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Medial Tibial Stress Syndrome

Wednesday, September 26, 2018   (0 Comments)
Posted by: Timothy Bertelsman, DC, DABCO
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Medial Tibial Stress Syndrome


Autumn means that youth overuse injuries increase as school sports resume, and lower extremity stress is particularly amplified when athletes move indoors onto hard floors. Medial tibial stress syndrome (MTSS), aka Medial Tibial Traction Periostitis, is a common result of this increased load. The diagnosis of MTSS describes exercise-induced pain along the posteromedial border of the tibia.  The condition is commonly referred to as "shin splints" and is a familiar malady in athletes and soldiers where it affects up to 1/3 of those populations.  (1-4) MTSS is responsible for approximately 15% of all running injuries.  (1)

The condition affects the vulnerable insertion points of the tibial fascia and deep ankle flexors along the medial tibial crest. MTSS is believed to result from repetitive eccentric contraction of the deep flexors during running, jumping, or impact loading.  (5) Repetitive traction on the medial tibial crest results in myofascial strain, periosteal inflammation, and bony stress reaction.  (6-13) Early etiological theories focused on myofascial strain, but current evidence suggests that a bony stress reaction is the most likely cause of MTSS.  (14-20) 

Newer research suggests that traction periostitis may be an inflammatory precursor to tibial stress fracture.  (21) The stress of exercise can weaken bone.  Healthy bone responds to this stress by remodeling itself more densely. Stress reactions occur when the normal adaptive remodeling response is unable to keep pace with the loads of excessive training, i.e., high demands with inadequate recovery times. (22,23) Prolonged insult may lead to tibial stress fracture, and many authors now believe that MTSS and stress fracture represent two different points along a continuum of bony stress reaction.  (24,25)  

The leading mechanism of injury is repetitive eccentric contraction from running or jumping on hard surfaces.  (26-28) Excessive or improper training is the leading factor in the development of MTSS.  (2,3,29-33) Common training errors include the “terrible too's” (too much, too fast, too long.)  (31-34) Athletes who run more than 20 miles per week are at increased risk of developing MTSS.  (35) Inexperienced runners or those with poor technique are at greater risk.  (4) Running with a narrow or "crossover" gait increases tibial stress. (87)

Foot hyperpronation is a significant risk factor for the development of MTSS, as a collapsing foot puts additional stress on the suspect tissues.  (4,10,12,14,28,36) Interestingly, the use of orthotics is associated with the development of MTSS, although orthotic use should not be viewed as an independent risk factor, since those using orthotics are likely to hyperpronate. (4) Females are affected more frequently and have a 1.5-3.5 increased likelihood of progressing to stress fracture.  (4,37) Additional risk factors include a prior history of MTSS and increased BMI.  (4) 
  
The clinical presentation of MTSS includes vague, diffuse pain over the middle to distal posteromedial tibia.  Athletes often present following an increase in activity intensity or duration.  Symptoms are often worse with exertion, particularly at the beginning of a work-out.  (38)  Initially, symptoms may subside during training, but as the condition progresses, symptoms may linger throughout activity or even at rest.  (38) Pain that persists more than five minutes post-activity carries a higher suspicion of stress fracture.  (49) Clinicians should be alert for symptoms of numbness or paresthesia, which could suggest exercise-induced compartment syndrome.  
 
Clinical evaluation demonstrates diffuse tenderness over the posteromedial tibial border. Prolonged stress may generate a periosteal reaction detectable as a "rough" or "bumpy" feel upon palpation.  (39) Tenderness from MTSS should involve at least 5 cm of the tibial border.  (39) More focal tenderness, the presence of anterior tibial tenderness, or any significant swelling, suggests stress fracture. Applying a vibrating tuning fork over the tibia may help detect stress fracture (75% sensitivity). (40) Single leg hopping is painful in about half of MTSS cases (and 70-100% of stress fractures) (41-43) The Talar Bump Test may help differentiate tibial stress fracture from MTSS.

Tenderness over the flexor digitorum longus and tibialis posterior is a clinical hallmark of the condition, although whether this is a primary cause or secondary effect remains uncertain.  (44,45) Clinicians should assess for the presence of hypertonicity in the gastroc or soleus, as this finding is commonly associated with MTSS.  (46,47) 
 
The presence of foot hyperpronation may be assessed through the navicular drop test (performed by marking the navicular and measuring the amount of drop from non-weight bearing to weight bearing.)  (48) Clinicians should assess for other potential risk factors, including inflexibility or imbalance of the hamstring and quadriceps, genu varus or valgus, tibial torsion, femoral anteversion, and leg length discrepancies.  (14) Hip abductor weakness is a common culprit of many lower chain overuse injuries and may be assessed through the "hip abductor weakness cluster."  (86) Excessive external rotation of the hip is another known contributor.  (4,50)

Assessment of gait or running patterns can identify biomechanical errors.  (51,52) Clinicians should assess joint mobility throughout the lower extremity. Neurovascular assessment is typically unremarkable.  (38) The presence of sensory or motor loss suggests an alternate diagnosis, including exertional compartment syndrome, peripheral neuropathy, or radiculopathy.  

Imaging of early and uncomplicated MTSS is often unnecessary.  (53) Imaging is appropriate in the presence of “red flags”: focal tenderness, pain at rest, or when the patient fails to improve with a reasonable trial of conservative care.  (53) Radiographs taken within the first 2-3weeks are not likely to show any change; however, patients with longstanding MTSS may demonstrate periosteal reaction, indicating callus formation and stress fracture. (55)  

Clinicians should be vigilant for the possibility of stress fracture.  Plain films frequently do not demonstrate the signs of tibial stress fracture (periosteal elevation/callus formation or cortical lucency). (42,56,57) Unresponsive patients or those with a higher likelihood of stress fracture (runners) may benefit from advanced imaging, including MRI or bone scan.  (58) MRI is highly sensitive (74-100%) and is best able to grade the progression of stress reaction from periosteal edema (Grade 1), to progressive bone marrow edema (Grade 2-3), to cortical stress fracture (Grade 4).  (59-61)  

In addition to stress fracture, the differential diagnosis of MTSS includes exertional compartment syndrome, peripheral vascular disease, muscle strain, occult fracture, infection, neoplasm, DVT, peripheral neuropathy, popliteal artery entrapment syndrome, lumbosacral radiculopathy, and vascular claudication.  (62-64)
 
The successful management of MTSS requires the removal of risk factors, and rest. Clinicians must identify the combination of training errors and biomechanical risk factors that led to the development of the patient's condition.  (65) No intervention has proven more successful than rest for the management of MTSS.  (4) Unfortunately, patients often are affected by MTSS during a time when they are training for a sport or upcoming event.  Continuance of the offending activity will often lead to undue chronicity, frustration for patient and clinician, and decreased performance capabilities. Athletes may need to decrease frequency, intensity, and duration of impact activities, including running and jumping. Athletes may need to consider non-weight bearing cross-training, such as stationary cycling or pool running. Initially, anti-inflammatory modalities, including ultrasound or e-stim, may provide relief.  (67)  Ice or home ice massage may provide an anti-inflammatory or palliative benefit.  

Resolution of MTSS requires correction of any associated kinetic chain dysfunction.  (68-70) Stretching exercises and myofascial release are appropriate for the gastroc, soleus, hip external rotators, tibialis posterior, and tibialis anterior muscles.  (71) Strengthening exercises may be appropriate for the tibialis posterior and hip abductors. Manipulation may be employed to resolve joint restrictions in the spine, sacroiliac joint, pelvis, and lower extremity.  (69,70,74) 

Arch supports or custom orthotics may be appropriate for patients with fallen arches (75), although at least one contradictory systematic review suggests that orthotics may be causative and are not useful for prevention.  (76) The use of compressive taping, bracing, or stockings are thought to enhance bone remodeling and are used by some providers, although supporting evidence is inconclusive.  (77-79) Additional possibilities for the management of MTSS include dry needling, autologous blood injection, platelet-rich plasma (PRP) injections, prolotherapy, and acupuncture.  (74,80) Extracorporeal shock wave therapy (ECST) may speed recovery times.  (81)
 
Return to activity should start slowly with a graded running program, beginning with a 1/4 mile run and progressing by 1/4 mile each time the athlete has no pain for two consecutive workouts.  (82) Athletes should initially avoid running on hard or uneven surfaces and begin at a lower intensity and distance, increasing by no more than 10-15% per week. Runners should first increase distance, then pace, and avoid hard or unlevel surfaces, including hills. Runners with a narrow gait may benefit from incorporating a wider step width. (87) Clinicians should assess shoes for excessive wear and match the patient to the most appropriate shoe (i.e., stability, neutral, cushioning). Running shoes lose half of their shock absorption capacity after 300-500 miles and should be replaced within that range.  (83-85)
  
Surgical intervention, including posterior fasciotomy, is rarely indicated for MTSS. (74)

References 
1. Clement DB, Taunton JE, Smart GW, McNicol KL.  A survey of overuse running injuries.  Phys Sportsmed 1981;9:47-58. Cited in Yates B, Allen MJ, Barnes MR.  Outcome of surgical treatment of medial tibial stress syndrome.  J Bone Joint Surg Am 2003;85(10):1974-1980.
2. Almeida S, Trone D, Leone D, Shaffer R.  Gender differences in musculoskeletal injury rates: a function of symptom reporting? Med Sci Sports Exerc 1999;31:1807-1812. cited in Yates B, White S. The Incidence and Risk Factors in the Development of Medial Tibial Stress Syndrome Among Naval Recruits.  Am J Sports Med 2004;32(3):772-780
3. Yates B, White S.  The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits.  Am J Sports Med 2004;32(3):772-780.
4. Phil Newman, Jeremy Witchalls, Gordon Waddington, and Roger Adams Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis J Sports Med. 2013; 4: 229–241. 
5. Bouché RT, Johnson CH.  Medial tibial stress syndrome a proposed pathomechanical model involving fascial traction.  JAPMA 2007;97(1):31-36.
6. Mubarak SJ, Gould RN, Lee YF, Schmidt DA, Hargens AR. The medial tibial stress syndrome a cause of shin splints. Am J Sports Med. 1982;10(4):201–205.
7. Michael RH, Holder LE. The soleus syndrome. A cause of medial tibial stress (shin splints) Am J Sports Med. 1985;13(2):87–94.
8. Bhatt R, Lauder I, Finlay DB, Allen MJ, Belton IP. Correlation of bone scintigraphy and histological findings in medial tibial syndrome. Br J Sports Med. 2000;34(1):49–53.
9. Johnell O, Rausing A, Wendeberg B, Westlin N. Morphological changes in shin splints. Clin Orthop Relat Res. 1982;(167):180–184
10. Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20(5):501-5. 
11. Craig DI. Medial tibial stress syndrome: evidence-based prevention. J Athl Train 2008; 43(3):316-18. 
12. Viitsalo JT, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sports Med 1983; 11(3):125-130. 
13. Krivickas LS. Anatomical factors associated with overuse sports injuries. Sports Med 1997; 24(2):132-46. 14. Beck BR. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med. 1998;26(4):265–279
15. Magnusson HI, Ahlborg HG, Karlsson C, Nyquist F, Karlsson MK. Low regional tibial bone density in athletes with medial tibial stress syndrome normalizes after recovery from symptoms. Am J Sports Med. 2003;31(4):596–600
16. Magnusson HI, Westlin NE, Nyqvist F, Gärdsell P, Seeman E, Karlsson MK. Abnormally decreased regional bone density in athletes with medial tibial stress syndrome. Am J Sports Med. 2001;29(6):712–715. 
17. Batt ME, Ugalde V, Anderson MW, Shelton DK. A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc. 1998;30(11):1564–1571. 
18. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472–481. 
19. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553–561. 
20. Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC. Medial tibial stress syndrome: a critical review. Sports Med. 2009;39(7):523–546.
21. Tweed JL, Avil SJ, Campbell JA, Barnes MA.  Etiologic factors in the development of medial tibial stress syndrome:  a review of the literature.  JAPMA 2008;98(2):107-111.
22. Anderson MW, Greenspan A. Stress fractures. Radiology 1996; 199(1):1-12.
23. Roub W, Gumerman LW, Hanley EN, et al. Bone stress: a radionuclide imaging perspective. Radiology 1979; 132(2):431-8.
24. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med 1997; 16(2):291-306.
25. Johnson LC, Stradford HT, Geis RW, Dineen JR, Kerley E. Histogenesis of stress fractures. JBJS 1963; 45A:1542.
26. Slocum DB. The shin splint syndrome. Medical aspects and differential diagnosis. Am J Surg 1967; 114(6):875-881.
27. James S, Ali K, Pocock C, Robertson C, Walter J, Bell J. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007;41(8):518–522
28. Bouché RT, Johnson CH.  Medial tibial stress syndrome a proposed pathomechanical model involving fascial traction.  JAPMA 2007;97(1):31-36.
29. Street D. Medial Tibial Stress Syndrome in Sporting Adults: A Clinical Management Guideline. Podiatry & Posture Ltd
30.  Galbraith R et al. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. Sep 2009; 2(3): 127–133.
31. Kortebein P, Kaufman K, Basford J, Stuart M. Medial tibial stress syndrome. Med Sci Sports Exerc. 2000;32(3 suppl):S27–S33
32. Fredericson M. Common injuries in runners. Diagnosis, rehabilitation and prevention. Sports Med. 1996;21:49–72.
33. Wilder R, Seth S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55–81. 
34. Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–552. 
35. Dugan S, Weber K. Stress fracture and rehabilitation. Phys Med Rehabil Clin N Am. 2007;18(3):401–416.
36. Bartosik KE, Sitler M, Hillstrom HJ, Palamarchuk H, Huxel K, Kim E. Anatomical and biomechanical assessments of medial tibial stress syndrome. J Am Podiatr Med Assoc. 2010;100(2):121–132.
37. Dugan S, Weber K. Stress fracture and rehabilitation. Phys Med Rehabil Clin N Am. 2007;18(3):401–416.
38. Kortebein P, Kaufman K, Basford J, Stuart M. Medial tibial stress syndrome. Med Sci Sports Exerc. 2000;32(3 suppl):S27–S33
39. Yates B, White S.  The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits.  Am J Sports Med 2004;32(3):772-780.
40. Lesho EP. Can tuning forks replace bone scans for identification of tibial stress fractures? Mil Med. 1997;162(12):802–803.
41.  Clement DB, Ammann W, Taunton JE, et al. Exercise-induced stress injuries to the femur. Int J Sports Med. 1993;14(6):347–352.
42. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79–84.
43. Batt ME, Ugalde V, Anderson MW, Shelton DK. A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc. 1998;30(11):1564–1571.  
44. Yates B, White S.  The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits.  Am J Sports Med 2004;32(3):772-780
45. Newman P, Adams R, Waddington G. Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test. Br J Sports Med. 2012;46(12):861–864.
46. Beck B. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med. 1998;26(4):265–279.
47. M Winters, H Veldt, E W Bakker, M H Moen.  Intrinsic factors associated with medial tibial stress syndrome in athletes: A large case-control study S Afr J SM 2013;25(3):63-67.
48. Bennett JE, Reinking MF, Pluemer B, et al. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther 2001:31(9):504-510.
49. Kirby KA. Foot and lower extremity biomechanics II: Precision Intricast newsletters, 2002-2008. Precision Intricast Inc., Payson, Ariz., 2009.
50. Burne SG, Khan KM, Boudville PB, et al. Risk factors associated with exertional tibial pain: A twelve months prospective clinical study. Br J Sports Med 2004:38(4):441-445.
51. Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–552.
52. Dugan S, Weber K. Stress fracture and rehabilitation. Phys Med Rehabil Clin N Am. 2007;18(3):401–416.
53. Mellion M, Walsh W, Madden C, Putukian M, Shelton G. The team physician's handbook. 3rd ed. Philadelphia, PA: Hanley & Belfus; 2002. p. 517, 583.
55. Couture C, Karlson K. Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints'. Phys Sportsmed. 2002;30(6):29–36
56. Berger F, de Jonge M, Smithuis R, Maas M. Stress Fractures. www.radiologyassistant. 5/23/07. accessed 6/21/14. 
57. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46–58.
58. Young A, McAllister D. Evaluation and treatment of tibial stress fractures. Clin Sports Med. 2006;25(1):117–128.
59. Fredericson M, Bergman G, Hoffman K, Dillingham M. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23:427–481
60. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553–561.
61. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472–481.
62. Fredericson M, Wun C. Differential diagnosis of leg pain in the athlete. JAPMA 2003; 93(4):321-4.
63. Schon LC, Baxter DE, Clanton TO. Chronic exercise-induced leg pain in active people: more than just shin splints. Phys Sports Med 1992; 20:100-114.
64. Korkola M, Amendola A. Exercise-induced leg pain. Sifting through a broad differential. Phys Sportsmed. 2001;29(6):35–50
65. Fredericson M. Common injuries in runners. Diagnosis, rehabilitation and prevention. Sports Med. 1996;21:49–72.
67. Galbraith RM, Laverlee ME.  Medial tibial stress syndrome: conservative treatment options.  Cur Rev Musculoskelet Med 2009;2:127-133.
68.  Wilder R, Seth S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55–81.
69.  Greenman P. Principles of manual medicine. 3rd ed., chap. 11. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: p. 337–403, 489.
70.  Karageanes S. Principles of manual sports medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 2005. pp. 467–468.
71. Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–552.
74. Galbraith RM, Laverlee ME.  Medial tibial stress syndrome: conservative treatment options.  Cur Rev Musculoskelet Med 2009;2:127-133.
75. Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005;(2):CD000450.
76. Richter RR, Austin TM, Reinking MF. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis-critical appraisal and commentary. J Athl Train. 2011;46(1):103–106.
77. Zimmermann WO, Paantjes MA: Sport compression stockings: user satisfaction 50 military personnel.  Dutch J Mil Med 2009, 62:209-213.
78. Roelofsen J, Klein-Nulend J, Burger EH: Mechanical stimulation by intermittent hydrostatic compression promotes bone-specific gene expression in vitro. J Biomech 1995, 33(12):1493-1503.
79. Moen MH, Bongers T, Bakker EWP, Weir A, Zimmerman WO, van der Werve M, Backx FJG.  The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomised study.  JR Army Med Corps 2010;156(4):236-240.
80. Ravin T, Cantieri M, Pasquarello G. Principles of prolotherapy, vol. 233. Denver, CO: American Academy of Musculoskeletal Medicine; 2008. p. 250–1
81. Moen MH, Rayer S, Schipper M, Schmikli S, Weir A, Tol JL, Backx FJG.  Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study.  Br J Sports Med 2011;10.1136/bjsm.2010.081992.
82.  Moen et al. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2012, 4:12 
83.  Messier SP, Edwards DG, Martin DF, et al. Etiology of Iliotibial Band Friction Syndrome in Distance Runners. Medicine & Science in Sports & Exercise 1995; 27(7):951-60.
84. Reid DC. Sports Injury Assessment and Rehabilitation. New York:Churchill Livingston, 1992.
85. Messier SP, Edwards DG, Martin DF, et al. Etiology of Iliotibial Band Friction Syndrome in Distance Runners. Medicine & Science in Sports & Exercise 1995; 27(7):951-60. 
86. Niemuth P, Johnson R, Myers M, Thieman T. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med. 2005;15(1):14–21.
87. Meardon SA, Derrick TR. J Biomech. Effect of step width manipulation on tibial stress during running. 2014 Aug 22;47(11):2738-44. 

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