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Medial Tibial Stress Syndrome (MTSS) is a frequent overuse lower extremity injury in athletes and military personnel. MTSS is exercise-induced pain over the anterior tibia and is an early stress injury in the continuum of tibial stress fractures.[rx] It has the layman’s moniker of “shin splints.”[rx]
Medial tibial stress syndrome (MTSS) is an overuse injury or repetitive-stress injury of the shin area. Various stress reactions of the tibia and surrounding musculature occur when the body is unable to heal properly in response to repetitive muscle contractions and tibial tendon. সহজ বাংলা: মাংসপেশি/টেনডনে টান।" data-rx-term="strain" data-rx-definition="A strain is injury to a muscle or tendon. সহজ বাংলা: মাংসপেশি/টেনডনে টান।">strain.
Pathophysiology
The underlying pathophysiologic process resulting in MTSS is related to unrepaired microdamage accumulation in the cortical bone of the distal tibia. There is typically an overlying periostitis at the site of bony injury, which also correlates with the tendinous attachments of the soleus, flexor digitorum longus, and posterior tibialis. Given the mechanical connection of Sharpey’s fiber’s, which are perforating fibers of connective tissue linking periosteum to the bone, the belief is that repetitive muscle traction may be the underlying cause of the periostitis and cortical microtrauma. However, it remains unclear if periostitis occurs before cortical microtrauma or vice versa.[rx][rx]
Causes of Medial Tibial Stress Syndrome
Medial tibial stress syndrome is an overuse condition, specifically a tibial bony overload injury with associated periostitis, that clinicians commonly encounter in participants of recurrent impact exercise, such as running and jumping athletics as well as in military personnel.[rx]
Symptoms of Medial Tibial Stress Syndrome
If you have shin splints, you might notice pain when an area is touched or pressed. সহজ বাংলা: চাপ দিলে ব্যথা।" data-rx-term="tenderness" data-rx-definition="Tenderness means pain when an area is touched or pressed. সহজ বাংলা: চাপ দিলে ব্যথা।">tenderness, soreness or pain along the inner side of your shinbone and mild swelling in your lower leg. At first, the pain might stop when you stop exercising. Eventually, however, the pain can be continuous and might progress to a stress reaction or stress fracture.
Diagnosis of Medial Tibial Stress Syndrome
History and Physical
In the evaluation of lower extremity pain, reliable diagnosis of medial tibial stress syndrome is via history and physical examination.
Information elicited during history taking that supports MTSS includes:
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Presence of exercise-induced pain along the distal two-thirds of the medial tibial border
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Presence of pain provoked during or after physical activity, which reduces with relative rest
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The absence of cramping, burning pain over the posterior compartment &/or numbness/tingling in the foot
Physical examination should include palpation and inspection of the lower extremity. Physical exam findings that support MTSS include:
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Presence of recognizable pain reproduced with palpation of the posteromedial tibial border > 5 cm
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The absence of other findings not typical of MTSS (e.g., severe swelling, allergy, infection, or inflammation. সহজ বাংলা: চামড়া লাল হয়ে যাওয়া।" data-rx-term="erythema" data-rx-definition="Erythema means skin redness, often from irritation, allergy, infection, or inflammation. সহজ বাংলা: চামড়া লাল হয়ে যাওয়া।">erythema, loss of distal pulses, etc.)
If the above components are present, then the diagnosis of MTSS can reliably be made. If the above components of history and physical examination are not present, MTSS is unlikely the cause of the lower extremity pain and suspicion and investigation should focus on a different cause of lower extremity pain.[8]
Evaluation
Medial tibial stress syndrome is a clinical diagnosis and can be reliably made by history and physical examination findings. However, imaging is often performed if uncertain of etiology or to rule out other common exercise-induced lower extremity injuries. In particular, the situation warrants imaging if concerned for a more significant tibial stress injury. Plain radiographs are normal in patients with MTSS and are often normal with an early stress fracture. Radiograph findings of the “dreaded black line” is indicative of stress fracture. MRI is the preferred imaging modality for identifying MTSS as well as a higher grade bone stress injury such as a tibial stress fracture. Nuclear bone scans are a reasonable alternative but are less specific and sensitive than MRI. MRI findings include periosteal edema and bone marrow edema. Nuclear bone scans demonstrate increased radionuclide uptake in the cortical bone with characteristic “double stripe” pattern. High-resolution CT is another viable advanced imaging option, but with lower sensitivity than MRI or nuclear bone scan.[rx][rx] Evaluating for vitamin D deficiency may also be warranted, especially for recalcitrant cases.
Treatment of Medial Tibial Stress Syndrome
Management of medial tibial stress syndrome is conservative, mainly focusing on rest and activity modification with less repetitive, load-bearing exercise. There are no specific recommendations on the duration of rest required for resolution of symptoms, and it is likely variable depending on the individual. Additional therapies that have shown beneficial effect with low-quality evidence include iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking, and extracorporeal shockwave therapy. Therapies that have yielded no benefit include low-energy laser therapy, stretching, strengthening exercises, lower leg braces, and compression stockings. Regarding prevention, a recent study on naval recruits showed prefabricated orthotics reduced MTSS.[rx][rx][rx]
For recalcitrant cases with a limited or slow response to rest and activity modification, optimizing calcium and vitamin D status and gait retraining may improve recovery and prevent further progression of the injury.[rx][rx]
Conservative treatment options
Acute phase
Rest, ice
Most literature supports “rest” as the most important treatment in the acute phase of MTSS [rx, rx]. For many athletes, however, prolonged rest from activity is not ideal, and other therapies are necessary to help the athlete return to activity quickly and safely. Patients may require “relative” rest and cessation of sport for prolonged periods of time (from 2 to 6 weeks), depending on the severity of their symptoms. NSAIDs and Acetaminophen are often used for analgesia. Cryotherapy is also commonly used in the acute period. Ice may be applied to the affected area directly after exercise for approximately 15–20 min.
Therapy
Physical therapy modalities, such as ultrasound, whirlpool baths, phonophoresis, augmented soft tissue mobilization, electrical stimulation, and unweighted ambulation, may be used in the acute setting, but they have not been shown to be definitively efficacious over other treatment options [rx, rx, rx, rx].
Subacute phase
Modify the training routine
After the acute phase, the goal of treatment should focus on modifying training regimens and addressing biomechanical abnormalities [rx, rx, rx, rx]. Decreasing weekly running distance, frequency, and intensity by 50% will likely improve symptoms without complete cessation of activity [rx, rx, rx, rx]. Runners are encouraged to avoid running on hills and uneven or very firm surfaces [8]. Synthetic track or a uniform surface of moderate firmness provides more shock absorption and cause less tendon. সহজ বাংলা: মাংসপেশি/টেনডনে টান।" data-rx-term="strain" data-rx-definition="A strain is injury to a muscle or tendon. সহজ বাংলা: মাংসপেশি/টেনডনে টান।">strain on the lower extremity [rx]
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Summary of treatment goals for MTSS
| Rest and ice in the acute phase |
| Modify training program: decrease intensity, frequency, and duration |
| Use low-impact and cross-training exercises during rehabilitation period |
| Gradually return to sport with pain-free activity |
| Perform regular stretching and strengthening exercises |
| Wear proper-fitting shoes with good shock absorption |
| Change shoes every 250–500 miles |
| Consider orthotics if indicated |
| Female athletes may have special considerations |
| Treat key dysfunctions of the entire kinetic chain; use manual therapy |
| Consider other treatment options: ESWT, injections, acupuncture |
| Surgery for recalcitrant cases |
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During this time, athletes can benefit from cross-training with other low-impact exercises, such as pool running, swimming, using an elliptical machine, or riding a stationary bicycle [rx, rx, rx, rx]. Clinicians can work with athletes to develop an appropriate rehabilitation plan with emphasis on proper technique, gait retraining, and return to activity in a step-wise fashion. Over a period of weeks, athletes may slowly increase training intensity and duration and add sport-specific activities, jumping exercises, and hill running to their rehabilitation program as long as they remain pain-free [rx]. Athletes should scale back any exercises that exacerbate their symptoms or cause pain.
Stretching and strengthening exercises
Literature has widely supported a daily regimen of calf stretching and eccentric calf exercises to prevent muscle fatigue [rx, rx, rx]. Other exercises focus on strengthening the tibialis anterior and other muscles controlling both inversion and eversion of the foot.
Eccentric calf stretches and strengthening exercises. Courtesy: R. Michael Galbraith
Patients may also benefit from strengthening core hip muscles [rx, rx]. Developing core stability with strong abdominal, gluteal, and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. Developing muscle strength will improve endurance, but should not be done in the acute phase as they may exacerbate the injury due to increased strain on the tibia [rx].
Footwear
Many reports have found that appropriate footwear can reduce the incidence of MTSS [rx, rx]. Athletes should seek out shoes with sufficient shock-absorbing soles and insoles, as they reduce forces through the lower extremity and can prevent repeat episodes of MTSS [rx, rx]. Shoes should fit properly with a stable heel counter. Some physicians recommend alternating running shoes especially when one pair is wet, as this compromises the shoe’s integrity. Runners should also change running shoes every 250–500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities and overall support [rx, rx, rx]
Orthotics
Individuals with biomechanical problems of the foot may benefit from orthotics [ rx, rx]. Often, over-the-counter orthosis (flexible or semi-rigid) are sufficient to help with excessive foot pronation and pes planus. Mal-alignments caused by forefoot or rearfoot abnormalities may benefit from custom orthotics [rx, rx, rx].
Manual therapy
Treatment for MTSS should include correction of key dysfunctions of the kinetic chain [8, 22, 25]. Manual therapy may be used to correct musculoskeletal abnormalities of the spine, sacroiliac joint, pelvis, and various muscle imbalances. A wide variety of manual medicine techniques, including osteopathic manipulation and physical therapy, can be used to address these dysfunctions [rx]. The goal of manual medicine is to restore normal range of motion of joints, improve symmetry of muscles and soft tissues and, ultimately, restore maximal function of the body as a unit [rx]. Correcting musculoskeletal dysfunctions can improve pain and overall function and may be helpful in preventing recurrence. Manual medicine has been commonly used to treat other lower extremity injuries with the benefit of improved pain and function [rx, rx, rx, rx–rx]. However, there is a paucity of RCTs about the role of manual medicine in treating specifically MTSS.
Proprioceptive training
Proprioceptive balance training is crucial in neuromuscular education [rx, rx]. This can be done with a one-legged stand, wobble board, 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.
Intrinsic factors and gender
Clinicians may need to address certain intrinsic factors with at-risk female athletes, including nutritional, hormonal, and other medical abnormalities [rx]. Proper calcium replacement (ranging from 1000 to 2000 mg daily) and Vitamin D (800 IU daily) are essential for bone strength and commonly prescribed for females [rx, rx]. Estrogen supplementation (i.e., oral contraceptive pills) may be considered to help restore normal menstruation and increase bone density [rx, rx]. Female athletes with the above disorders should have a thorough medical evaluation with a DEXA scan and proper psychosocial evaluation and treatment [rx, rx].
Splinting/bracing
Crutches may be necessary for temporary non-weightbearing and rest. Casting of the limb or a pneumatic brace is only recommended for more severe cases of MTSS and tibial stress fractures [rx, rx, rx, rx, rx].
Other potential treatments
Extracorporeal shock wave therapy – Extracorporeal shock wave therapy (ESWT) has been used to treat various tendinopathies of the lower extremity with varying success. Studies show mixed results with ESWT for treating tendinopathies of the foot and ankle, including plantar fasciitis and Achilles tendonitis [rx–rx]. No RCTs were identified for ESWT and MTSS.
Injections –Various injection methods, including cortisone, have successfully been used for decades to treat injuries of the lower extremity [rx, rx–rx]. Newer methods, such as dry-needling, autologous blood injection, platelet-rich plasma, and prolotherapy, seek to stimulate a local healing response in injured tissues. Some physicians have proposed injecting the spring and short plantar ligaments to treat laxity and poor mechanics of the foot arch, which are common factors contributing to hyperpronation [rx]. However, no RCTs have been performed with these different injection techniques for MTSS.
Acupuncture – One study identified benefit of acupuncture for MTSS, but the study had a small sample size and various methodological shortcomings [rx]. One case report and review article showed potential benefit with acupuncture for plantar fasciitis, but no other studies were identified for acupuncture for other lower extremity injuries [rx–rx].
The efficacy of ESWT, injections, and acupuncture remains unclear due to conflicting results of trials and insufficient research. As some of these potential treatments have shown benefit for numerous other lower extremity musculoskeletal conditions, one wonders if this can be extrapolated for MTSS. Clearly, further research is warranted.
Differential Diagnosis
Given the location on the lower extremity, the differential diagnosis includes the following: tibial stress fracture, chronic exertional compartment syndrome (CECS), and vascular etiologies (e.g., functional popliteal artery entrapment syndrome, peripheral arterial disease, etc.).
Tibial stress fractures can be difficult to distinguish from MTSS and are likely part of the same continuum of tibial bone stress injury. Anterior cortex stress fractures are more common than posteromedial tibial stress fractures and are distinguished by point tenderness (<5 cm) along the tibia. Radiographs may reveal the “dreaded black line,” and MRI can help determine the severity of the stress injury.[rx]
Chronic exertional compartment syndrome (CECS) is considered a disorder of muscular origin and presents similarly with exercise-induced lower extremity pain that is also diffusely located. It often involves both extremities, relieved by rest, and may have additional symptoms such as paresthesias, pallor, cold skin temperature, and loss of pulses in the distal lower extremity. CECS diagnosis is made by measuring intramuscular compartment pressures.
Functional popliteal artery entrapment syndrome (FPAES) and peripheral arterial disease (PAD) both manifest as claudication. FPAES is thought to be due to anatomic variations or hypertrophy of the musculature in the popliteal fossa leading to popliteal artery compression with increased activity. FPAES diagnosis is by stress arteriography. PAD is often due to atherosclerosis and is diagnosed by arteriography or Doppler ultrasound examination.[rx]
Complications
Acute complications for athletes and military personnel include pain leading to decreased performance and/or time away from training/participation. The presumption is that medial tibial stress syndrome (MTSS) may progress to a tibial stress fracture, as cortical microtrauma may evolve into cortical fracture. However not every patient that experiences MTSS develops a tibial stress fracture.[rx][rx] Severe tibial stress fractures may require surgical intervention.
Prevention
To help prevent shin splints:
- Analyze your movement – A formal video analysis of your running technique can help to identify movement patterns that can contribute to shin splints. In many cases, a slight change in your running can help decrease your risk.
- Avoid overdoing – Too much running or other high-impact activity performed for too long at too high an intensity can overload the shins.
- Choose the right shoes – If you’re a runner, replace your shoes about every 350 to 500 miles (560 to 800 kilometers).
- Consider arch supports – Arch supports can help prevent the pain of shin splints, especially if you have flat arches.
- Consider shock-absorbing insoles – They might reduce shin splint symptoms and prevent recurrence.
- Lessen the impact. Cross-train with a sport that places less impact on your shins, such as swimming, walking or biking. Remember to start new activities slowly. Increase time and intensity gradually.
- Add strength training to your workout – Exercises to strengthen and stabilize your legs, ankles, hips and core can help prepare your legs to deal with high-impact sports.
References
- https://www.ncbi.nlm.nih.gov/books/NBK507835/
- https://www.ncbi.nlm.nih.gov/books/NBK544354/
- https://www.ncbi.nlm.nih.gov/books/NBK448124/
- https://www.ncbi.nlm.nih.gov/books/NBK538488/
- https://www.ncbi.nlm.nih.gov/books/NBK542178/
- https://www.ncbi.nlm.nih.gov/books/NBK507835/
- https://www.ncbi.nlm.nih.gov/books/NBK538479/
