Medial Tibial Stress Syndrome: Difference between revisions

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== Introduction ==
== Introduction ==
[[File:Tibia - frontal view.png|thumb|Pain generally in the inner and lower 2/3rds of tibia.]]
[[File:Tibia - frontal view.png|thumb|Pain generally in the inner and lower 2/3rds of tibia.|alt=|240x240px]]
Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers<ref>Radiopedia  Medial tibial stress syndrome Available: https://radiopaedia.org/articles/medial-tibial-stress-syndrome-1<nowiki/>(accessed 2.6.2022)</ref>. It presents as exercise-induced pain over the anterior tibia and is an early stress injury in the continuum of tibial stress fractures.<ref name=":9">McClure CJ, Oh R. Medial Tibial Stress Syndrome. 2019 Available:https://www.ncbi.nlm.nih.gov/books/NBK538479/ (accessed 2.6.2022)</ref>. It is provoked on palpation over a length of ≥ 5 consecutive centimetres. <ref name=":0">Winters, M. Medial tibial stress syndrome: diagnosis, treatment and outcome assessment (PhD Academy Award). Br J Sports Med. 2018</ref><ref name=":1">Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey, C. D. The prevention of shin splints in sports: a systematic review of literature. Medicine & Science in Sports & Exercise. 2002; ''34''(1): 32-40.</ref><ref name=":2">Galbraith, R. M., & Lavallee, M. E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848339/pdf/12178_2009_Article_9055.pdf Medial tibial stress syndrome: conservative treatment options]. Current reviews in musculoskeletal medicine. 2009; ''2''(3): 127-133.</ref>
Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers<ref name=":10">Radiopedia  Medial tibial stress syndrome Available: https://radiopaedia.org/articles/medial-tibial-stress-syndrome-1<nowiki/>(accessed 2.6.2022)</ref>. It presents as exercise-induced pain over the anterior [[tibia]] and is an early stress injury in the continuum of tibial [[Stress Fractures|stress fractures]].<ref name=":9">McClure CJ, Oh R. Medial Tibial Stress Syndrome. 2019 Available:https://www.ncbi.nlm.nih.gov/books/NBK538479/ (accessed 2.6.2022)</ref>.  


It has the layman's moniker of “shin splints.”<ref name=":9" />
It has the layman's moniker of “shin splints.”<ref name=":9" />
== Epidemiology ==
== Epidemiology ==
The incidence of MTSS ranges between 13.6% to 20% in runners and up to 35% in military recruits.  In dancers it is present in 20% of the population and up to 35% of the new recruits of runners and dancers will develop it<ref name=":3">Lohrer, H., Malliaropoulos, N., Korakakis, V., & Padhiar, N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. The Physician and sports medicine. 2018</ref>
[[File:Runner surface and shoes.jpg|thumb|Risk factor- quick increase in running volume]]
The incidence of MTSS ranges between 13.6% to 20% in runners and up to 35% in military recruits.  In dancers it is present in 20% of the population and up to 35% of the new recruits of runners and [[Dancer's Tendonitis|dancers]] will develop it.<ref name=":3">Lohrer, H., Malliaropoulos, N., Korakakis, V., & Padhiar, N. [https://scholar.google.com/scholar_url?url=https://www.tandfonline.com/doi/abs/10.1080/00913847.2018.1537861&hl=en&sa=T&oi=gsb&ct=res&cd=0&d=14631594707254492548&ei=_eU0Y_H8BZCXywTOrbawDQ&scisig=AAGBfm3OdinnrYmQUWLRtFcZkUHgI0G7iA Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies]. The Physician and sports medicine. 2018</ref>


Large increase in loads, volume and high impact exercise can put at risk individuals to MTSS.  Intrinsic risk factors include being a female, previous history of MTSS, high [[Body Mass Index|BMI]], [[Navicular Drop Test|navicular drop]], reduced hip external rotation range of motion,<ref name=":9" />muscle imbalance and inflexibility of the triceps surae (gastrocnemius, soleus, and plantaris muscles), muscle weakness of the triceps surae (prone to muscle fatigue leading to altered running mechanics, and strain on the tibia). <ref name=":2" /> &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
Large increase in [[Load Management|load]], volume and high impact exercise can put at risk individuals to MTSS.  Risk factors include being a female, previous history of MTSS, high [[Body Mass Index|BMI]], [[Navicular Drop Test|navicular drop]], reduced hip external rotation [https://www.physio-pedia.com/Range_of_Motion range of motion], muscle imbalance and inflexibility of the [[Triceps Surae|triceps surae]]), muscle weakness of the triceps surae (prone to muscle fatigue leading to altered running mechanics, and strain on the tibia), running on a hard or uneven surface and bad running shoes <ref name=":9" /><ref name=":2">Galbraith, R. M., & Lavallee, M. E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848339/pdf/12178_2009_Article_9055.pdf Medial tibial stress syndrome: conservative treatment options]. Current reviews in musculoskeletal medicine. 2009; ''2''(3): 127-133.</ref> <ref name="Broos, 1991">Broos P. Sportletsels : [https://scholar.google.com/scholar_url?url=https://books.google.com/books%3Fhl%3Den%26lr%3D%26id%3D2FpjR04UCa8C%26oi%3Dfnd%26pg%3DPA15%26dq%3DBroos%2BP.%2BSportletsels%25C2%25A0%2B%2Baan%2Bhet%2Blocomotorisch%2Bapparaat.%2BLeuven%2B%2BGarant,%2B1991.%2B(Level%2Bof%2BEvidence%2B%2B5)%26ots%3DOnE9hHIuQQ%26sig%3DSNzM0EcqnaojVd0KEZzcn8C6YQM&hl=en&sa=T&oi=gsb&ct=res&cd=0&d=15174174591971393226&ei=K-Y0Y7uaIo3MyQSdgLaoAw&scisig=AAGBfm006F6JmHsTT0RP_Ek7dEvR0173aw aan het locomotorisch apparaat. Leuven: Garant, 1991]. (Level of Evidence: 5)</ref>&nbsp;


Running on a hard or uneven surface and bad running shoes (like a poor shock absorbing capacity) could be one of the factors related to the casualty. <ref name="Broos, 1991">Broos P. Sportletsels : aan het locomotorisch apparaat. Leuven: Garant, 1991. (Level of Evidence: 5)</ref>&nbsp;
== Pathophysiology ==
== Characteristics/Clinical Presentation  ==
[[File:Periosteum (green).png|thumb|Periosteum, vivid green]]
The pathophysiologic process resulting in MTSS is related to unrepaired microdamage accumulation in the cortical bone of the distal tibia, however this has not been definitively established. Two current theories are:  


The main symptom is dull pain at the distal two third of the posteromedial tibial border. The pain is non-focal but extends over “at least 5 cm” <ref name=":3" /> and is often bilateral<ref>Reid DC. Sports Injury Assessment and Rehabilitation. New York: Churchill Livingstone. 1992</ref>.It also worsens at each moment of contact.<ref name="Broos, 1991" /> A mild edema in this painful area may also be present and tenderness on palpation is typically present following the inducing activity for up to several days.<ref name=":3" />
# The pain is secondary to [[Inflammation Acute and Chronic|inflammation]] of the periosteum as a result of excessive traction of the [[Tibialis Posterior|tibialis posterior]] or [[soleus]], supported by bone scintigraphy findings of a broad linear band of increased uptake along the medial tibial [[periosteum]]. But a case-controlled ultrasound based study which compared periosteal and tendinous edema of athletes with and without medial tibial stress syndrome found no difference between the groups.
 
# Bony overload injury, with resultant microdamage and targeted remodeling. A study evaluating tibia biopsy specimens from the painful area of six athletes suffering from medial tibial stress syndrome gave only equivocal support for this theory. Linear microcracks were found in only three specimens and there was no associated repair reaction<ref name=":11">Milgrom C, Zloczower E, Fleischmann C, Spitzer E, Landau R, Bader T, Finestone AS. [https://sbrate.com.br/wp-content/uploads/2021/01/Artigo-Andr%C3%A9-Pedrinelli-Ot%C3%A1vio-Assis-COMPLEMENTO-JSAMS_MEDIAL_TIBIAL_STRESS_GUIDELINES.pdf Medial tibial stress fracture diagnosis and treatment guidelines]. Journal of science and medicine in sport. 2021 Jun 1;24(6):526-30. (accessed 2.6.2022)</ref>.
At first the patient only feels pain at the beginning of the workout, often disappearing while exercising, only to return during the cool-down period. When shin splints get worse the pain can remain during exercise and also could be present for hours of days after cessation of the inducing activity.<ref name=":3" />
== Clinical Presentation and Assessment ==
 
The most common complication of shin-splints is a stress fracture, which shows itself by tenderness of the anterior tibia.<ref name=":2" /> Neurovascular signs and symptoms are not commonly attributable to MTSS and when present, other pathologies such as chronic exertional compartment syndrome (CECS) or vascular deficiencies should be considered as the source of leg pain.<ref name=":4" /><ref name=":5" /><ref name="Broos, 1991" />
 
== Differential Diagnosis  ==
An algorithmic approach has been established for further differentiating exercise-induced leg pain entities<ref name=":3" />:
# Pain at rest with palpable tenderness indicates bone stress injuries (MTSS and stress fractures),
# No pain at rest with palpable tenderness proposes nerve entrapment syndromes
# No pain at rest with no palpable tenderness makes functional popliteal artery entrapment syndrome and chronic exertional compartment syndrome likely 
MTSS may overlap with the diagnosis of deep posterior compartment syndrome but the critical point for differentiation is the longer lasting post-exercise pain when compared with deep posterior chronic exertional compartment syndrome.
 
Compared with stress fractures, the painful area extends over more than 5 cm on the distal two thirds of the medial tibial border.
{| class="wikitable"
{| class="wikitable"
! colspan="2" |KEY POINTS FOR ASSESSMENT AND MANAGEMENT FOR MTSS<ref name=":3" />
! colspan="2" |KEY POINTS FOR ASSESSMENT MTSS<ref name=":3" />
|-
|-
|HISTORY
|HISTORY
|Increasing pain during exercise related to the medial tibial border in the middle and lower third
|
 
* Increasing pain during exercise related to the medial tibial border in the middle and lower third
Pain persists for hours or days after cessation of activity
* Pain persists for hours or days after cessation of activity
* Pain decreases with running (early stage)
* Differentiate from exertional compartment syndrome, for which pain increases with running
* Earlier onset of pain with more frequent training (later stages)
|-
|-
|PHYSICAL EXAMINATION
|PHYSICAL EXAMINATION
|Intensive tenderness of the involved medial tibial border
|
More than 5 cm
* Intensive tenderness of the involved medial tibial border, more than 5 cm
* Pes planus
* Tight Achilles tendon
* A "one-leg hop test" is a functional test, that can be used to distinguish between medial tibial stress syndrome and a stress fracture: a patient with medial tibial stress syndrome can hop at least 10 times on the affected leg where a patient with a stress fracture cannot hop without severe pain. The sensitivity of the hop test for diagnosing medial tibial stress fracture when pain and tenderness were present was 100%, the specificity 45%, the positive predictive value 74%, and the negative predictive value 100%
* Provocative test: pain on resisted plantar flexion
|-
|-
|IMAGING
|IMAGING
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|-
|-
|TREATMENT
|TREATMENT
|Mainly conservative (running retraining, ESWT)
|See later in page
|}
|}
It is important to differentiate MTSS from:
*Stress Fracture
*Chronic Exertional Compartmental Syndrome
*Sciatica
*Deep Vein Thrombosis (DVT)
*Popliteal Artery Entrapment
*Muscle Strain
*Tumour
*Arterial endofibrosis
*Infection
*Nerve entrapment (common/superficial peroneus and saphenous)
The following are two conditions that are sometimes mistakenly diagnosed as shin splints.&nbsp;


Pain on the anterior (outside) part of the lower leg may be compartment syndrome: Swelling of muscles within a closed compartment which creates pressure. The symptoms of compartment syndrome include leg pain, unusual nerve sensations, and eventually muscle weakness.&nbsp;  
<ref name=":0">Winters, M. [https://scholar.google.com/scholar_url?url=https://bjsm.bmj.com/content/bjsports/early/2018/03/23/bjsports-2017-098907.full.pdf&hl=en&sa=T&oi=gsb-ggp&ct=res&cd=0&d=3120398065407133087&ei=eeY0Y9aDG-2KywSS3bH4Bg&scisig=AAGBfm2fh9BOQCGC1Yf8URbtP1putOqQ9Q Medial tibial stress syndrome: diagnosis, treatment and outcome assessment] (PhD Academy Award). Br J Sports Med. 2018</ref><ref name=":1">Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey, C. D. The prevention of shin splints in sports: a systematic review of literature. Medicine & Science in Sports & Exercise. 2002; ''34''(1): 32-40.</ref><ref name=":2" /><ref name=":3" /><ref name=":11" />


Pain in the lower leg could also be a stress fracture (an incomplete crack in the bone), which is a far more serious injury than shin splints. The pain of a stress fracture is focal with tenderness in less than 5 cm. that can be find with a fingerprint as a definite spot of sharp pain. Additionally, stress fractures often feel better in the morning because the bone has rested all night; shin splints often feel worse in the morning because the soft tissue tightens overnight. Shin splints are also at their most painful when patient forcibly try to lift the foot up at the ankle and flex the foot. <ref name=":4">The runner´s world editors. Everything you need to know about shin splints. Available from<sup>:</sup> http://www.runnersworld.com/tag/shin-splints. (Accessed 10/12/2018) Level of evidence 5</ref>
Watch this video on MTSS.
== Diagnostic Procedures ==
Making the diagnosis based on history and physical examination is the most logical approach.<ref name=":0" /><ref name=":1" /> 
# A standardised history include questions on the onset and location of the pain:
#* If there is exercise-induced pain along the distal 2/3 of the medial tibial border: MTSS diagnosis is suspected
#* The athlete is asked of what aggravated and relieved their pain: If pain is provoked during or after physical activity and reduced with relative rest, MTSS diagnosis is suspected
#* The athlete is asked about cramping, burning and pressure-like calf pain and/or pins and needles in the foot (their presence could be signs of chronic exertional compartment syndrome, which could be a concurrent injury or the sole explanation for their pain): If no present, MTSS diagnosis is suspected
# Physical examination If MTSS is suspected after the history: the posteromedial tibial border is palpated and the athletes are asked for the presence of recognisable pain (ie, from painful activities). 
#* If no pain on palpation is present, or the pain is palpated over less than 5 cm: other lower leg injuries (eg, a stress fracture) has to be considered to be present and the athlete is labelled as not having MTSS
#* If other symptoms not typical of MTSS are present (severe and visible swelling or erythema along the medial border): other leg injury should be considered
#* If recognisable pain is present on palpation over 5 cm or more and no atypical symptoms are present, the diagnosis MTSS is confirmed. 
 
Detmer in 1986 developed a classification system to subdivide MTSS into three types: <ref name=":5">Moen, M. H., Tol, J. L., Weir, A., Steunebrink, M., & De Winter, T. C. Medial tibial stress syndrome. Sports medicine. ''2009;'' ''39''(7): 523-546. (Level of evidence 3A)</ref>
# Type I - tibial microfracture, bone stress reaction or cortical fracture
# Type II - periostalgia from chronic avulsion of the periosteum at the perios teal-fascial junction
# Type lll – chronic compartment syndrome.
Imaging studies are not necessary to diagnose shin-splints, but when a conservative treatment fails, it could be useful to undertake an echo. If the injury has evolved into a stress fracture, an x-ray scan can show black lines. A triple-phase bone scan can show the difference between a stress fracture and a medial tibial stress syndrome.[7] The MRI can also exclude tumors/edemas.<ref name="Broos, 1991" />
 
It is important that clinicians be aware that about 1/3 (32%) of the athletes with MTSS have co-existing lower leg injuries<ref name=":3" />
 
== Outcome Measures  ==
 
The MTSS score should be used as a primary outcome measure in MTSS because is valid, reliable and responsive. It measures:<ref name=":0" />
* Pain at rest
* Pain while performing activities of daily living
* Limitations in sporting activities
* Pain while performing sporting activities. 
The MTSS score specifically measures pain along the shin and limitations due to shin pain.
== Examination  ==


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{{#ev:youtube|KrCpFoR5PCY}}


Examination demonstrates an intensive tenderness on palpation along the medial tibial border, the anterior tibia, however, is usually nontender. Neurovascular symptoms are usually absent. Different from stress fracture, the pain is not focused to a specific point but covers a variable distance of several centimeters in the distal medial and proximal distal third of the tibia.<ref name=":3" /> In the painful area, there is no real muscle origin, but the deep crural fascia is attached to the medial tibial border. From clinical experience, a painful transverse band can frequently be palpated which most probably corresponds to the soleal aponeurosis .Therefore, MTSS is currently hypothesized to originate from tibial bone overload and not from adjacent soft tissue stress<ref name=":3" />
== Management ==
[[File:Navicular drop test.png|thumb|Navicular drop test]]
Management of MTSS is conservative, focusing on rest and activity modification with less repetitive, load-bearing exercise. No specific recommendations on the duration of rest required for resolution of symptoms, and it is likely variable depending on the individual.  


Physicians should carefully evaluate for possible knee abnormalities (especially genu varus or valgus), tibial torsion, femoral anteversion, foot arch abnormalities, or a leg-length discrepancy. Ankle movements and subtalar motion should also be evaluated. Clinicians should also examine for inflexibility and imbalance of the hamstring and quadriceps muscles and weakness of “core muscles”. Core and pelvic muscle stability may be assessed by evaluating patient’s ability to maintain a controlled, level pelvis during a pelvic bridge from the supine position, or a standing single-leg knee bend.<br>Examining patient’s shoes may reveal generally worn-out shoes or patterns consistent with a leg-length discrepancy or other biomechanical abnormalities. <br>Abnormal gait patterns should be evaluated with the patient walking and running on a treadmill. <ref name=":5" /><ref name=":6">Beck B. [http://bands.ua.edu/wp-content/uploads/2015/07/Tibial-Stress-Injuries-Review.pdf Tibial stress injuries: an aetiological review for the purposes of guiding management.] Sports Medicine. 1998; 26(4):265-279.</ref><ref>Kortebein PM, Kaufman KR, Basford JR, Stuart MJ. Medial tibial stress syndrome. Med Sci Sports Exerc 2000;32(3 Suppl):S27-33.(Level of evidence 1A)</ref><ref>Wilder R, Seth S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23(1):55-81. (Level of evidence 4)</ref><ref>Fredericson M. Common injuries in runners. Diagnosis, rehabilitation and prevention. Sports Med. 1996;21:49–72. (Level of evidence 4)</ref><ref name=":2" /> <ref>Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–552.(Level of evidence 2A)</ref><ref name=":8">Dugan S, Weber K. Stress fracture and rehabilitation. Phys Med Rehabil Clin N Am. 2007;18(3):401–416. (Level of evidence 3A)</ref><ref>Sommer H, Vallentyne S. Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc. 1995;27:800–804. (Level of evidence 3A)</ref><ref>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. (Level of evidence 1A)</ref><ref>Greenman P. Principles of manual medicine. Philadelphia, PA: Lippincott Williams &amp; Wilkins. 2003;3(11):337–403, 489. . (Level of evidence 1A)</ref><ref>Howell J. [http://jaoa.org/article.aspx?articleid=2093316 Effect of counterstrain on stretch reflexes, Hoffmann reflexes, and clinical outcomes in subjects with plantar fasciitis]. J Am Osteopath Assoc. 2006;106(9):547–556. (Level of evidence 1B)</ref><ref>Karageanes S. Principles of manual sports medicine. Philadelphia, PA: Lippincott, Williams and Wilkins. 2005: 467–468. Level of evidence 1A)</ref>
Other therapies available (with low-quality evidence) include iontophoresis, phonophoresis, [https://www.physio-pedia.com/Cryotherapy ice] massage, [https://www.physio-pedia.com/Therapeutic_Ultrasound ultrasound therapy], periosteal pecking, and [[Extracorporeal Shockwave Therapy |extracorporeal shockwave therapy]]. A recent study on naval recruits showed prefabricated [[Introduction to Orthotics]] reduced MTSS<ref name=":9" />.


== Medical Management    ==
Complications: Recurrence common after resumption of heavy activity.<ref name=":4" />


Treatment is predominantly conservative and there is no treatment proven to be effective for athletes. Therefore, temporary reduction or even cessation of the provoking activity is most frequently the initial response of the athlete and trainer alike to reduce the symptoms.<ref name=":3" />
Treatment options include ultrasound, extracorporeal shockwave therapy, and steroid injections. Schulze et al looked at various treatment options from application of local and systemic anti-inflammatory medicaments to physiotherapy with ultrasound, phonophoresis, and local friction. However, they concluded none of these methods has proven to be superior to the others. <ref>Moen, M. H., Holtslag, L., Bakker, E., Barten, C., Weir, A., Tol, J. L., & Backx, F. T[https://bmcsportsscimedrehabil.biomedcentral.com/track/pdf/10.1186/1758-2555-4-12 he treatment of medial tibial stress syndrome in athletes; a randomized clinical trial.] Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology.2012; ''4''(1): 12.(Level of evidence 1A)</ref>
Surgical treatment is rarely needed. It is indicated in the athlete who has failed one year's conservative treatment or in whom the condition is recurrent (two or more times). The surgical procedure consists in a deep posterior fascia release, to relieve tension or pressure commonly to treat the resulting loss of circulation, The described technique is an open procedure with fasciotomy by doing one or more incisions, of the deep posterior compartment, release of the ‘soleus bridge’, and resection of a periosteal strip from the involved medial tibia.<ref name=":3" /> 
35% and 34% had an excellent and good result while 22% and 9% were fair and poor respectively and only “41% of the athletes fully returned to their presymptom sports activity”<ref name=":3" />
Postoperatively patients must follow a graded rehabilitation program similar to that used in non-operative treatment. <ref>Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. J Bone Joint Surg Am. 2003;85-A(10):1974-80. (Level of evidence 4)</ref><ref>Holen KJ, Engebretsen L, Grontvedt T, Rossvoll I, Hammer S, Stoltz V. Surgical treatment of medial tibial stress syndrome (shin splint) by fasciotomy of the superficial posterior compartment of the leg. Scand J Med Sci Sports. 1995;5(1):40-3. (Level of evidence 1A)</ref>
== Physical Therapy Management    ==
== Physical Therapy Management    ==
Patient education and a graded loading exposure program seem the most logical treatments.<ref name=":0" /> Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors.<ref name=":3" />Recently ‘running retraining’ has been advocated as a promising treatment strategy and graded running programme has been suggested as a gradual tissue-loading intervention.<ref name=":3" />  
Patient education and a graded loading exposure program seem the most logical treatments.<ref name=":0" /> Conservative therapy should initially aim to correct functional gait, and biomechanical overload factors.<ref name=":3" />Recently ‘running retraining’ has been advocated as a promising treatment strategy and graded running programme has been suggested as a gradual tissue-loading intervention.<ref name=":3" />  


Prevention of MTSS was investigated in few studies and shock-absorbing insoles, pronation control insoles, and graduated running programs were advocated.<ref name=":3" />
Prevention of MTSS was investigated in few studies and shock-absorbing insoles, pronation control insoles, and graduated running programs were advocated.<ref name=":3" />


Overstress avoidance is the main preventive measure of MTSS or shin-splints. The main goals of shin-splints treatment are pain relieve and return to pain‑free activities.<ref>Alfayez, S. M., Ahmed, M. L., & Alomar, A. Z. A review article of medial tibial stress syndrome. Journal of Musculoskeletal Surgery and Research. 2017; ''1''(1): 2. (Level of Evidence: 4) </ref>  
Over-stress avoidance is the main preventive measure of MTSS or shin-splints. The main goals of shin-splints treatment are pain relieve and return to pain‑free activities.<ref>Alfayez, S. M., Ahmed, M. L., & Alomar, A. Z. [https://scholar.google.com/scholar_url?url=https://journalmsr.com/a-review-article-of-medial-tibial-stress-syndrome/&hl=en&sa=T&oi=gsb-ggp&ct=res&cd=0&d=15053537490463950903&ei=puY0Y57SFIHeyQTv06PwDQ&scisig=AAGBfm13OxVYa3JO_AGvF9k0TbYwp3Dqiw A review article of medial tibial stress syndrome]. Journal of Musculoskeletal Surgery and Research. 2017; ''1''(1): 2. (Level of Evidence: 4) </ref>
 
For the treatment of shin-splints it’s important to screen the risk factors, this makes it easier to make a diagnosis and to prevent this disease. In the next table you can find them.<ref>Winkelmann, Z. K., Anderson, D., Games, K. E., & Eberman, L. E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5264561/pdf/i1062-6050-51-12-1049.pdf Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. Journal of athletic training]. 2016; 51(12):1049-1052. (Level of Evidence: 1a)</ref> (Level of Evidence: 1a)
{| width="300" border="1" cellspacing="1" cellpadding="1"
|-
| '''Intrinsic factors'''
| '''Extrinsic factors'''
|-
| Age <br>Sex<br>Height<br>Weight<br>Body fat<br>Femoral neck anteversion<br>Genu valgus<br>Pes clavus<br>Hyperpronation<br>Joint laxity<br>Aerobic endurance/conditioning<br>Fatigue<br>Strength of and balance between<br>flexors and extensors<br>Flexibility of muscles/joints<br>Sporting skill/coordination<br>Physiological factors<br>
| Sports-related factors<br>Type of sport<br>Exposure (e.g., running on one side of the road)<br>Nature of event (e.g., running on hills)<br>Equipment<br>Shoe/surface interface<br>Venue/supervision<br>Playing surface<br>Safety measures<br>Weather conditions<br>Temperature<br>
|}
 
Control of risk factors could be a relevant strategy to initially avoid and treat MTSS: MIO2
* Female gender
* Previous history of MTSS
* Fewer years of running experience
* Orthotic use
* Increased body mass index
* Pronated foot posture (increased navicular drop)
* Increased ankle plantarflexion
* Increased hip external rotation
The role of hip internal rotation motion is unclear. Differences between hip muscle performance in MTSS and control subjects might be the effect rather than the cause MIO2


=== Acute phase ===
=== Acute phase ===
<br>2-6 weeks of rest combined with medication is recommended to improve the symptoms and for a quick and safe return after a period of rest. NSAIDs and Acetaminophen are often used for analgesia. Also cryotherapy with Ice-packs and eventually analgesic gels can be used after exercise for a period of 20 minutes.   
2-6 weeks of rest combined with medication is recommended to improve the symptoms and for a quick and safe return after a period of rest. NSAIDs and Acetaminophen are often used for analgesia. Also cryotherapy with Ice-packs and eventually analgesic gels can be used after exercise for a period of 20 minutes.   


There are a number of physical therapy modalities to use in the acute phase but there is no proof that these therapies such as ultrasound, soft tissue mobilization, electrical stimulation<ref name=":6" /> would be effective.<ref name=":2" /> A corticoid injection is contraindicated because this can give a worse sense of health. Because the healthy tissue is also treated. A corticoid injection is given to reduce the pain, but only in connection with rest.<ref name="Broos, 1991" />&nbsp;
* There are a number of physical therapy modalities to use in the acute phase but there is no proof that these therapies such as ultrasound, soft tissue mobilization, electrical stimulation<ref name=":6">Beck B. [http://bands.ua.edu/wp-content/uploads/2015/07/Tibial-Stress-Injuries-Review.pdf Tibial stress injuries: an aetiological review for the purposes of guiding management.] Sports Medicine. 1998; 26(4):265-279.</ref> would be effective.<ref name=":2" /> A corticoid injection is contraindicated because this can give a worse sense of health. Because the healthy tissue is also treated. A corticoid injection is given to reduce the pain, but only in connection with rest.<ref name="Broos, 1991" />
 
* Prolonged rest is not ideal for an athlete.
Prolonged rest is not ideal for an athlete  


=== Subacute phase ===
=== Subacute phase ===
The treatment should aim to modify training conditions and to address eventual biomechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency&nbsp; and intensity by 50%. It is advised to avoid hills and uneven surfaces.<br>
The treatment should aim to modify training conditions and to address eventual biomechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency&nbsp;and intensity by 50%. It is advised to avoid hills and uneven surfaces.  


During the rehabilitation period the patient can do low impact and cross-training exercises (like running on a hydro-gym machine).). After a few weeks athletes may slowly increase training intensity and duration and add sport-specific activities, and hill running to their rehabilitation program as long as they remain pain-free. <br>A stretching and strengthening (eccentric) calf exercise program can be introduced to prevent muscle fatigue. <ref name=":8" /><ref>Couture C, Karlson K. Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints’. Phys Sportsmed. 2002;30(6):29–36.(Level of Evidence: 3a)</ref><ref name=":7">DeLee J, Drez D, Miller M. DeLee and Drez’s orthopaedic sports medicine principles and practice. Philadelphia, PA: Saunders. 2003:2155–2159.(Level of Evidence: 5)</ref> (Level of Evidence: 3a) (Level of Evidence: 3a) (Level of Evidence: 5). Patients may also benefit from strengthening core hip muscles. Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. <ref name=":7" /> <br>  
* During the rehabilitation period the patient can do low impact and cross-training exercises (like running on a hydro-gym machine). After a few weeks athletes may slowly increase training intensity and duration and add sport-specific activities, and hill running to their rehabilitation program as long as they remain pain-free.
* A stretching and strengthening (eccentric) calf exercise program can be introduced to prevent muscle fatigue. <ref name=":8">Dugan S, Weber K. [https://pubmed.ncbi.nlm.nih.gov/17678759/ Stress fracture and rehabilitation.] Phys Med Rehabil Clin N Am. 2007;18(3):401–416. (Level of evidence 3A)</ref><ref>Couture C, Karlson K. [https://scholar.google.com/scholar_url?url=https://www.tandfonline.com/doi/abs/10.3810/psm.2002.06.337&hl=en&sa=T&oi=gsb&ct=res&cd=0&d=9979500497343675539&ei=A-c0Y76OIoHeyQTv06PwDQ&scisig=AAGBfm1oGFVoivU0Ez5hJtHPoQEQiDgZbA Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints]’. Phys Sportsmed. 2002;30(6):29–36.(Level of Evidence: 3a)</ref><ref name=":7">DeLee J, Drez D, Miller M. DeLee and Drez’s orthopaedic sports medicine principles and practice. Philadelphia, PA: Saunders. 2003:2155–2159.(Level of Evidence: 5)</ref> Patients may also benefit from [https://www.physio-pedia.com/Strength_Training strengthening] core hip muscles. Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. <ref name=":7" />
* Proprioceptive [https://www.physio-pedia.com/Balance_Training balance training] is crucial in neuromuscular education. This can be done with a one-legged stand or balance board. Improved [https://www.physio-pedia.com/Proprioception proprioception] will increase the efficiency of joint and postural-stabilizing muscles and help the body react to running surface incongruities, also key in preventing re-injury.<ref name=":7" />
* Choosing good shoes with good shock absorption can help to prevent a new or re-injury. Therefore it is important to change the athlete's shoes every 250-500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities.<br>In case of biomechanical problems of the foot, individuals may benefit from [[Introduction to Orthotics]]. An over-the-counter orthosis (flexible or semi-rigid) can help with excessive foot pronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.<ref name=":2" />
* [https://www.physio-pedia.com/Manual_Therapy Manual therapy] can be used to control several biomechanical abnormalities of the spine, sacro-illiacal joint and various muscle imbalances. They are often used to prevent relapsing to the old injury.
* There is also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but their efficiency is not yet proved.


Proprioceptive balance training is crucial in neuromuscular education. This can be done with a one-legged stand or balance board. Improved proprioception will increase the efficiency of joint and postural-stabilizing muscles and help the body react to running surface incongruities, also key in preventing re-injury.<ref name=":7" /> 
== Differential Diagnosis ==
 
{| class="wikitable"
Choossing good shoes with good shock absorption can help to prevent a new or re-injury. Therefore it is important to change the athlete's shoes every 250-500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities. 
| colspan="0" |'''Condition'''
 
| colspan="0" |'''Characteristics'''
<br>In case of biomechanical problems of the foot may individuals benefit from orthotics. An over-the-counter orthosis (flexible or semi-rigid) can help with excessive foot pronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.<ref name=":2" /><br><br>Manual therapy can be used to control several biomechanical abnormalities of the spine, sacro-illiacal joint and various muscle imbalances. They are often used to prevent relapsing to the old injury. 
| colspan="0" |'''Tissue origin'''
|-
| colspan="0" |Anterior tibial stress syndrome
| colspan="0" |Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise that decreases during training
| rowspan="2" |Periosteum
|-
| colspan="0" |Medial tibial stress syndrome
| colspan="0" |Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, that decreases during training
|-
| colspan="0" |Tibial/fibular stress fracture
| colspan="0" |Pain with running, point tenderness over fracture site, "dreaded black line" on lateral x-ray
| colspan="0" |Bone
|-
| colspan="0" |Exertional compartment syndrome
| colspan="0" |Symptoms begin 10min into exercise andresolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures
| colspan="0" |Muscle and fascia
|-
| colspan="0" |Leg Tendinopathy
| colspan="0" |May be Achilles tendon, peroneal tendon, or tibialis posterior
| colspan="0" |Tendon
|-
| colspan="0" |Sural or SPN entrapment
| colspan="0" |Dermatomal distribution of symptoms
| rowspan="2" |Nerve
|-
| colspan="0" |Lumbar radiculopathy
| colspan="0" |Worse with lumbar tension position (sitting)
|-
| colspan="0" |Popliteal artery entrapment
| colspan="0" |Diagnosed with vascular studies
| colspan="0" |Blood vessel
|}
<ref name=":4">Ortho bullets [https://www.orthobullets.com/knee-and-sports/3108/tibial-stress-syndrome-shin-splints Tibial Stress Syndrome] (Shin Splints) Available: https://www.orthobullets.com/knee-and-sports/3108/tibial-stress-syndrome-shin-splints<nowiki/>(accessed 2.6.2022)</ref>


There is also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but their efficiency is not yet proved.
== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


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[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Vrije_Universiteit_Brussel_Project]]

Latest revision as of 18:25, 9 January 2024

Original Editors - Karsten De Koster

Top Contributors - Karsten De Koster, Claudia Karina, Nick Van Doorsselaer, Alex Palmer, Lucinda hampton, Admin, Kenza Mostaqim, Arno Van Hemelryck, Luna Antonis, Kim Jackson, Bieke Bardyn, Sally Ngo, WikiSysop, Wanda van Niekerk, Naomi O'Reilly, Fitz Van Roy, 127.0.0.1, Claire Knott, Venus Pagare, Chelsea Mclene, Daniele Barilla and Kai A. Sigel  

Introduction[edit | edit source]

Pain generally in the inner and lower 2/3rds of tibia.

Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers[1]. It presents as exercise-induced pain over the anterior tibia and is an early stress injury in the continuum of tibial stress fractures.[2].

It has the layman's moniker of “shin splints.”[2]

Epidemiology[edit | edit source]

Risk factor- quick increase in running volume

The incidence of MTSS ranges between 13.6% to 20% in runners and up to 35% in military recruits. In dancers it is present in 20% of the population and up to 35% of the new recruits of runners and dancers will develop it.[3]

Large increase in load, volume and high impact exercise can put at risk individuals to MTSS.  Risk factors include being a female, previous history of MTSS, high BMI, navicular drop, reduced hip external rotation range of motion, muscle imbalance and inflexibility of the triceps surae), muscle weakness of the triceps surae (prone to muscle fatigue leading to altered running mechanics, and strain on the tibia), running on a hard or uneven surface and bad running shoes [2][4] [5] 

Pathophysiology[edit | edit source]

Periosteum, vivid green

The pathophysiologic process resulting in MTSS is related to unrepaired microdamage accumulation in the cortical bone of the distal tibia, however this has not been definitively established. Two current theories are:

  1. The pain is secondary to inflammation of the periosteum as a result of excessive traction of the tibialis posterior or soleus, supported by bone scintigraphy findings of a broad linear band of increased uptake along the medial tibial periosteum. But a case-controlled ultrasound based study which compared periosteal and tendinous edema of athletes with and without medial tibial stress syndrome found no difference between the groups.
  2. Bony overload injury, with resultant microdamage and targeted remodeling. A study evaluating tibia biopsy specimens from the painful area of six athletes suffering from medial tibial stress syndrome gave only equivocal support for this theory. Linear microcracks were found in only three specimens and there was no associated repair reaction[6].

Clinical Presentation and Assessment[edit | edit source]

KEY POINTS FOR ASSESSMENT MTSS[3]
HISTORY
  • Increasing pain during exercise related to the medial tibial border in the middle and lower third
  • Pain persists for hours or days after cessation of activity
  • Pain decreases with running (early stage)
  • Differentiate from exertional compartment syndrome, for which pain increases with running
  • Earlier onset of pain with more frequent training (later stages)
PHYSICAL EXAMINATION
  • Intensive tenderness of the involved medial tibial border, more than 5 cm
  • Pes planus
  • Tight Achilles tendon
  • A "one-leg hop test" is a functional test, that can be used to distinguish between medial tibial stress syndrome and a stress fracture: a patient with medial tibial stress syndrome can hop at least 10 times on the affected leg where a patient with a stress fracture cannot hop without severe pain. The sensitivity of the hop test for diagnosing medial tibial stress fracture when pain and tenderness were present was 100%, the specificity 45%, the positive predictive value 74%, and the negative predictive value 100%
  • Provocative test: pain on resisted plantar flexion
IMAGING MRI: Periosteal reaction and edema
TREATMENT See later in page

[7][8][4][3][6]

Watch this video on MTSS.

Management[edit | edit source]

Navicular drop test

Management of MTSS is conservative, focusing on rest and activity modification with less repetitive, load-bearing exercise. No specific recommendations on the duration of rest required for resolution of symptoms, and it is likely variable depending on the individual.

Other therapies available (with low-quality evidence) include iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking, and extracorporeal shockwave therapy. A recent study on naval recruits showed prefabricated Introduction to Orthotics reduced MTSS[2].

Complications: Recurrence common after resumption of heavy activity.[9]

Physical Therapy Management[edit | edit source]

Patient education and a graded loading exposure program seem the most logical treatments.[7] Conservative therapy should initially aim to correct functional gait, and biomechanical overload factors.[3]Recently ‘running retraining’ has been advocated as a promising treatment strategy and graded running programme has been suggested as a gradual tissue-loading intervention.[3]

Prevention of MTSS was investigated in few studies and shock-absorbing insoles, pronation control insoles, and graduated running programs were advocated.[3]

Over-stress avoidance is the main preventive measure of MTSS or shin-splints. The main goals of shin-splints treatment are pain relieve and return to pain‑free activities.[10]

Acute phase[edit | edit source]

2-6 weeks of rest combined with medication is recommended to improve the symptoms and for a quick and safe return after a period of rest. NSAIDs and Acetaminophen are often used for analgesia. Also cryotherapy with Ice-packs and eventually analgesic gels can be used after exercise for a period of 20 minutes.

  • There are a number of physical therapy modalities to use in the acute phase but there is no proof that these therapies such as ultrasound, soft tissue mobilization, electrical stimulation[11] would be effective.[4] A corticoid injection is contraindicated because this can give a worse sense of health. Because the healthy tissue is also treated. A corticoid injection is given to reduce the pain, but only in connection with rest.[5]
  • Prolonged rest is not ideal for an athlete.

Subacute phase[edit | edit source]

The treatment should aim to modify training conditions and to address eventual biomechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency and intensity by 50%. It is advised to avoid hills and uneven surfaces.

  • During the rehabilitation period the patient can do low impact and cross-training exercises (like running on a hydro-gym machine). After a few weeks athletes may slowly increase training intensity and duration and add sport-specific activities, and hill running to their rehabilitation program as long as they remain pain-free.
  • A stretching and strengthening (eccentric) calf exercise program can be introduced to prevent muscle fatigue. [12][13][14] Patients may also benefit from strengthening core hip muscles. Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. [14]
  • Proprioceptive balance training is crucial in neuromuscular education. This can be done with a one-legged stand or balance board. Improved proprioception will increase the efficiency of joint and postural-stabilizing muscles and help the body react to running surface incongruities, also key in preventing re-injury.[14]
  • Choosing good shoes with good shock absorption can help to prevent a new or re-injury. Therefore it is important to change the athlete's shoes every 250-500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities.
    In case of biomechanical problems of the foot, individuals may benefit from Introduction to Orthotics. An over-the-counter orthosis (flexible or semi-rigid) can help with excessive foot pronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.[4]
  • Manual therapy can be used to control several biomechanical abnormalities of the spine, sacro-illiacal joint and various muscle imbalances. They are often used to prevent relapsing to the old injury.
  • There is also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but their efficiency is not yet proved.

Differential Diagnosis[edit | edit source]

Condition Characteristics Tissue origin
Anterior tibial stress syndrome Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise that decreases during training Periosteum
Medial tibial stress syndrome Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, that decreases during training
Tibial/fibular stress fracture Pain with running, point tenderness over fracture site, "dreaded black line" on lateral x-ray Bone
Exertional compartment syndrome Symptoms begin 10min into exercise andresolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures Muscle and fascia
Leg Tendinopathy May be Achilles tendon, peroneal tendon, or tibialis posterior Tendon
Sural or SPN entrapment Dermatomal distribution of symptoms Nerve
Lumbar radiculopathy Worse with lumbar tension position (sitting)
Popliteal artery entrapment Diagnosed with vascular studies Blood vessel

[9]

Clinical Bottom Line[edit | edit source]

‘Shin splints’ is a vague term that implicates pain and discomfort in the lower leg, caused by repetitive loading stress. There can be all sorts of causes to this pathology according to different researches. Therefore, a good knowledge of the anatomy is always important, but it’s also important you know the other disorders of the lower leg to rule out other possibilities, which makes it easier to understand what’s going wrong. Also a detailed screening of known’s risk factors, intrinsic as well as extrinsic, to recognize factors that could add to the cause of the condition and address these problems.

References[edit | edit source]

  1. ↑ Radiopedia Medial tibial stress syndrome Available: https://radiopaedia.org/articles/medial-tibial-stress-syndrome-1(accessed 2.6.2022)
  2. ↑ 2.0 2.1 2.2 2.3 McClure CJ, Oh R. Medial Tibial Stress Syndrome. 2019 Available:https://www.ncbi.nlm.nih.gov/books/NBK538479/ (accessed 2.6.2022)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Lohrer, H., Malliaropoulos, N., Korakakis, V., & Padhiar, N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. The Physician and sports medicine. 2018
  4. ↑ 4.0 4.1 4.2 4.3 Galbraith, R. M., & Lavallee, M. E. Medial tibial stress syndrome: conservative treatment options. Current reviews in musculoskeletal medicine. 2009; 2(3): 127-133.
  5. ↑ 5.0 5.1 Broos P. Sportletsels : aan het locomotorisch apparaat. Leuven: Garant, 1991. (Level of Evidence: 5)
  6. ↑ 6.0 6.1 Milgrom C, Zloczower E, Fleischmann C, Spitzer E, Landau R, Bader T, Finestone AS. Medial tibial stress fracture diagnosis and treatment guidelines. Journal of science and medicine in sport. 2021 Jun 1;24(6):526-30. (accessed 2.6.2022)
  7. ↑ 7.0 7.1 Winters, M. Medial tibial stress syndrome: diagnosis, treatment and outcome assessment (PhD Academy Award). Br J Sports Med. 2018
  8. ↑ Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey, C. D. The prevention of shin splints in sports: a systematic review of literature. Medicine & Science in Sports & Exercise. 2002; 34(1): 32-40.
  9. ↑ 9.0 9.1 Ortho bullets Tibial Stress Syndrome (Shin Splints) Available: https://www.orthobullets.com/knee-and-sports/3108/tibial-stress-syndrome-shin-splints(accessed 2.6.2022)
  10. ↑ Alfayez, S. M., Ahmed, M. L., & Alomar, A. Z. A review article of medial tibial stress syndrome. Journal of Musculoskeletal Surgery and Research. 2017; 1(1): 2. (Level of Evidence: 4)
  11. ↑ Beck B. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Medicine. 1998; 26(4):265-279.
  12. ↑ Dugan S, Weber K. Stress fracture and rehabilitation. Phys Med Rehabil Clin N Am. 2007;18(3):401–416. (Level of evidence 3A)
  13. ↑ Couture C, Karlson K. Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints’. Phys Sportsmed. 2002;30(6):29–36.(Level of Evidence: 3a)
  14. ↑ 14.0 14.1 14.2 DeLee J, Drez D, Miller M. DeLee and Drez’s orthopaedic sports medicine principles and practice. Philadelphia, PA: Saunders. 2003:2155–2159.(Level of Evidence: 5)
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