Medial Tibial Stress Syndrome

What is Medial Tibial Stress Syndrome?

Overuse or repetitive – stress injury causes damage to the shin area, which is clinically termed as Medial Tibial Stress Syndrome (MTSS). A variety of stress reactions of the tibia and adjoining musculature arise when the body is not capable of repairing due to tibial strain and recurring muscle contractions¹.

Pathophysiology

Researchers assume that the origin of Medial Tibial Stress Syndrome is periostitis of the tibia and that develops due to the excessive load of tibial strain. But recent evidence stated that a range of tibial stress injuries is mainly implicated for MTSS development, such as tendinopathy, reactive stress in the tibia, periostitis, and periosteal remodeling.

Other included conditions like tibialis anterior, tibialis posterior and soleus muscles are also frequently involved. All these included tibial stress injuries occur due to changes in tibial loading, like persistent, recurring loads provides anomalous strain and twisting of the tibia. Although it is not necessary that only mentioned etiologies are involved in Medial Tibial Stress Syndrome, but a continuum bone stress reactions also cause tibial stress fractures^1,2,3.

Symptoms

The primary symptom of Medial Tibial Stress Syndrome is a pain. The nature of pain in MTSS is usually indistinguishable, scatter type and the pain mainly occur at the lower limb, along with the middle-distal tibia interrelated with physical exertion.

At the initial stage of the MTSS, the pain symptom is aggravated with the commencement of the exercise and slowly drop the intensity of the pain by continuing the training or after stopping of exercise. At the later stage of the syndrome, pain arises even with a less activity or at resting stage.

Athletes, such as runners, football players, basketball players, soccer players, and dancers are more susceptible towards Medial Tibial Stress Syndrome. The common risk factors, which are responsible for generating Medial Tibial Stress Syndrome, specifically for athletes include

• Intensity of exercise routinely performed
• Selected mileage for running regularly
• Pace between training session
• The provision of comfort during training session including terrain, footwear etc.

Above mentioned training related errors are the most considerable reason for the development of MTSS. In previous days “too much, too fast” are two applicable words for athlete’s training and that is liable for increased activity, intensity, or duration. But recently training program pattern is amended^1,4.

Prevalence

The prevalence of MTSS has some gender biases, females are almost 1.5 to 3.5 times more prevalent than males. The reasons behind this include eating disorder, a deficit of nutrients, hypocalcemia, osteoporosis, abnormal menses and amenorrhea, which lead to diminished bone density⁵.

Diagnosis

Diagnosis of MTSS is essential to treat the condition. Following are the different diagnostic tools use for MTSS.

Physical examination

Clinician usually checks the palpability and tenderness of distal and middle region of the tibia, as in MTSS the medial ridge of the tibia become tender to palpation. During the physical examination, clinician usually checks possible knee abnormalities, femoral anteversion, tibial torsion, foot arch abnormalities, or a leg-length discrepancy. The clinician also checks inflexibility and imbalance of adjoining muscles. Core and pelvic muscle stability also assessed during a physical examination, as hip and pelvic muscle strength is a significant factor in determining lower limb strength. Even checking of the shoe is also important^1,2,6.

X-Ray

At the initial step, X-Ray cannot able to detect the structural abnormality. But in chronic Medial Tibial Stress Syndrome, X-Ray can provide the images of periosteal exostoses. X- ray can provide the indication of progression of MTSS to stress fracture⁷.

Triple-phase Bone Scan

Previously, a Triple-phase Bone Scan is the gold standard for detection of a diffuse stress fracture in MTSS. But recently, magnetic resonance imaging provides more authentic result in detection of tissue injury in MTSS⁴.

MRI

MRI or magnetic resonance imaging is more popular nowadays due to some advantages. MRI can better to detect adjoin tissue injuries. The stages of MTSS progression, which includes tissue impairments, periosteal edema development, the gradual involvement of marrow and at last cortical stress fracture. MRI can assist in the grading of MTSS, which depends upon the involvement of tibial injuries. The grading of MTSS is an important factor for determination of healing period⁸.

Treatment

Treatment approaches are not same for every case. Depending on the severity, the method of treatment is also changed.

Acute phase

In acute phase following two initial treatment can start to heal the injury^1,2,4,8

Relative rest

In the acute stage of MTSS, rest is very crucial. But the period of ‘relative’ rest also important, as prolonged period of rest is also not recommended for athletes. Usually recommended a duration of relative rest is from 2 weeks to 6 weeks depending upon patient condition.

Cryotherapy

Cryotherapy or application of ice to treat the injury provides effective result against local tissue injury. The duration of direct application of ice is usually 15 to 20 minutes immediately after the injury.

Medicines

Non-steroidal-anti-inflammatory drugs like ibuprofen, acetaminophen are also prescribed to treat pain in MTSS.

Physiotherapy

There are multiple physiotherapy options such as ultrasound, phonophoresis, whirlpool baths, electrical stimulation, augmented soft tissue mobilization and unweighted ambulation may recommend at the acute stage.

Subacute Phase

Following are different treatment options available for sub-acute phase^1,2,4,8.

Training routine modification

Biochemical modification occurs at subacute phase. The different modified training routine like reduction of routine running distance, intensity, and frequency can provide symptomatic improvement unlike to complete rest. Clinician always suggests that runners should not run on firm and uneven surface, hills etc.

Exercises

Cross training for Low impact exercise is also beneficial for athletes to overcome the stress injury. The low impact exercise training program includes pool running, riding a stationary bicycle, or using an elliptical machine and swimming. Doctors can plan for rehabilitation therapy with discussing with the affected individual and that emphasizes on appropriate practice, step retraining, and return back to activity in a sequential fashion.

The Scientific document referred to the routine practice of eccentric calf exercises and calf stretching for prevention of muscle fatigue. Specific exercise programs can assist in strengthening the tibialis anterior and other muscles regulating both inversion and eversion of the foot.

Footwear

Clinicians give special attention on footwear to avoid MTSS. Shock-absorbing soles which can reduce the forces at the lower extremities helps to prevent recurrence of MTSS and chronic condition.

Injection

A cortisone injection is very well established medication for most of the inflammatory pain conditions, including stress injury at the local extremities.

Novel therapy includes autologous blood injection, dry needling, prolotherapy and platelet rich plasma are applied for local healing.

Acupuncture

One research study provides the evidence that Acupuncture can improve plantar fasciitis. Therefore there is a future prospect of acupuncture to provide to improvement against MTSS.

Surgical Intervention

If the patient is not responding to conservative treatment, then “posterior fasciotomy”  a surgical intervention requires improving the patient condition. Surgical intervention may not effective to complete symptomatic reduction, but improve pain and functionality^3,4.

References

1. R. Michael Galbraith, Mark E. Lavallee; Medial tibial stress syndrome: conservative treatment options; Curr Rev Musculoskelet Med. 2009 Sep; 2(3): 127–133. Published online 2009 Oct 7. doi: 10.1007/s12178-009-9055-6
2. Beck B. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med. 1998;26(4):265–279. doi: 10.2165/00007256-199826040-00005.
3. Detmer D. Chronic shin splints. Classification and management of medial tibial stress syndrome. Sports Med. 1986;3(6):436–446. doi: 10.2165/00007256-198603060-00005
4. Kortebein P, Kaufman K, Basford J, Stuart M. Medial tibial stress syndrome. Med Sci Sports Exerc. 2000;32(3 suppl):S27–S33.
5. Dugan S, Weber K. Stress fracture and rehabilitation. Phys Med Rehabil Clin N Am. 2007;18(3):401–416.
6. Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–552.
7. Couture C, Karlson K. Tibial stress injuries: decisive diagnosis and treatment of ‘shin splints’. Phys Sportsmed. 2002;30(6):29–36.
8. Fredericson M, Bergman G, Hoffman K, Dillingham M. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23:427–481. doi: 10.1177/036354659502300418.