Shin Splints: A Research Based Approach to Medial Tibial Stress Syndrome

Stretch your calves.

Strengthen your legs.

Change your shoes.

Try orthotics.

Get shockwave.

Change the way you run.

Or simply stop running.

A 2026 systematic review published in Physical Therapy in Sport examined non-invasive treatment for medial tibial stress syndrome — commonly called shin splints — and found only three randomised controlled trials involving 130 runners.

The conclusion? There is currently no clearly superior treatment for shin splints (Teles et al., 2026).

That finding fits closely with the approach advocated by Australian physiotherapist and running injury researcher Professor Christian Barton.

In a 2025 Australian Physiotherapy Association InMotion article, Barton describes running injuries as multifactorial and argues against recipe based rehabilitation. Instead, management should consider the individual runner, combining education, load management, objective assessment, exercise, gait retraining where appropriate, footwear and a progressive return to running (Barton, 2025).

For shin splints, that is probably the most useful way to interpret the research.

What we need to consider in management of shin MTTS is – why has this runner’s current loading exceeded the capacity of their lower leg — and what needs to change to get them running again.

The clinical term usually used is medial tibial stress syndrome (MTSS).

MTSS is characterised by exercise induced pain along the distal posteromedial border of the tibia — the inside edge of the shin bone above the ankle.

A recognised clinical feature is familiar pain when palpating an area extending 5 cm or more along the posteromedial tibial border (Winters, 2020).

Typical symptoms include:

• pain during or after running
• tenderness along the inner border of the tibia
• symptoms that may initially improve as the runner warms up
• increasing pain as training load continues
• pain reproduced when the area is pressed

But this is important – not every painful shin is “shin splints”.

More focal bony tenderness, worsening pain, symptoms during normal walking or pain that is becoming increasingly persistent may raise concern for a tibial bone stress injury.

Other causes of lower leg pain can include chronic exertional compartment syndrome & a muscular injury.

Careful assessment is key in making the correct diagnosis.

Teles & colleagues searched 3 randomised trials (130 runners) with 62% female participants with an average age of about 26 years. The researchers assessed interventions including exercise, foot orthoses and multimodal treatment. Their conclusion was that evidence remains limited & no clearly superior treatment identified(Teles et al., 2026).

It suggests MTSS should not be treated as though every runner has the same problem requiring the same solution.

Do orthotics work? Possibly — for some runners and particularly in the short term. The 2026 systematic review found that arch support foot orthoses added to multimodal care reduced short term pain compared to sham orthoses. However, benefits not sustained longer term (Teles et al., 2026).

Previous systematic reviews have found associations between MTSS & factors such as greater navicular drop and certain other lower limb characteristics (Newman et al., 2013; Hamstra-Wright et al., 2015).

For example, Newman and colleagues found that previous MTSS, fewer years of running experience, greater navicular drop and several other characteristics were associated with future MTSS risk (Newman et al., 2013).

These are only risk associations – so do not prove that changing any one factor will cure the injury.

Strengthening is routinely prescribed for shin splints with good clinical reasons to build the capacity of tissues involved in running.

The 2026 systematic review found that adding exercise did not consistently outperform comparison treatments & no particular exercise program emerged as clearly superior (Teles et al., 2026).

Exercise should be prescribed according to what the runner needs.

That may include improving:

• soleus & gastrocnemius capacity
• gastrocnemius strength
• foot & ankle strength
• proximal lower limb strength (glutes)
• hopping capacity
• plyometric ability
• graded loading (Alter-G Treadmill)

A double-blind trial found a standard dose shockwave was not superior to sham treatment for improving running pain or running distance (Newman et al., 2017) – but another randomised trial in military cadets reported better short term running outcomes when focused shockwave was added to an exercise program compared with exercise alone.

The evidence is still too limited to identify one clearly superior treatment – but passive treatments (such as shockwave) may be useful as an adjunct (Teles et al., 2026), but it should not replace rehabilitation.

Barton’s InMotion discussion specifically emphasises the use of video gait assessment & objective assessment to understand potentially relevant contributors, followed by safe gait retraining where appropriate.

He also points out that gait retraining goes beyond simply changing step rate or foot-strike pattern (Barton, 2025).

Research has identified associations between MTSS & biomechanical characteristics, but there is no single running style that explains every case.

So every runner with shin pain does not automatically need to:

• increase cadence or stop heel striking
• become a forefoot runner
• reduce pronation

It is reasonable to investigate if there something about this runner’s gait that is contributing to their symptoms – but in isolation, there is no reason to change running technique just because the runner has MTSS.

Another important piece of recent research looked at preventing MTSS rather than treating it. A 2025 systematic review and meta-analysis included 12 studies with 8,197 participants (Marques et al., 2025).

The researchers reported evidence supporting

• neuromuscular training for reducing MTSS incidence
• some evidence supporting orthotics targeted at overpronation

In contrast:

• shock-absorbing insoles did not significantly reduce MTSS
• static stretching programs were not supported
• special socks were not supported.

Improving the athlete’s ability to tolerate load is likely to be more useful than relying solely on passive treatment.

The best interpretation of the research, combined with Barton’s running injury framework, is to treat the individual runner rather than the diagnosis alone.

1. Confirm the diagnosis.

Careful physical assessment, consideration of general and recent history should determine whether the presentation is actually MTSS. Other diagnoses where symptoms are atypical or more focal, severe or persistent should be carefully excluded.

2. Understand the runner.

A detailed history will include any recent changes in training. These may include changes to:

• weekly running volume
• speed training
• flat and hill running
• training frequency
• the runner returning after a break
• running surfaces
• running or sporting footwear
• gym or additional sporting load
• recovery periods / days

MTSS should be viewed as what has increased load relative to the runner’s current capacity.

3. Look how load can be modified without automatically stopping everything.

Pain may require temporary changes to training. That might involve reducing:

• running volume
• frequency
• speed work
• hills
• impact exposure
• competitions

But where possible, the aim should be to maintain fitness using tolerable alternatives. This can include using deep water running, Alter-G Treadmill (run at reduced load) and cross training. Complete rest may reduce pain but will reduce the runner’s capacity. We must prepare the athlete to run again.

4. Build capacity.

The rehabilitation program should reflect the athlete’s deficits. Depending on the assessment, this may include:

• soleus and gastrocnemius strength & capacity
• foot strength & capacity
• hip (glute) and knee strength
• gradual inclusion of double and single leg plyometrics
• running specific strength, control and loading

The objective is not simply to get stronger, but to increase the runner’s capacity to tolerate the forces required for running.

5. Assess running gait when it is relevant.

Video gait analysis may help identify potentially modifiable factors but running technique should only be changed when there is a clear rationale. As Barton emphasises, gait retraining should be individualised rather than reduced to changing cadence or foot strike in every runner (Barton, 2025).

6. Consider footwear and orthotics.

Footwear influences gait and loading and may be relevant for some athletes. Orthotics may also reduce short term symptoms in selected runners.

Neither should automatically be prescribed simply because someone has shin splints.

7. Have a return-to-run plan

This is one of Barton’s central messages. Treatment is not finished when the shin stops hurting, the athlete needs to progressively restore the ability to tolerate running.

That could involve gradually and objectively adding and increasing one source of load at a time.

• start with easy running
• gradual increase in running volume
• gradual increase in time/distance of continuous running
• addition of hills
• addition of sport specific or competition demands

The exact progression should be individualised.

References

Barton, C. (2025). The road back from running injury. InMotion, Australian Physiotherapy Association. 29 October 2025.

Hamstra-Wright, K. L., Huxel Bliven, K. C., & Bay, C. (2015). Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(6), 362–369. https://doi.org/10.1136/bjsports-2014-093462

Marques, T. B. T., Rangel, R. P. S., Martins, L. V., & Vidal, A. P. C. (2025). Preventive interventions for medial tibial stress syndrome: Systematic review and meta-analysis. Gait & Posture, 122, 92–98. https://doi.org/10.1016/j.gaitpost.2025.07.312

Newman, P., Witchalls, J., Waddington, G., & Adams, R. (2013). Risk factors associated with medial tibial stress syndrome in runners: A systematic review and meta-analysis. Open Access Journal of Sports Medicine, 4, 229–241. https://doi.org/10.2147/OAJSM.S39331

Newman, P., Waddington, G., & Adams, R. (2017). Shockwave treatment for medial tibial stress syndrome: A randomized double blind sham-controlled pilot trial. Journal of Science and Medicine in Sport, 20(3), 220–224. https://doi.org/10.1016/j.jsams.2016.07.006

Teles, A. I., da Silva Carto, J. P., Parpa, K., Thuany, M., & de Vasconcelos, G. S. (2026). Load-induced medial leg pain in runners: A systematic review of non-invasive treatment approaches. Physical Therapy in Sport, 81, 101962. https://doi.org/10.1016/j.ptsp.2026.101962

Winters, M. (2020). The diagnosis and management of medial tibial stress syndrome: An evidence update. Der Unfallchirurg, 123(Suppl 1), 15–19. https://doi.org/10.1007/s00113-019-0667-z

Zhang, Z., Li, M., Fan, T., & Sun, Y. (2026). Psychologically informed patient education combined with exercise intervention is associated with improvements in tibial loading regulation, joint kinematics, and kinesiophobia in runners with medial tibial stress syndrome: A randomized controlled trial. Frontiers in Psychology, 17, 1880253. https://doi.org/10.3389/fpsyg.2026.1880253