Medial Tibial Stress Syndrome: Difference between revisions

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== Search Strategy&nbsp; ==
== Introduction ==
[[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 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>.


Search on Pubmed and Pedro with keywords: “Shin-splints”, “Medial tibial stress-syndrome” , “shin pain”and “tibial periostitis”. Search in libraries books about sport injuries, sports medicine, sport anatomy.  
It has the layman's moniker of “shin splints.”<ref name=":9" />
== Epidemiology ==
[[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>


== Definition/Description  ==
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;


The American Medical Association defines shin-splint syndrome as “pain and discomfort in the leg from repetitive activity on hard surfaces, or due to forceable, excessive use of the foot flexors<ref name="Reid et al.">Reid D.C. et al.,(1992) Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo, Churchill Livingstone, (p.269-280).</ref>. The diagnosis should be limited to musculoskeletal inflammation, excluding stress fractures or ischemic disorders” (<ref name="Reid et al.">1. Reid D.C. et al.,(1992) Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo, Churchill Livingstone, (p.269-280).</ref>&nbsp;Citation).  
== Pathophysiology ==
[[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:


Shin-splints is a general term for overuse injuries of the lower leg, except stress fractures and compartmental syndrome.<ref name="Kjær M. et al">Kjær M. et al,(2003) Sports Medicine; Basic science and clinical aspects of sports injury and physical activity, Oxford, Blackwell Publishing, (p.530-535).</ref> Hutchins C.P. says that shin-splints is a controversial term, because authors disagree about the in- and exclusion criteria’s.<ref name="Thacker et al.">THACKER S.B.,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine &amp;amp; science in sports &amp;amp; exercises, the first of November 2002, (p.32-40).</ref>
# 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>.
== Clinical Presentation and Assessment ==
{| class="wikitable"
! colspan="2" |KEY POINTS FOR ASSESSMENT MTSS<ref name=":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
|}


A synonym for shin-splints is: medial tibial stress syndrome. But Bruckner and Kahn say: “A more descriptive term that accounts for the inflammatory, traction event on the tibial aspect of the leg common in runners is medial tibial traction periostitis or just medial tibial periostitis “.  
<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" />


There are five possibilities which can describe the experienced shin pain: bone stress, inflammation, vascular insufficiency, nerve entrapment and a raised intracompartmental pressure.<ref name="Bruckner and Khan">BRUCKNER P. and KHAN K., ‘Clinical sports medicine’, 3th edition,North Ryde: McGraw-Hill, 2007(p.555-575).</ref>
Watch this  video on MTSS.


== Clinically Relevant Anatomy  ==
{{#ev:youtube|KrCpFoR5PCY}}


The most important clinical region is the lower leg. A dysfunction of tibialis anterior and posterior, of soleus muscles are commonly implicated, also the area of attachment of these muscles can be the location of pain.&nbsp;<ref name="D'Ambrosia">THACKER S.B. (referred D’AMBROSIA) ,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine &amp;amp; science in sports &amp;amp; exercises, the first of November 2002, (p.32-40).</ref>
== 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.  


<br>Figure1: <br>Chasan N., shin-splints, http://srcpt.blogspot.com/2009/02/shin-splints.html, 2 February 2009<br>[[Image:Shin splints1.jpg|anatomy lower leg]]  
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" />.


== Epidemiology /Etiology&nbsp;<br> ==
Complications: Recurrence common after resumption of heavy activity.<ref name=":4" />


Shin-splints is most common with athletes who made training errors, especially when they overload or when they run too fast for his potential. As we can see this injury can also be related to changes in the training program like an increase in distance, intensity and duration.<ref name="Galbraith and Lavalee">6. GALBRAITH R.M. and LAVALEE M.E., ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med.; September 2009, 2(3):127-133.</ref>&nbsp;(A1) Running on a hard or uneven surface and bad running shoes (like a poor shock absorbing capacity) could also be one of the factors related to the casualty. Biomechanical abnormalities as foot arch abnormalities, hyperpronation of the foot, unequal leg length,..<ref name="Broos">Broos P., Sportletsels, Leuven/Apeldoorn: Garant, 1991. (p.22, 179-181).</ref> (D) are the most frequently mentioned intrinsic factors.
== 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" />  


Women have an increased risk to incur stress fractures, especially this syndrome. This is due to nutrional, hormonal and biomechanical abnormalities. Individuals who suffer of overweight are more susceptible for this syndrome. Therefore it’s important that people with overweight combine their exercises with a diet or try to lose weight before starting a therapy or a training program. These people, along with poor conditioned people, should always slowly increase their training level. Cold weather contributes to this symptom, therefore it’s important (even more than usual) to warm up properly. <ref name="Reid et al.">1. Reid D.C. et al.,(1992) Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo, Churchill Livingstone, (p.269-280).</ref> (A1)
Prevention of MTSS was investigated in few studies and shock-absorbing insoles, pronation control insoles, and graduated running programs were advocated.<ref name=":3" />


“Internally a chronic inflammation of the muscular attachment along the posterior medial tibia and bony changes are considered to be the most likely cause of the medial tibial stress syndrome. “<ref name="Peterson and Renström">Peterson L. and Renström Per, (2001) Sports injuries: their prevention and treatment, 3th edition London, Dunitz, (p.11,339-342).</ref>&nbsp;
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>


== Characteristics/Clinical Presentation  ==
=== Acute phase ===
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. 


&nbsp;The most common complication of shin-splints is a stress fracture which shows itself by tenderness of the anterior tibia.<ref name="Galbraith and Lavalee">GALBRAITH R.M. and LAVALEE M.E., ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med.; September 2009, 2(3):127-133.</ref> Sensor and motor loss in association with exertional lower leg pain are another possible clinical symptom. Also pheripheral vascular disease could be a cause of the pain.<ref name="Galbraith and Lavalee" /> (A1)So the main symptom is pain on the medial side, in the second third of the leg. The pain is caused by repeated landing and take-off from the surface&nbsp;<ref name="Peterson and Renström">Peterson L. and Renström Per, (2001) Sports injuries: their prevention and treatment, 3th edition London, Dunitz, (p.11,339-342).</ref> . This pain worsens at each moment of contact.<ref name="Broos">Broos P., Sportletsels, Leuven/Apeldoorn: Garant, 1991. (p.22, 179-181)</ref> The symptoms are often bilateral<ref name="Reid et al." />.  
* 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.


At first the patient only felt pain when starting the training but further on the pain could remain even when in rest. In some cases we can also see a certain degree of swelling. <ref name="Peterson and Renström" />
=== 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.


== Differential Diagnosis ==
* 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.


add text here
== Differential Diagnosis ==
 
{| class="wikitable"
== Diagnostic Procedures  ==
| colspan="0" |'''Condition'''
 
| colspan="0" |'''Characteristics'''
Medial Tibial Stress syndrome gives a pain in the second third of the lower leg, when the lower leg is under load. In all of these cases the lower leg is very sensitive.<ref name="Reid et al." />
| colspan="0" |'''Tissue origin'''
 
|-
Imaging studies are not necessary to diagnose shin-splints, but when a conservative treatment fails, it could be useful to take an echo. When the injury evolves to a stress fracture, an x-ray scan can show black lines. A triple-phase bone scan can make the difference between a stress fracture and a medial tibial stress syndrome.<ref name="Peterson and Renström" /> The MRI can also exclude tumors/edemas.<ref name="Broos" /> But for the diagnostic procedure a good anamnesis and physical examination are designated. Shin-splints can also be a symptom of a chronic posterior.[[Compartment Syndrome of the Lower Leg|Compartment_Syndrome_of_the_Lower_Leg]]. &nbsp;Sometimes an elevated intracompartmental pressure in the deep compartment has been noticed says Puranen.<ref name="Thacker et al." /> (A1)
| colspan="0" |Anterior tibial stress syndrome
 
| colspan="0" |Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise that decreases during training
Some other risk factors for shin-splits are an increased pronation, an increased varus tendency, increased muscular strength of the plantar flexors, increased double heel strikes during dance and an increased angular displacement during running.<ref name="Thacker et al." />
| rowspan="2" |Periosteum
 
|-
== Outcome Measures  ==
| colspan="0" |Medial tibial stress syndrome
 
| colspan="0" |Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, that decreases during training
add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])
|-
 
| colspan="0" |Tibial/fibular stress fracture
== Examination  ==
| colspan="0" |Pain with running, point tenderness over fracture site, "dreaded black line" on lateral x-ray
 
| colspan="0" |Bone
During examination the anamnesis and physical examination of the lower leg will be sufficient. For the physical examination a good palpation of the lower leg will be necessary.
|-
 
| colspan="0" |Exertional compartment syndrome
== Medical Management <br>  ==
| colspan="0" |Symptoms begin 10min into exercise andresolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures
 
| colspan="0" |Muscle and fascia
In most cases conservative treatment will suffice, but for recalcitrant cases surgical treatment can be designated. They are often not a complete resolution but may improve symptoms of pain and function. A posterior fasciotomy is the common procedure performed. Surgical treatment can improve pain and functions.&nbsp;<ref name="Galbraith and Lavalee" />
|-
 
| colspan="0" |Leg Tendinopathy
== Physical Therapy Management <br>  ==
| colspan="0" |May be Achilles tendon, peroneal tendon, or tibialis posterior
 
| colspan="0" |Tendon
Shin-splints can be threatened conservatively or surgically. Essentially the treatment may focus on: (a) reducing stress; (b) relieving pain; (c) providing alternative programs to maintain fitness; (d) correcting specific etiologic factors and (e) reintegration of the athlete into activity.<ref name="Reid et al." /> We will start with a conservative treatment:
|-
 
| colspan="0" |Sural or SPN entrapment
<br>The conservative treatment of this injury starts with rest. A therapist will recommend you 2-6 weeks of rest. This rest should be strictly applied. Otherwise the symptoms can be worsened. Prolonged rest is not ideal for an athlete, thus other therapies are necessary for a quick and safe return after a period of rest. This rest can be assisted by medication. The second thing a therapist will say is to use ice and eventually analgesic gels. The cryotherapy can be used after an 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 mobilization tissue,..<ref name="Beck">BECK B., (1998) ‘Tibial stress injuries: an aetiological review for the purposes of guiding management’, Sports Medicine, 1998, 26(4) 265-279.</ref> (A2))would be effective.<ref name="Galbraith and Lavalee" /> (A1)A corticoid injection is contraindicated because this can give a worse sense of healthy. 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" /> (D)
| colspan="0" |Dermatomal distribution of symptoms
 
| rowspan="2" |Nerve
<br>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 name="Thacker et al." />(A1):
 
{| border="1" cellspacing="1" cellpadding="1" width="300"
|-
|-
| '''Intrinsic factors'''
| colspan="0" |Lumbar radiculopathy
| '''Extrinsic factors'''
| colspan="0" |Worse with lumbar tension position (sitting)
|-
|-
| 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>
| colspan="0" |Popliteal artery entrapment
| 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>
| 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>
<br><br>In the subacute phase, in this phase the treatment would exist of modifying training conditions and to address eventual biomechanical abnormalities, change of training conditions could be decreased running distance, intensively and frequency. 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 while the athlete should gradually return to his activities. In the next period they can increase some factors as intensity slowly<ref name="Galbraith and Lavalee" />(A1). Also a (eccentric) stretching and strengthening program can be introduced to overcome detectable muscle imbalance or contractures<ref name="Reid et al." />. Also a proprioceptive training is designated, like this the effectiveness of joint, the stability and reaction on strange uneven surface can be stimulated. Also a heat retrainer can be of value<ref name="Peterson and Renström" />.
 
<br>Another thing that can help prevent a new or re-injury is to choose good shoes with good shock absorption. Therefore it’s important to change your shoes when the shock-absorbing mechanism of your shoes wears of (after 250-500 miles). Some patients strap their leg or the longitudinal arch. This can be inconvenient for some people, but success indicates that an orthosis can be helpful<ref name="Rasmussen">Reid D.C. et al. (referred Rasmussen),(1992) Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo, Churchill Livingstone, (p.269-280).</ref>. Another thing that can help to prevent shin-splints is to wear orthotics, in case of a biomechanical abnormality. An over-the-counter orthosis can help with excessive footpronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.<ref name="Galbraith and Lavalee" /><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. But manual therapy is not the only therapy that can be used; we have also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but heir efficiency is not yet proved.<ref name="Galbraith and Lavalee" /> (A1)
 
<br>In most cases conservative treatment will suffice, but for recalcitrant cases surgical treatment can be designated. They are often not a complete resolution but may improve symptoms of pain and function.<ref name="Galbraith and Lavalee" />(A1)<br><br>
 
== Key Research  ==
 
This text is mostly based on text of Galbraith R.M. and Lavallee M. E..
 
== Resources <br>  ==
 
Primary resources<br>GALBRAITH R.M. and LAVALEE M.E., ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med.; September 2009, 2(3):127-133. (E)<br>Craig D.I., ‘Medial Tibial Stress Syndrome: Evidence-based Prevention’, J Athl Training, June 2008; 43(3): 316-318. (A)<br>THACKER S.B.,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine &amp; science in sports &amp; exercises, the first of November 2002; 34(1):32-40. (A)<br>PURANEN J. and ORAVA S., (1979) ‘ Athletes’ leg pain’, British Journal of Sports Medcine, Spetmber 1979; 13(3):p.92-97. (C)
 
Secondary resources: Broos P., Sportletsels, Leuven/Apeldoorn: Garant, 1991. (p.22, 179-181). <br>Kjær M. et al, Sports Medicine; Basic science and clinical aspects of sports injury and physical activity, Oxford: Blackwell Publishing,2003. (p.530-535). <br>Peterson L. and Renström Per, Sports injuries: their prevention and treatment, 3th edition, London: Dunitz, 2001. (p.11,339-342).<br>Reid D.C. et al., Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo: Churchill Livingstone,1992. (p.269-280).<br>BECK B., (1998) ‘Tibial stress injuries: an aetiological review for the purposes of guiding management’, Sports Medicine, 1998, 26(4) 265-279.<br>BRUCKNER P. and KHAN K., ‘Clinical sports medicine’, 3th edition,North Ryde: McGraw-Hill, 2007(p.555-575).<br>Chasan N., shin-splints, (http://srcpt.blogspot.com/2009/02/shin-splints.html), 2 February 2009.<br>Sportsinjuryclininc, shin splints, (http://www.youtube.com/watch?v=jg79mQqiacM), online video, last accessed, 13 October 2007.<br>Widmark E., How to indentify, treat and prevent medial tibial stress syndrome, (http://www.fysionutrition.se/wp-content/uploads/How-to-treat-and-prevent-medial-tibial-stress-syndrome.pdf), 2009.<br>  


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


A good knowledge of the anatomy is always important, but it’s also important you know the other disorders of the lower leg, which makes it easier to understand what’s going wrong. Also a detailed screening of known’s risk factors to recognize factor that could add to the cause of the condition and address these….
‘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   ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
<span id="fck_dom_range_temp_1293393507582_461" />GALBRAITH R.M. and LAVALEE M.E., (2009) ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med., September 2009, (p.127-133)
<div class="researchbox"></div>
== References ==
 
see [[Adding References|adding references tutorial]].


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Latest revision as of 18:25, 9 January 2024

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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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