, Rev 01/2024). Medial Tibial Stress Syndrome Rehabilitation Guideline.
• Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey, C. D. (2002). The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc, 34(1), 32–40.
• Winters, M., Eskes, M., Weir, A., Moen, M. H., Backx, F. J. G., & Bakker, E. W. P. (2013). Treatment of Medial Tibial Stress Syndrome: A Systematic Review. Sports Medicine, 43, 1315–1333.