











































MANUSCRIPT TYPE


VALIDATION CASE STUDY 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: 
A Validation Case Series 
Daniel Delgado, DAT, LAT, ATC*; Matthew J. Drescher, DAT, LAT, ATC*; Justin P. Young, DAT, LAT, ATC*; Zachary K. Winkelmann; 
PhD, SCAT, ATC†; Matthew J. Rivera, DAT, LAT, ATC*  
*Indiana State University, Terre Haute, IN;†University of South Carolina, Columbia, SC  

 
ABSTRACT 
Current literature reports that an increase in body mass index (BMI), navicular drop, ankle plantarflexion range of motion (ROM), 
and hip external rotation ROM are key modifiable risk factors in the development of medial tibial stress syndrome (MTSS) in 
physically active adults. The purpose of this validation case series was to investigate these four measures as risk factors of MTSS in 
adolescent athletes. In total, 100 cross country, volleyball, and/or basketball athletes (age = 15.89±1.31 years, 54 assigned 
female at birth) were included. The competitive sports season was the intervention in this case series and all athletes experienced 6 
athlete-exposures per week. Of the 100 athletes, 21% (n = 21/100) of participants developed MTSS during their respective sports 
season. Demographic data were analyzed using measures of central tendency. Mean differences (MD) between the MTSS and non-
MTSS groups were calculated for the main outcome variables. A Kruskal-Wallis one-way analysis of variance was used to determine 
differences in main outcome variables between groups. There were no significant differences in BMI (p ≥ 0.42), navicular drop (p ≥ 
0.27), active ankle plantarflexion ROM (p ≥ 0.65), or active hip external rotation ROM (p ≥ 0.77) between MTSS and non-MTSS 
groups. The MD between groups were BMI = 0.22, navicular drop = 0.95mm, active ankle plantarflexion ROM = -1.36°, and active 
hip external rotation ROM = -0.40°. These results do not prospectively confirm adolescents who develop MTSS have a significant 
increase in the risk factors described in the literature. Therefore, more research should be performed to determine if the risk factors 
for MTSS between adults and adolescents differ. 
Content Focus  
Health Care Competence  
 
Correspondence 
Dr. Daniel Delgado, 567 N 5th St, Terre Haute, IN 47802. 
E-mail: dan.delgado.atc@gmail.com  
 
Full Citation 
Delgado D, Drescher MJ, Young JP, Winkelmann ZK, Rivera MJ. Risk factors of medial tibial stress syndrome in active 
adolescents: A validation case series. Clin Pract Athl Train. 2023;6(1): 13-20. 
https://doi.org/10.31622/2023/0006.01.3.  
 
Submitted: May 13, 2021 Accepted: March 24, 2022. 

 
ARTICLE CITATION AND SUMMARY 

Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active 
individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 
2015;49(6):362-369. doi:10.1136/bjsports-2014-093462 

ARTICLE SUMMARY  

Medial tibial stress syndrome (MTSS), often referred to as “shin splints,” is described as an “exercise-induced, 
localized pain along the distal two thirds of the posterior-medial tibia,”1 and is a common musculoskeletal 
condition in those who are physically active.2-6 Runners are particularly affected by MTSS with an incidence 
rate as high as 13.6-20%.2,3 Despite how common this condition is, there still is a lack of consensus within the 
literature about the etiology of the condition.2,3 Multiple conjectures have been made about the anatomical 
source of the pain with myofascial strain, enthesopathy, periosteal inflammation, and bone stress reaction 
being the most widely accepted causes.7 Our murky understanding of the involved tissue makes this condition 
difficult to treat and even more difficult to prevent. Identifying risk factors for MTSS could benefit a large 
proportion of those who are physically active, as it would provide clinicians with the necessary information 
to develop and implement risk reduction programming. Developing this programming would help minimize 
the negative effects of the risk factors. 

mailto:dan.delgado.atc@gmail.com
https://doi.org/10.31622/2023/0006.01.3


Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: A Validation Case Series 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 

 

A guiding systematic review and meta-analysis2 that identified risk factors for developing MTSS in physically 
active individuals was selected for this case validation series. The authors of the review searched the 
Database of Abstracts of Reviews of Effects (DARE) and the Cochrane Database of Systematic Reviews 
(CDSR) for systematic reviews pertaining to risk factors of MTSS as well as the Cochrane Central Register of 
Controlled Trials (CENTRAL), MEDLINE (OVID SP), EMBASE, and CINAHL for studies meeting the inclusion 
criteria. Studies were included in the review if they were original research, investigated risk factors 
associated with MTSS, compared physically active individuals with and without MTSS, were published in 
English, and were accessible, full papers, in peer-reviewed journals. 

After removing duplicates and investigations that did not align with the research question, a total of 21 
original research articles were included and the  following relevant data points were extracted: research 
design, study duration, participant selection, population, groups, MTSS diagnosis, investigated risk factors, 
risk factor definitions, means, standardized deviations (SD), confidence intervals (CI), effect sizes, and odds 
ratios (OR). This information was then classified into risk factor categories including arch height or angle, 
BMI, bone parameters, calcaneus and rearfoot position and displacement, calf girth, flexibility/ROM, foot 
posture index, forefoot position, gait variables, leg angle and tibia angle, medical history and symptoms, 
Ober’s test, strength, structure/alignment, training variables/fitness level, and demographic variables. The 
21 included articles consisted of three cross-sectional, nine case-control, and nine prospective cohort studies. 
Individuals with increased BMI (mean difference [MD] = 0.79, 95% CI 0.38-1.20, p < 0.001, I2 = 0.00%), 
increased navicular drop (MD = 1.19mm, 95% CI 0.54-1.84, p < 0.001, I2 = 40.19%), increased ankle 
plantarflexion ROM (MD = 5.94°, 95% CI 3.65-8.24, p < 0.001, I2 = 0.00%), and increased hip external 
rotation ROM (MD = 3.95°, 95% CI 1.78-6.13, p < 0.001, I2 = 0.00%) were found to be more likely to 
develop MTSS. The increase in each of these four main outcome measures were deemed statistically 
significant when comparing physically active adults that did develop MTSS to those that did not develop the 
condition. 

OBJECTIVE  

The purpose of this case validation series was to investigate these four main outcome measures as risk factors 
of MTSS in secondary school (grades 9 to 12) athletes at the point-of-care. With this information, comparisons 
to previous literature that has investigated these risk factors can be made to allow for better 
recommendations for MTSS prevention measures in the secondary school athlete patient population. 

PATIENT POPULATION  

The clinical practice setting for this study included student-athletes at five secondary schools in rural Indiana. 
In total, 100 athletes, 13 of which participated in more than one sport, were included. Participant 
demographics can be found in Table 1 with the MTSS diagnoses. Those who participated in more than one 
sport were observed during both sports seasons if they did not develop MTSS during the first sport season. 
A breakdown of the number of participants by school and sex assigned at birth can be found in Table 2. 
Patients were included in this study if they were in high school and participated in cross country, volleyball, 
and/or basketball. Individuals were included regardless of MTSS history, however they had to be injury 
free at the time the risk factors were measured at the beginning of their respective sports season.  

INTERVENTION 

This case validation series followed the main findings from the guiding review which indicated that four main 
outcome measures were significantly different between those who developed MTSS and those who did not.  



Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: A Validation Case Series 

 

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In this case validation series, the athletic trainer(s) at each school calculated BMI (𝑘𝑘𝑘𝑘 ÷ 𝑚𝑚2) and measured 
navicular drop, ankle plantarflexion ROM, and hip external rotation ROM. Both ankle plantarflexion and 
hip external rotation were measured actively. 

Although BMI is not a great predictor of body mass, specifically body fat percentage in an athletic 
population, individuals with an increased BMI compared to controls are more likely to develop MTSS.2 A BMI 
of 18.5-24.9 would be considered a “healthy” height-to-weight ratio, so an individual with a BMI greater 
than this may develop MTSS because of the response of bones to loading. When tibial bowing or bending 
occurs, the load producing this bowing or bending stimulates periosteal activation, causing the tibia to 
become stronger to prevent bony overload.8,9 Those with a higher BMI would be subject to a greater load 
and may require a more gradual and prolonged increase in activity levels to account for the slow, 
progressive process of osteogenesis that needs to occur to prevent the tibia from becoming injured due to 
overloading.2  

Navicular drop and arch height have been shown to be related to tibial internal rotation during running.2 
Having a more rigid arch, one that is not hypermobile allowing the navicular to drop significantly while 
weight bearing, is good because it allows for more tibial internal rotation.10,11 This may be one way the 
body is able to better absorb impact forces.2 On the other hand, individuals with a greater amount of 
navicular drop experience a decrease in arch height, or increased foot pronation, leading to less tibial 

Table 1. Participant demographics 
Age (y) (mean±SD) 15.89±1.31  
 n MTSS 

Diagnosis n 
(%) 

Sex Assigned at 
Birth (n) 
Female 
Male 

 
54 
46 

 
10 (18.52%) 
11 (23.91%) 

Sport Participation 
(n) 
Cross Country 
Volleyball 
Basketball 

 
46 
20 
47 

 
14 (30.43%) 

0 (0%) 
7 (14.89%) 

Table 2. Number of participants by school and sex 
assigned at birth 

 Males Females Total 

School 1 27 29 56 

School 2 6 13 19 

School 3 8 3 11 

School 4 5 0 5 

School 5 0 9 9 

Total 46 54 100* 

*Of the 100 total participants, 13 participated 
in more than one sport (3 males, 10 females). 

Figure 1. Navicular Drop. 

A) The navicular tuberosity is marked on the 
patient’s skin. B) Next, the level of the 
navicular tuberosity is marked on a notecard 
while the patient is non-weightbearing. C) The 
patient is then asked to stand, and the level 
of the navicular tuberosity is marked on the 
notecard while the patient is weightbearing. 
The distance between the two markings on the 
notecard is then measured in millimeters (mm). 



Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: A Validation Case Series 

 

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internal rotation and a decreased ability to absorb impact forces.16  Having a navicular drop ≥10mm 
represents an overly pronated foot,12 meaning the tibia itself must absorb the majority of impact forces, 
predisposing  individuals to MTSS.16  

The relationship between plantarflexion ROM and the development of MTSS has less evidence than the 
previous risk factors.2 Researchers have hypothesized those with greater degrees of plantarflexion, of which 
the normative active ROM is 50°,12 are more likely to land on their forefoot when running as opposed to 
landing on the rearfoot.4 This landing position may contribute to an increase in the amount of strain being 
placed on the posteromedial aspect of the tibia.13 However, there are currently no investigations that have 
corroborated this hypothesis. Another possible explanation is that increased navicular drop and increased 
plantarflexion are interconnected. During the first half of the stance phase during running, foot pronation, 
which is a combination of ankle dorsiflexion, rearfoot eversion, and foot abduction, occurs.14 Individuals with 
greater pronation, indicating increased navicular drop, may push through their first ray more forcefully 
during midstance, when the foot pronates to absorb impact forces.2 These greater push off forces can lead 
to a greater active ROM in plantarflexion and therefore greater extensibility of the ankle dorsiflexors.2 
Increased extensibility of the anterior tibialis, a strong dorsiflexor which attaches to the base of the first ray, 
associated with greater plantarflexion ROM, may influence navicular drop due to its proximity to the 
navicular bone.2 Though these biomechanical connections can be make hypothetically, there remains a lack 
of substantial evidence to make these connections definitive, further demonstrating the need for screening 
and prevention.  

 

Possibly more unclear than the connection between plantarflexion and MTSS is the association between 
increased hip external rotation ROM and MTSS.2 The normative active ROM for hip external rotation is 
45°.12 Hip external rotation ROM greater than this could lead to excessive medial tibial loading; however, 
the same is true for decreased hip ranges of motion,4 as well as limited evidence suggesting greater internal 
rotation can lead to MTSS.17 Changes in the available degrees in various ranges of motion of the hip may 
result from anteversion or retroversion of the femoral neck,15 changing the orientation of the femur on the 

Figure 2. Active Ankle Plantarflexion ROM Measurement with Goniometer 

A) Starting Position: The fulcrum of the goniometer is placed over the apex of the lateral malleolus, the stationary 
arm is aligned parallel to the axis of the fibula using the head of the fibula as a distal reference, and the moving 
arm is aligned parallel to the axis of the 5th metatarsal during movement. B) The patient is asked to plantarflex 
their ankle and the clinician ensures all parts of the goniometer remain correctly aligned. 



Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: A Validation Case Series 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 

 

tibia.2 Another possible theory is that the total arc of rotation at the hip, meaning the total degrees of hip 
internal and external rotation combined, could influence tibial loading, though there is limited empirical 
evidence to make a concrete connection here.2 Even so, more research should be conducted to identify the 
relationship between hip external rotation ROM and ankle plantarflexion ROM on the development of MTSS.  

 

MAIN FINDINGS  

Participants of this case validation series were divided into two groups, MTSS and non-MTSS, based on the 
development of the condition. Descriptive statistics were completed for both groups. Measures of central 
tendency were used to analyze the demographic variables and main outcome measures. Mean differences 
were calculated between the two groups. The groups were not normally distributed, so a Kruskal-Wallis 
one-way analysis of variance was used to determine differences.  

During their respective sport season, 21% (n = 21/100) of participants developed MTSS. The supervising 
athletic trainer at their respective school used the following diagnostic criteria for MTSS: injury must have 
been exercise-induced, pain must be localized, and pain must be along the distal two-thirds of the 
posteromedial tibia.1 The means and standard deviations for each main outcome variable by group can be 
found in Table 3 with the normative values for the general population for comparison. The MD between 
groups was calculated by subtracting the mean of those who did not develop MTSS from those that did. The 
MD of each of the measures were as follows: BMI = 0.22, navicular drop = 0.95mm, active ankle 
plantarflexion ROM = -1.36°, and active hip external rotation ROM = -0.40°. There were no significant 
differences in BMI (p ≥ 0.42), navicular drop (p ≥ 0.27), active ankle plantarflexion ROM (p ≥ 0.65), or 
active hip external rotation ROM (p ≥ 0.77) between participants who did and did not develop MTSS. 

Table 3. Side-by-side comparison of the results to normative values between groups (MTSS and non-MTSS) 
 Normative Values MTSS Group 

(n=21) 
Non-MTSS 

(n=79) 
BMI 

 
Healthy = 18.5-24.9 22.36±4.35 

(95% CI 20.50-24.22) 
22.14±3.09 

(95% CI 19.05-25.23) 
Navicular Drop Normal ≤ 10mm 8.33±3.14 

(95% CI 6.99-9.67mm) 
7.38±3.63 

(95% CI 6.58-8.18mm) 
Active Ankle  

Plantarflexion ROM 
0-50° 55.24±9.54° 

(95% CI 51.16-59.32°) 
56.59±10.75° 

(95% CI 54.23-58.96°) 
Active Hip External 

Rotation ROM 
0-45° 33.98±7.30° 

(95% CI 30.85-37.10°) 
34.38±9.91° 

(95% CI 32.19-36.57°) 
 

Figure 3. Active Hip External Rotation ROM 
Measurement with Goniometer 

A) Starting Position: The fulcrum of the goniometer 
is placed over the middle of the patella, the 
stationary arm is aligned perpendicular to the 
floor or tabletop, and the moving arm is aligned 
parallel to the axis of the tibia during movement 
using the center of the talocrural joint as a distal 
reference. B) The patient is asked to externally 
rotate their hip and the clinician ensures all parts 
of the goniometer remain correctly aligned.  

 



Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: A Validation Case Series 

 

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DISCUSSION   

The purpose of this validation case series was to investigate risk factors of MTSS in an adolescent sporting 
population. Identifying risk factors in this population would be a necessary step for the development and 
implementation of preventative training programs to reduce the incidence rate of this injury. The current 
investigation found no significant differences between the four main outcome measures between patients 
who developed MTSS and those who did not. The average BMI of individuals in this study fell within the 
normative range (18.5-24.9) for both individuals who developed the condition and those who did not. 
Similarly, the average navicular drop for both groups was between 7.38±3.63mm and 8.33±3.14mm for 
the non-MTSS and MTSS groups respectfully, which would be considered in the normative range below 
10mm. Overall, active ankle plantarflexion ROM for both groups was approximately 5-7° greater than 
population normative values. However, since this finding was present in both groups, the difference between 
groups was not found to be significant. Lastly, the average active hip external rotation ROM for both groups 
was about 11° less than population normative values. Though previous literature has suggested both 
increased and decreased hip ranges of motion could affect tibial loading,4 both those who developed MTSS 
and those who did not develop MTSS demonstrated a decrease in external rotation ROM.  

In this study, there were some key limitations that need to be addressed in future research. This study included 
a small sample size (n = 100) and the patient population of this study was solely adolescent athletes between 
the ages of 13 and 18. Adolescent athletes may have different anthropometric characteristics that 
predispose them to developing MTSS when compared to adults. Another limitation of this study was the use 
of ROM measures as a surrogate for gait analysis. While ROM theoretically influences biomechanics, an in-
depth biomechanical analysis should be utilized to more accurately identify these changes. In addition, this 
study was conducted during the COVID-19 pandemic which saw sports teams regularly quarantine when an 
individual on a team tested positive for the virus. This may have had an effect on the number of individuals 
in the study who experienced MTSS because the quarantine period created unusual rest periods throughout 
the sports season, where patients were not subjected to the same training regimen and decreased loading 
of the tibia. Additionally, with the consistent changes in training load, we did not include training load and 
mileage ran for each participant. Finally, when conducting a multi-site investigation at the point-of-care, 
coordination and collaboration are paramount for data collection. 

Future studies should utilize larger sample sizes and investigate the differences between adolescents and 
adults who develop MTSS from those that do not develop MTSS. Specifically, research should continue to 
investigate the influence of hip external rotation ROM and running biomechanics. Also, information related 
to training load and training intensity should be considered in future research on this topic, as previous 
investigations have shown that increased training load can predispose individuals to MTSS. 

CLINICAL BOTTOM LINE 

Adolescents with significantly greater BMI, navicular drop, active ankle plantarflexion ROM, and/or active 
hip external rotation ROM may not be more likely to develop MTSS. More research should be performed 
with a larger sample size as well as to investigate if the risk factors for MTSS between adults and adolescents 
differ. A reduction in the total number of adolescents experiencing MTSS should also have a larger impact 
on the entire healthcare system, reducing the time and financial burden that is exacerbated treating 
preventable conditions. 

 



Risk Factors of Medial Tibial Stress Syndrome in Active Adolescents: A Validation Case Series 

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 

 

ACKNOWLEDGEMENTS  

Thank you to Dr. Karina Gonzalez, Dr. Grace Mills, Dr. Andrew Schweitzer, and Kyrie Potter for assisting in 
the data collection process. 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 

 

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https://doi.org/10.1136%2Fbjsm.2002.004499

	ABSTRACT

