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Evaluation of Conditioning and Predisposition to
Medial Tibial Stress Syndrome (MTSS) in College
Athletes
Krista L. Capelli, LAT, ATC; Thomas F. West, PhD, LAT, ATC
*California University of Pennsylvania, California, PA
Objective: The primary purpose of this study is to
determine whether athletes suffering from MTSS
have a greater participation in flexibility,
plyometric, balance, cardiorespiratory, resistance,
and/or speed, agility, and quickness (SAQ)
training than those without MTSS.
Subjects: The subjects for this study consisted of
Division II and III student athletes at NCAA
colleges/universities. The study looked at both
male and female athletes from a number of
college sports teams.
Measurements:We assessed athletes’ perceived
diagnosis of symptoms related to MTSS using a
diagnosis survey titled "The Medial Tibial Stress
Syndrome Score: A New Patient-reported
Outcome Measure” by Marius Winters13
as well as
their frequency, duration and intensity of training
by design of the researcher’s own questionnaire.
The Rate of Perceived Exertion (RPE) Scale was
used to measure level of intensity.
Results: 69 completed surveys were submitted
for data analyses. We found that 9 (13%) were
considered having signs of MTSS while 60 (87%)
showed no signs of MTSS. The average intensity
of plyometric training as well as the duration of
cardiovascular training for athletes with MTSS
was significantly greater than athletes without
MTSS. There was no huge difference of means
between groups in any other form of training.
Conclusions: Athletes with MTSS showed no
significant difference in training than those without
MTSS. Females were found to be at a higher risk
for symptoms associated with MTSS than males.
Key Words: MTSS, athletic training
______________________________________________
Introduction
Many athletes suffer a number of lower
extremity overuse injuries. Medial tibial stress
syndrome (MTSS), more commonly referred to
as “shin splints” is one of the most common
lower leg injuries. Some studies show that
MTSS accounts for 6% to 16% of all running
injuries. Research has also shown that MTSS
is responsible for as much as 50% of all lower
leg injuries reported in select populations1-3
.
The exact cause for MTSS is inconsistent
within the research and varies based on
athlete and sport. Much of the research found
MTSS is associated with repetitive activity on
hard surfaces, forceful and excessive foot
pronation, rapid increases in training, improper
shoe wear, inadequate calcium intake, muscle
imbalances between genders, navicular drop,
foot length, history and BMI1-6
. It is important
that athletic trainers recognize the signs and
symptoms as well as predisposing risks of
MTSS to prevent further and more serious
injuries like stress fractures from occurring. If
an athlete should suffer from stress fractures, it
could result in a greater loss of time through
periods of immobilization, rehabilitation, and
overall return to play. Although there have
been many methods to prevent and treat for
MTSS, research is still limited 1, 2, 7
.
According to the review of the literature, the
athlete should be advised to use nonsteroidal

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anti-inflammatory drugs (NSAIDS) for pain and
crutches to keep the athlete non-weight
bearing or partial weight bearing. Although
surgery has been shown to relieve symptoms
associated with MTSS, conservative treatment
has been seen to be the better option.
Treatment may include modalities such as
ultrasound, electrical stimulation, cryotherapy
and other forms such as orthotics, arch taping,
and shoe modifications8
. A rehabilitation plan
may include non-aggravating activities for
flexibility, strength, and cardiovascular fitness,
as well as modified training routines with low-
impact exercises8
. Other methods of treatment
like bisphosphonates to inhibit bone
reabsorption and interfere with the action of
osteoclasts, pneumatic leg braces, and
extracorporeal shockwave therapy (ESWT) to
reduce symptoms of MTSS require further
research9-12
.
The purpose of this study is to determine
whether athletes suffering from MTSS have a
greater participation in flexibility, plyometric,
balance, resistance, and/or
speed/agility/quickness (SAQ) training than
those without MTSS. It is important to
understand the different components of
training in order to determine which specific
form of training causes a greater risk of MTSS.
Once the participation of training has been
identified, the next step is to determine a
prevention strategy. If athletic trainers can limit
or change some aspects of training, the overall
care of the athletes suffering from MTSS may
improve. Additionally, it may also be beneficial
to learn the effects of pre-existing injuries in
athletes playing at the colligate level as well as
differences in incidence rate between genders
and sports.
METHODS
Subjects
The subjects for this study were Division II
and III college student athletes at NCAA
colleges/universities. The study consisted of
both male and female athletes from all
collegiate sports (swimming, volleyball,
baseball, softball, soccer, football, track and
field, cross-country, lacrosse, wrestling, tennis,
field hockey, ice hockey, and basketball).
Instrumentation
The survey consisted of approximately 19
questions including demographic information,
sport, and most recently completed competitive
season and the availability of the strength and
conditioning coach at the athlete’s school. We
also collected the athlete’s signs and
symptoms for MTSS, and their participation in
flexibility, plyometric, balance,
cardiorespiratory, resistance, and SAQ
training. If the athlete reported under the age of
17, the survey was complete and was not used
for the study. For the second portion of the
study, we included a validated MTSS scoring
system using a study by Marinus Winters et.
al13
. All athletes were asked to choose
complaints of a specific shin followed by point
valued questions based on level of pain with
sporting activities, pain with walking, and pain
during rest. Also, we explored their frequency
(days), intensity (BORG Rating of Perceived
Exertion) and duration of training (minutes)
looking at specific training categories.
Preliminary Research
A panel of experts reviewed the survey
before any research was conducted. The panel
members consisted of 10 certified athletic
trainers who added to the content validity of
the survey.
A draft of the cover letter explaining the
design and the experts’ responsibilities were
sent out via email in this study. Members were
also given the researcher’s problem statement
and a copy of the “Shin Splints and Training”
survey.
Members reviewed the survey instrument and
added to the content validity by adding any
recommendations for improvement. After
reviewing the survey, the panel members
provided critiques and changes. The
necessary changes were made to the survey
based on critiques by the panel of experts.
Procedures
The study was approved by the Institutional
Review Board (IRB) at California University of
Pennsylvania before beginning any data
collection or distribution of surveys. The
athletic directors of the selected colleges were

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contacted via email. The athletic directors were
asked for written or electronic approval to allow
the researcher to distribute surveys to coaches
who in turn would send the cover letter and link
to the survey to student athletes.
The participants for this study were then
notified of the questionnaire through the
students’ e-mail account. The cover letter
explained the purpose of the study to each
potential participant. Surveys were collected
for a 2-week period following distribution and
were deactivated after that time. This
timeframe was to allow adequate time for both
the subjects to complete the survey and the
researcher to collect adequate data. After one
week, a reminder was sent to coaches asking
them to remind athletes. All data was kept
confidential and organized into a spreadsheet
for analysis.
Null Hypothesis
Student athletes having MTSS will show
greater frequency and intensity of participation
in flexibility, plyometric, balance, resistance,
cardiorespiratory and/or SAQ training than
those without MTSS.
Data Analysis
All data was analyzed with SPSS 22.0
analysis software. The research hypothesis
was analyzed using an independent sample T-
test with a p≤ .05.
RESULTS
Descriptive Analyses
Of the 104 student-athletes who responded
to the questionnaire, 69 returned completed
surveys for data analyses. From this sample,
30 (43.5%) were male and 39 (56.5%) were
female between the ages of 18-23. 31
(44.9%)of those athletes play a Division II sport
and 38 (55.1%) are Division III athletes.
Winters et al.13 categorizes MTSS athletes
with smallest detectable change at a score
4.80 out of a total score of 10. Due to limited
responses, the score required for athletes to
be considered for MTSS was 3 out of 10. We
found that 9 (13%) were considered having
signs of MTSS while 60 (87%) showed no
signs of MTSS.
Of the 9 participants who were diagnosed
with having MTSS, 3 were male (33.3%) and 6
were female (66.7%). Athletes with MTSS
participated more in track and field (5), soccer
(1) tennis (2) and field hockey (1). From the 5
athletes that participated in track and field, 3 of
those athletes also participated in cross-
country.
Athletes with MTSS utilized their strength and
conditioning coach either 3-4 days per week or
not at all where athletes without MTSS would
also work 3-4 days per week (44.3%) or not at
all (31.1%).
Table 1: Means (Standard Deviation) of Frequency, Duration and Intensity
MTSS Frequency Duration Intensity
Flexibility Yes 3.56 (1.509) 4.11 (1.965) 6.11 (3.919)
No 2.97 (1.785) 3.05 (2.213) 5.83 (4.009)
Plyometric Yes 3.22 (2.167) 3.89 (3.296) 9.00 (3.905)
No 3.82 (2.119) 2.60 (2.330) 6.97 (4.042)
Balance Yes 3.44 (2.455) 2.78 (2.906) 5.67 (4.031)
No 3.87 (2.198) 2.07 (1.745) 7.12 (4.166)
Cardiorespiratory Yes 3.22 (1.787) 7.00 (3.428) 6.22 (3.153)
No 3.40 (1.709) 5.80 (3.896) 6.17 (3.335)
Resistance Yes 3.67 (1.936) 3.44 (3.167) 7.33 (4.444)
No 3.45 (1.926) 4.10 (3.150) 6.77 (3.837)
SAQ Yes 3.00 (1.871) 6.00 (2.872) 6.67 (3.742)
No 2.90 (1.526) 5.57 (3.387) 6.17 (3.263)

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Discussion
Table 1 illustrates the means and standard
deviation for frequency, duration, and intensity
of all components of training for this study of
athletes with and without MTSS. The mean
intensity of plyometric training for athletes with
MTSS (m= 9.00) is significantly greater than
athletes without MTSS (m= 6.97). There was
no statistical difference of means between
groups in any other form of training. The table
also shows the mean duration of
cardiorespiratory for athletes with MTSS (m=
7.00) is higher than those without MTSS (m=
5.80) and more than any other duration of
training.
An independent-samples t-test was
calculated comparing the mean score of the
frequency, duration, and intensity of flexibility,
plyometric, balance, resistance,
cardiorespiratory, and SAQ training in
participants with and without MTSS. The data
showed no significant difference between the
groups. Table 2 illustrates significance, t value,
and p-value for all components of training. If
the significance was larger than .05, the
variances were considered equal. The p-value
for duration (p=.148) and intensity (.162) of
plyometric training presented as the lowest
values.
MTSS Treatment
The researchers also investigated the
frequency of treatments for athletes with
MTSS. The study found that all 9 participants
use some form of cryotherapy (ice, cold
whirlpool, etc.). In regards to other types of
treatment the following percentages were
utilized: tape (33.3%), orthotics (11.1%), heat
(66.7%), ultrasound (22.2%), electrical
stimulation (55.6%), and massage (44.4%).
However, only 5 found cryotherapy to be a
successful treatment while other successful
uses for treatment included heat, electrical
stimulation, and massage. We asked
participants to include any other form of
successful treatments. These methods
included: pressure release techniques, manual
therapy (Graston, scrapping), acupuncture,
and shockwave therapy.
Conclusions
Though the sample size was small, the data
found that females are more at risk to having
signs and symptoms related to MTSS. The
research has found that no specific form of
training causes signs and symptoms
associated with MTSS. There is not enough
evidence in this study to show whether
plyometric training is the true cause for MTSS.
The need for further research would have to be
implicated.
Limitations
The limitation of this study was the
insignificant number of participants due to
student-athlete compliance and the minimal
selection of NCAA schools chosen for this
study. The participants were only considered
for data analysis if all necessary questions
were answered. If the athlete missed more
than one question, they were excluded from
the study. The researchers had no information
Table 2: Significance, t value, and p-
value for Frequency, Duration, and
Intensity for all Components of Training
Levene’s Test
for Equality of
Variances
t-test for
Equality of
Means
Sig. t Sig. (2-
tailed)
Flexibility
Frequency
Duration
Intensity
.441
.941
.663
.939
1.359
.194
.351
.179
.846
Plyometric
Frequency
Duration
Intensity
.503
.066
.200
-.783
1.462
1.413
.437
.148
.162
Balance
Frequency
Duration
Intensity
.406
.169
.145
-.530
1.035
-.977
.598
.304
.332
Resistance
Frequency
Duration
Intensity
.652
.393
.277
.315
-.582
.405
.754
.563
.687
Cardiorespiratory
Frequency
Duration
Intensity
.838
.390
.460
-.289
.873
.047
.773
.386
.963
SAQ
Frequency
Duration
Intensity
.331
.363
.682
.178
.364
.421
.859
.717
.675
*Equal variances assumed
*p-value≤ .05

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on any previous or current injuries to the lower
leg. Another limitation was compliance of
coaches to distribute surveys to their teams.
Acknowledgements
I would like to acknowledge Dr. Thomas
West for his initial contribution for this study,
and Dr. Shelly DiCesaro for her final
contribution. I would also like to thank the
graduate athletic training students for their role
in the preliminary study. This study was
conducted as the first author’s master’s thesis.
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