Stress fracture vs shin splints: how to tell them apart

Medial tibial stress syndrome (shin splints) and tibial stress fracture exist on a continuum of bone stress injury. MTSS is periosteal irritation, the surface of the bone is stressed but not compromised. A stress fracture is a frank crack in the cortical bone. Continuing to run on MTSS is painful but not dangerous. Continuing to run on a stress fracture risks complete fracture.

The clinical presentations overlap enough that the distinction cannot always be made from symptoms alone. When there is uncertainty, imaging is required.

Both: medial tibia pain, aggravated by running, common in novice or recently intensified runners, associated with training load errors. Both can produce pain on palpation of the medial tibial border.

MTSS: diffuse tenderness along 5–8 cm of the medial tibial border, pain that eases with warm-up and returns after activity, no pain at rest (or minimal), pain provoked by resisted plantar flexion.

Stress fracture: point tenderness at a specific location (you can put one finger on the spot), pain that does not ease with warm-up and may be constant, pain at rest, positive fulcrum test (the fulcrum test applies a bending force to the tibia, if this reproduces the point pain, stress fracture is more likely). Night pain is a red flag.

If stress fracture is suspected: MRI is the most sensitive imaging modality (picks up bone stress earlier than X-ray). No running until imaging is clear. Depending on the location (anterior tibia stress fractures are higher risk for complete fracture than posterior), orthopaedic input may be needed.

If MTSS is confirmed: graduated return-to-running protocol (50% volume reduction, 10% increase per week), hip strengthening, soft tissue work to the tibialis posterior and calf complex.