Successful treatment of medial tibial stress syndrome in a collegiate athlete focusing on clinical findings and kinesiological factors contributing to pain.

Medial tibial stress syndrome (MTSS) is characterized by the presence of diffuse pain in the posteromedial portion of the medial border of the tibia. Current evidence from the literature has not established an effective treatment and has not been able to demonstrate effectiveness of numerous modalities commonly used to treat MTSS pain. CASE DESCRIPTION: This report describes an 18-year-old male collegiate soccer player who presented with pain along the distal medial tibial border bilaterally consistent with the diagnosis of medial tibial stress syndrome (MTSS). Treatment focused on correcting clinical and kinesiological findings likely contributing to the patient's condition including fascial mobilization, interferential currents (IFC), strengthening and stretching exercises. After 10 sessions over 10 weeks the patient was able to return to training and competition without pain.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

The diagnosis and management of medial tibial stress syndrome : An evidence update.

Medial tibial stress syndrome is a common overuse injury in jumping and running athletes. It is defined as exercise-induced pain along the distal posteromedial border of the tibia and the presence of recognisable pain on palpation over a length of 5 or more centimetres. This overview article provides an evidence update on the diagnosis and management of athletes with medial tibial stress syndrome.

[The diagnosis and management of medial tibial stress syndrome : An evidence update-German version]. / Diagnostik und Therapie des Schienbeinkantensyndroms : Update zur Studienlage.

Medial tibial stress syndrome is a common overuse injury in jumping and running athletes. It is defined as exercise-induced pain along the distal posteromedial border of the tibia and the presence of recognisable pain on palpation over a length of 5 or more centimetres. This overview article provides an evidence update on the diagnosis and management of athletes with medial tibial stress syndrome.

Differences in muscle attachment proportion within the most common location of medial tibial stress syndrome in vivo.

INTRODUCTION: The medial tibial stress syndrome is one of the most common causes of running-related injuries. The primary study objective was to observe the attachment proportion of flexor digitorum longus and soleus, at the most common location of medial tibial stress syndrome, using ultrasonography, on a large cohort of young males and females to evaluate for gender-based anatomical differences. The secondary objective of this study was to investigate the relationship between the anatomical features and medial tibial stress syndrome. METHODS: In this study, we observed whether or not flexor digitorum longus and/or soleus attached at the middle and distal thirds of the medial margin of the tibia (most common location of medial tibial stress syndrome) using ultrasonography. History of medial tibial stress syndrome was defined by inquiries. RESULTS: The Chi2 tests showed that the attachment proportion of the soleus in female participants was significantly higher than that observed in male participants. In addition, Chi2 testing showed that there were no significant differences between attachment proportion of soleus of legs with history of medial tibial stress syndrome and legs without history of medial tibial stress syndrome, in both male and female participants. CONCLUSIONS: These results suggested that the anatomical features of flexor digitorum longus might be involved in medial tibial stress syndrome development, whereas the anatomical features of the soleus might not be involved in medial tibial stress syndrome development. LEVEL OF EVIDENCE: III, cross-sectional study.

Medial tibial stress syndrome can be diagnosed reliably using history and physical examination.

BACKGROUND: The majority of sporting injuries are clinically diagnosed using history and physical examination as the cornerstone. There are no studies supporting the reliability of making a clinical diagnosis of medial tibial stress syndrome (MTSS). AIM: Our aim was to assess if MTSS can be diagnosed reliably, using history and physical examination. We also investigated if clinicians were able to reliably identify concurrent lower leg injuries. METHODS: A clinical reliability study was performed at multiple sports medicine sites in The Netherlands. Athletes with non-traumatic lower leg pain were assessed for having MTSS by two clinicians, who were blinded to each others' diagnoses. We calculated the prevalence, percentage of agreement, observed percentage of positive agreement (Ppos), observed percentage of negative agreement (Pneg) and Kappa-statistic with 95%CI. RESULTS: Forty-nine athletes participated in this study, of whom 46 completed both assessments. The prevalence of MTSS was 74%. The percentage of agreement was 96%, with Ppos and Pneg of 97% and 92%, respectively. The inter-rater reliability was almost perfect; k=0.89 (95% CI 0.74 to 1.00), p<0.000001. Of the 34 athletes with MTSS, 11 (32%) had a concurrent lower leg injury, which was reliably noted by our clinicians, k=0.73, 95% CI 0.48 to 0.98, p<0.0001. CONCLUSION: Our findings show that MTSS can be reliably diagnosed clinically using history and physical examination, in clinical practice and research settings. We also found that concurrent lower leg injuries are common in athletes with MTSS.

Predicting individual risk for medial tibial stress syndrome in navy recruits.

OBJECTIVES: Quantifying individual risk for medial tibial stress syndrome (MTSS) is valuable due to the high prevalence, substantial financial and service costs, and lengthy recovery time of the condition. Identification of those at risk is a key first step in prevention of the condition. This study aimed to test a suite of best evidence risk factors in a cohort of Navy recruits and to develop a predictive model for individuals at risk of MTSS. DESIGN: Prospective cohort study of Navy recruits undergoing initial training METHODS: A prospective cohort design, this study screened recruits by assessing gender, MTSS history, years of running experience, orthotic use, BMI, navicular drop, ankle plantarflexion and hip external rotation at the beginning of basic training. Follow-up was conducted at completion of training (11 weeks). RESULTS: Volunteers included 123 recruits (28 females and 95 males). Thirty developed MTSS (19 males and 11 females). Stepwise logistic regression of one half of the data produced a significant model (p<0.001), comprising female gender (OR 4.4, 95% CI 1.0, 18.9, p=0.05), MTSS history (OR 18.3, 95% CI 3.6, 91.5, p<0.01) and increased hip ER (OR 1.1 per degree, 95% CI 1.0, 1.202, p=0.05). Findings validated with the other half of the cohort and receiver operating characteristic curve analysis showed the model had 82% sensitivity and 84% specificity. CONCLUSIONS: This predictive model provides military institutions, clinicians and instructors with a strong and accurate calculator for predicting an individual recruit's risk of MTSS.

Influence of outdoor running fatigue and medial tibial stress syndrome on accelerometer-based loading and stability.

Medial tibial stress syndrome (MTSS) is a common overuse running injury with pathomechanics likely to be exaggerated by fatigue. Wearable accelerometry provides a novel alternative to assess biomechanical parameters continuously while running in more ecologically valid settings. The purpose of this study was to determine the influence of outdoor running fatigue and MTSS on both dynamic loading and dynamic stability derived from trunk and tibial accelerometery. Runners with (n=14) and without (n=16) history of MTSS performed an outdoor fatigue run of 3200m. Accelerometer-based measures averaged per lap included dynamic loading of the trunk and tibia (i.e. axial peak positive acceleration, signal power magnitude, and shock attenuation) as well as dynamic trunk stability (i.e. tri-axial root mean square ratio, step and stride regularity, and sample entropy). Regression coefficients from generalised estimating equations were used to evaluate group by fatigue interactions. No evidence could be found for dynamic loading being higher with fatigue in runners with MTSS history (all measures p>0.05). One significant group by running fatigue interaction effect was detected for dynamic stability. Specifically, in MTSS only, decreases mediolateral sample entropy i.e. loss of complexity was associated with running fatigue (p<0.01). The current results indicate that entire acceleration waveform signals reflecting mediolateral trunk control is related to MTSS history, a compensation that went undetected in the non-fatigued running state. We suggest that a practical outdoor running fatigue protocol that concurrently captures trunk accelerometry-based movement complexity warrants further prospective investigation as an in-situ screening tool for MTSS individuals.

Chronic Exertional Compartment Syndrome.

Increased tissue pressure within a fascial compartment may be the result from any increase in volume within its contents, or any decrease in size of the fascial covering or its distensibility. This may lead to symptoms of leg tightness, pain or numbness brought about by exercise. There are multiple differential diagnoses of exercise induced leg pain and the proper diagnoses of chronic exertional compartment syndrome (CECS) is made by a careful history and by exclusion of other maladies and confirmed by compartment syndrome testing as detailed in this text. Surgical fasciotomies for the anterior, lateral, superficial and deep posterior compartments are described in detail along with ancillary procedures for chronic shin splints that should allow the athlete to return to competitive activity.

The medial tibial stress syndrome score: a new patient-reported outcome measure.

BACKGROUND: At present, there is no validated patient-reported outcome measure (PROM) for patients with medial tibial stress syndrome (MTSS). AIM: Our aim was to select and validate previously generated items and create a valid, reliable and responsive PROM for patients with MTSS: the MTSS score. METHODS: A prospective cohort study was performed in multiple sports medicine, physiotherapy and military facilities in the Netherlands. Participants with MTSS filled out the previously generated items for the MTSS score on 3 occasions. From previously generated items, we selected the best items. We assessed the MTSS score for its validity, reliability and responsiveness. RESULTS: The MTSS score was filled out by 133 participants with MTSS. Factor analysis showed the MTSS score to exhibit a single-factor structure with acceptable internal consistency (α=0.58) and good test-retest reliability (intraclass correlation coefficient=0.81). The MTSS score ranges from 0 to 10 points. The smallest detectable change in our sample was 0.69 at the group level and 4.80 at the individual level. Construct validity analysis showed significant moderate-to-large correlations (r=0.34-0.52, p<0.01). Responsiveness of the MTSS score was confirmed by a significant relation with the global perceived effect scale (ß=-0.288, R(2)=0.21, p<0.001). CONCLUSIONS: The MTSS score is a valid, reliable and responsive PROM to measure the severity of MTSS. It is designed to evaluate treatment outcomes in clinical studies.

Forefoot flexibility and medial tibial stress syndrome.

PURPOSE: To investigate the association between medial tibial stress syndrome (MTSS) and morphology and flexibility of the foot arches. METHODS: 131 feet from 74 healthy subjects and 31 feet from 27 patients with MTSS were classified as normal feet (n=78 in 40 subjects), flat feet (n=53 in 34 subjects), or MTSS feet (n=31 in 27 patients). The medial longitudinal arch (MLA) ratio and the transverse arch length (TAL) were measured in both rearfoot and forefoot loading positions. The difference between the 2 positions indicated the flexibility of the MLA (diff-MLA ratio) and the transverse arch (diff- TAL). RESULTS: The MLA ratio was higher in normal feet than MTSS feet or flat feet (15.1% vs. 12.8% vs. 12.3%, p<0.001). The diff-TAL was lower in MTSS feet than normal feet or flat feet (0.4% vs. 0.8% vs. 0.9%, p<0.001]). The 3 groups were comparable in terms of the diff-MLA ratio and the TAL. Respectively for the MLA ratio and the diff-TAL, the cut-off value was 11.9% and 0.61% based on the Youden index. The sensitivity, specificity, and odds ratio of the cut-off value were 0.4, 0.9, and 4.8 for the MLA ratio, and 0.6, 0.7, and 9.8 for the diff-TAL, respectively. CONCLUSION: Decreased flexibility of the transverse arch and decreased MLA ratio are risk factors for MTSS. In contrast, the flexibility of the MLA and the height of the transverse arch were not risk factors for MTSS.

Bilateral diaphyseal bone cysts of the tibia mimicking shin splints in a young professional athlete--a case report and depiction of a less-invasive surgical technique.

BACKGROUND: Medial tibial stress syndrome is one of the most common causes of exertional leg pain in runners whereas musculoskeletal tumors and tumor-like lesions are rare encounters in orthopedic sports medicine practice. Unicameral (simple) bone cyst is a well-known tumor-like lesions of the bone typically affecting children and adolescents. Bilateral occurrence is very rare though and has never been reported before in both tibiae. Failing to accurately diagnose a tumorous lesion can entail far-reaching consequences for both patients and physicians. CASE PRESENTATION: We report the case of large bilateral unicameral bone cysts of the diaphyseal tibiae mimicking medial tibial stress syndrome in a 17-year old professional athlete. This is the first report of symmetric tibial unicameral bone cysts in the literature. The patient complained about persisting shin splint-like symptoms over 5 months despite comprehensive conservative treatment before MRI revealed extensive osteolytic bone lesions in both diaphyseal tibiae. The patient-tailored, less-invasive surgical procedure, allowing the patient to return to his competitive sports level symptom-free 3 months after surgery and to eventually qualify for this years Biathlon Junior World Championships, is outlined briefly. Pathogenesis and various treatment options for this entity will be discussed. CONCLUSION: This report will help to raise awareness for musculoskeletal tumors as differential diagnosis for therapy-refractory symptoms in young athletes and encourage medical staff involved in sports medicine and athlete support to perform early high quality imaging and initiate sufficient surgical treatment in similar cases. Moreover, our less-invasive surgical procedure aiming for a fast return to sports might be an optimal compromise between traditional open curettage with low risk of recurrence and a soft tissue-saving and bone-sparing minimal-invasive technique.

Medial tibial stress syndrome: case report.

INTRODUCTION: Although it can be difficult to differentiate pain in lower legs, it is important for clinicians to differentiate medial tibial stress syndrome, which is a rather benign condition, from acute compartment syndrome, which is an emergency, as well as from different types of stress fractures described in this region. The aim of this case report was to present medial tibial stress syndrome as a clinical diagnosis, possible dilemmas in differential diagnosis and the efficacy of rehabilitation treatment. CASE REPORT: A 25-year old male patient sought medical help complaining of the pain along the distal third of tibia. The pain was present on palpation of the distal two-thirds of the lateral and medial tibial border over the length of 9 cm and on muscle manual testing of foot flexors. The patient underwent physical and exercise treatment for three weeks. The recovery was monitored by visual analogue scale, which measured the lower leg pain, pain on palpation and manual muscle testing. In addition, the patient himself assessed his ability to resume sport activities on the 5-point Likert scale. The final evaluation and measurements showed his complete functional recovery. CONCLUSION: The results obtained in this case show the importance of accurate clinical diagnosis and rehabilitation for medial tibial stress syndrome.

Shin-splints: common exercise-related syndromes affecting the lower leg.

Lower leg pain is a common complaint of athletically active individuals, often limiting physical activities. As such, the group of lower leg conditions related to athletic pursuits and physical exercise confer considerable operational implications for the military. Whilst acute injuries to the lower limb are commonly encountered and are clearly of significance, this article focuses instead on chronic conditions related to physical activity. These include insults to bone such as stress fractures and medial tibial stress syndrome, and those related to the soft tissues such as chronic exertional compartment syndrome. In this article we will examine the presentation and management of these conditions.

Triathlon: running injuries.

The running portion of the triathlon represents the final leg of the competition and, by some reports, the most important part in determining a triathlete's overall success. Although most triathletes spend most of their training time on cycling, running injuries are the most common injuries encountered. Common causes of running injuries include overuse, lack of rest, and activities that aggravate biomechanical predisposers of specific injuries. We discuss the running-associated injuries in the hip, knee, lower leg, ankle, and foot of the triathlete, and the causes, presentation, evaluation, and treatment of each.

Biomechanical and lifestyle risk factors for medial tibia stress syndrome in army recruits: a prospective study.

Medial tibial stress syndrome (MTSS) is a common injury in active populations and has been suggested to be a result of both biomechanical and lifestyle factors. The main aim of this study was to determine prospectively whether gait biomechanics and lifestyle factors can be used as a predictor of MTSS development. British infantry male recruits (n=468) were selected for the study. Plantar pressure variables, lifestyle factors comprising smoking habit and aerobic fitness as measured by a 1.5 mile timed-run were collected on the first day of training. Injury data were collected during the 26 week training period and incidence rate was 7.9% (n=37). A logistic regression model for membership of the MTSS and non-MTSS groups was developed. An imbalance in foot pressure with greater pressure on the medial side than on the lateral side was the primary risk factor. Low aerobic fitness, as deduced from a 1.5 mile timed-run and smoking habit were also important, but were additive risk factors for MTSS. In conclusion, "poor" biomechanics were the strongest predictors of MTSS development but lifestyle factors were also important. The logistic regression model combining all three risk factors was capable of predicting 96.9% of the non-injured group and 67.5% of the MTSS group with an overall accuracy of 87.7%. While the model has yet to be validated against an external sample and limitations exist with regards to the quality of the data collected, it is nonetheless suggested that the combined analysis of biomechanical and lifestyle factors has the potential to improve the prediction of MTSS.

The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study.

OBJECTIVE: To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits. METHODS: In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures. RESULTS: In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 +/- 27.7 (mean +/- SD) vs Non-Brace 57.9 +/- 26.2 (mean +/- SD, p = 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 +/- 1.1 (mean +/- SD) on a 1-10 scale for the brace group and 7.1 +/- 0.7 (mean +/- SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 +/- 1.3 (mean +/- SD) on a 1-10 scale. CONCLUSIONS: No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.