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Medial Tibial Stress Syndrome/Chronic Exertional Compartment Syndrome

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What is Medial Tibial Stress Syndrome and Chronic Exertional Compartment Syndrome?

Medial Tibial Stress Syndrome (MTSS) is a common injury that often occurs in athletes participating in running and jumping sports, such as: soccer, rugby, figure skating, basketball, and football. MTSS manifests as pain along the inside of the shin (i.e. the tibia) toward the lower third of the leg. Typically, the pain is very localized and can become very painful and debilitating. The pain is caused by increased pressure onto the tibia bone as a result of increased traction from muscles in the shin (i.e. soleus, tibialis posterior, and/or the flexor digitorum longus).

MTSS typically presents as such: at rest there is no pain, but with the start of activity/warm-up the pain intensifies. Often the pain will subside through the middle of activity and will resolve with rest, but the pain can be present the next morning. As the injury progresses, pain will be present during activity and can cause one to stop exercise due to pain. Additionally, the pain from MTSS will be felt even at rest. If not properly dealt with, MTSS can lead to stress fractures.

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Chronic Exertional Compartment Syndrome (CECS) is another injury that occurs in the leg, and is caused by repetitive overuse. In the leg, there are various muscle compartments: anterior, posterior, lateral, deep posterior and superficial. In CECS, the volume of the one of the above-mentioned compartments increases due to repetitive microtrauma (i.e. overuse). This impacts the movement of lymph, blood and even nerve impulses. This can lead to increased pressure onto the bone as well. The most common compartment involved in CECS is the anterior (front) part of the leg.

CECS presents differently compared to MTSS, the pain is often reproduced not at the start of exercise, but at a predictable time point during activity. The pain usually described as cramping and/or burning in the affected compartment, and often times people will complain of associated numbness and/or weakness in their leg/foot. This results in people having to stop exercise due to the pain. Furthermore, the pain from CECS does not subside after exercise.

What Causes Medial Tibial Stress Syndrome and Chronic Exertional Compartment Syndrome:

While there is no one specific cause of MTSS and CECS, it is usually a combination of factors/causes that lead to the development of MTSS and CECS.

  • Over pronation of foot (flat foot)

  • Rapid increase in activity/excessive running

  • Training volume (repetitive days training with no rest/recovery)

  • Training surface (street running as opposed to oval/track running)

  • Poor/old footwear (minimalist footwear)

  • High and low body mass index

  • Low bone mineral density

  • Stiffness in foot/ankle musculature (poor shock absorption)

  • Previous injury

  • Novice runners

  • Gender, women are more prone to developing MTSS, but the incidence in CECS is equal between genders

How to Treat Medial Tibial Stress Syndrome and Chronic Exertional Compartment Syndrome?

Treatment strategies will vary from person to person, but below is a general outline for treating MTSS and CECS:

  • Rest from activity to help reduce excessive stress on the tibia

  • Air cast if fracture

    • X-rays to rule out stress fracture of tibia

  • Manual Therapy to help decrease stiffness in foot/ankle to help with better shock absorption through foot/ankle

  • Eccentric strength and endurance training of affected musculature in the shin

  • Strengthening intrinsic muscles of the foot

  • Improved running/training technique to help decrease load onto injured structures

    • Reviewing biomechanics of the whole body, with focus on the foot/ankle

  • Soft tissue techniques to help decrease excessive muscle tone along the tibia/shin

  • Training modification: interval training, soft surface such as oval/track

    • Decreasing frequency, intensity, and distance of training

  • Footwear/bracing/taping

    • Orthotics if appropriate

In some cases, referral to your family doctor for imaging may be necessary to rule out a fracture or any other serious pathology.

The presentation of MTSS and CECS will differ between each person. It is essential to seek a thorough assessment and treatment from a physiotherapist when dealing with MTSS or CECS. Early detection and intervention of MTSS and CECS is essential to help prevent further progression of the injury (e.g. stress fracture). Physiotherapy will help to develop an individualized treatment plan for you. This is critical to help ensure recovery and return to your desired sport/activity pain-free, and assist with prevention of future injuries!


1 Brown, A. A. (2016). Medial tibial stress syndrome: muscles located at the site of pain. Scientifica, 2016, 1-4. doi:

2 Craig D. I. (2008). Medial tibial stress syndrome: evidence-based prevention. Journal of athletic training, 43(3), 316–318. doi:

3 Plisky, M. S., Rauh, M. J., Heiderscheit, B., Underwood, F. B., & Tank, R. T. (2007). Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. journal of orthopaedic & sports physical therapy, 37(2), 40-47.

4 Reinking M. F. (2007). Exercise Related Leg Pain (ERLP): A review of The Literature. North American journal of sports physical therapy: NAJSPT, 2(3), 170–180.

Daniel Folino graduated with his Master’s of Physical Therapy from the University of British Columbia. Prior to completing his Master’s degree, he graduated with a Bachelor of Kinesiology at the University of British Columbia. He is a member of the Physiotherapy Association of B.C. and the Canadian Physiotherapy Association. Book with Dan today.


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