IS Case 345: Medial tibial stress syndrome / shin splints

Daniel O'Connor, MD

Imaging Sciences URMC

2009 URMC Imaging Sciences
Publication Date: 2009-11-09


Patient is a 13-year-old male and competitive runner, presenting with left lower extremity pain for three weeks and clinical suspicion of stress fracture of the tibia. Radiographs of the left tibia and fibula were normal.


Tc99m MDP 3-phase bone scan was performed. Perfusion and blood pool images demonstrated bilaterally symmetric perfusion and radiotracer uptake in the lower extremities. Delayed images taken at three hours demonstrated patchy, ill-defined increased radiotracer uptake along the posteromedial aspect of the tibial shafts bilaterally, left greater than right. Otherwise, scintigraphic appearance of visualized structures was normal for patient age. Review of comparison plain radiographs of the left tibia and fibula demonstrate subtle prominence of periosteum in this region, which retrospectively may have represented periosteal reaction.


Medial tibial stress syndrome / "shin splints"


Medial tibial stress syndrome, known colloquially as "shin splints", is a common repetitive overuse syndrome most often associated with competitive runners and long-distance hikers. Patients usually present with a history of overuse (as did this patient) and often have posteromedial tibial tenderness to palpation at the origin of the soleus muscle which is exacerbated with exertion if the patient returns to exercise without adequate time for the injury to heal.

Plain radiographs are often normal, although subtle periosteal reaction may be appreciated along the posteromedial aspect of the tibia secondary to avulsion injury. Long-standing disease may result in thickening of the medial tibial cortex. MRI is diagnostic, with increased fluid signal along the origin of the soleus muscle and regional marrow edema best appreciated in T2W sequences. Tc99m MDP bone scan may also be used, and is characterized by normal perfusion and blood flow images with increased uptake of radionuclide at the soleus origin in delayed images, as demonstrated in our patient.

Medial tibial stress syndrome exists in a continuum with frank stress fracture representing the most severe form of the repetitive stress injury process. Disease is more common in women and is uncommon in patients less than 15 years, although it may present in competitive athletes of any age.


  1. Hodler J, Steinert H, Zanetti M, et al. Radiographically negative stress related bone injury. MR imaging versus two-phase bone scintigraphy. Acta Radiol. 1998 Jul;39(4):416-20. PMID: 9685830
  2. Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ. Radionuclide bone imaging: an illustrative review. Radiographics. 2003 Mar-Apr;23(2):341-58. PMID: 12640151

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