Return to Sports in Stress Reaction and Stress Fractures in Indian Athletes: A Case Series.

Introduction: A stress fracture is a painful condition which occurs when the adaptive ability of the bone is unbalanced. This imbalance predominantly occurs due to increased intensity, frequency, or duration of training. Identifying the etiology of stress fracture and its proper treatment prevents recurrence. Besides, evidence-based and supervised rehabilitation is indispensable for permanent remission of pain and return to sports to preinjury functional levels. The case series discusses the continuum of stress reaction to stress fracture in athletes, causes of stress fractures, their management, and return to sport. The paper aims to give a clear discussion about the management with rehabilitation guidelines for metabolic causes of stress fractures. Case Report: This study was a case series of five cases coming to Sports Medicine outpatient clinic of Sports Injury Centre, VMMC and Safdarjung Hospital, New Delhi, and physical medicine and rehabilitation outpatient clinic of Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow over a period of 1 year. The discussed cases are young Indian athletes, both male and females, who have presentation along the continuum of medial tibial stress syndrome (MTSS) to stress reactions and stress fracture. Conclusion: The findings of the paper highlight the significance of rehabilitation for individuals suffering from MTSS. Accurate diagnosis with targeted rehabilitation leads to quicker return to sports. The rehabilitation program comprises of identifying and treating the cause of stress fracture, removing any risk factors, biomechanical correction wherever indicated, structured exercise program, training in underwater treadmill, cyclical increase in loading, reducing activity every 3rd week.

Medial Tibial Stress Syndrome (Shin Splint): Prevalence, Causes, Prevention, and Management in Saudi Arabia.

Background/aims Medial tibial stress syndrome (MTSS), also known as "shin splint", is most often described as exertional leg pain along the shinbone (tibia), which occurs due to the inflammation of the muscles, tendons, and bone tissue in this area. This study aims to assess the prevalence, risk factors, and their association with the development of MTSS, as well as the effective treatments that reduce pain and improve functions among the Saudi general population. Materials and method The present cross-sectional study was conducted on the general population of Saudi Arabia through an electronic survey over a period of three months. The study sample of 443 patients was deemed and considered. The study included participants from the general population in Saudi Arabia above the age of 18. A structured self-response questionnaire was given to the participants after institutional research ethical approval was obtained for the study. Results Among the 443 participants, the majority were male (n = 228, 51.5%), aged 18-29 (n = 227, 51.2%), and residing in the central region of Saudi Arabia (n = 398, 89.8%). Most participants reported engaging in sporting activities (n = 211, 47.6%), with high-intensity training being the most common (n = 93, 44.1%). Only a small proportion (n = 8, 1.8%) reported a previous diagnosis of MTSS. Analysis revealed associations between MTSS prevalence and certain demographic factors, including walking surface preferences and engagement in specific sports. Treatment strategies for MTSS included rest, ice application, physiotherapy, and pain-relieving medication, with varying degrees of satisfaction and recurrence rates among participants. Conclusion The study provides valuable insights into the prevalence, risk factors, management, and preventive measures related to MTSS among the Saudi general population. While certain demographic factors and exercise practices were associated with MTSS prevalence, effective treatment options such as rest, physiotherapy, and appropriate footwear were reported. Moreover, adherence to preventive measures such as stretching, proper footwear selection, and gradual training progression may help mitigate the risk of MTSS development.

Effect of the Graston Technique and Cupping Therapy on Pain and Functions in Individuals With Medial Tibial Stress Syndrome: A Randomized Clinical Trial.

Background The discomfort in the mid-shaft and distal end of the tibia caused by shin splints or tibial periostitis also known as medial tibial stress syndrome (MTSS) is frequently induced by participating in sports or other strenuous activities. The two treatment methods used in this study are the Graston technique and cupping therapy; we have compared cupping with the Graston technique. Method It was an interventional study at Ravi Nair Physiotherapy College and Acharya Vinoba Bhave Rural Hospital. A total of 46 participants with MTSS were included in the study. The participants were randomly divided into two groups and treated for three weeks with four weekly sessions. Result Statistical analysis was done after the completion of sampling. Paired and unpaired t-tests were used. A p-value of <0.05 was considered significant. The result was obtained after comparing the pre and post values of the visual analog scale (VAS), treadmill test, step-up and step-down tests, manual muscle testing (MMT), and range of motion (ROM) of the ankle joint. After three weeks of treatment, pain with a p-value of 0.01 S showed a significant effect, and improved functions were reduced in the cupping and Graston technique groups. When compared, cupping therapy showed better results than the Graston technique. Conclusion We saw that the cupping therapy might be better than the Graston technique in reducing pain and improving functions.

Chronic Exertional Compartment Syndrome in Athletes: An Overview of the Current Literature.

Chronic exertional compartment syndrome is an incapacitating condition that primarily affects athletes and individuals with high activity levels. The exact etiology of the condition is unknown to date, but multiple factors play a role in its occurrence. The clinical presentation includes pain, tightness, muscle weakness, paresthesia, and cramps. Common tools utilized during the diagnostic approach include intramuscular compartment pressure measurement, advanced imaging to exclude other disorder entities, near-infrared spectrometry, and shear wave elastography, with the clinical diagnosis being the gold standard. Management includes both conservative and surgical options. Conservative treatment includes gait re-training and botulinum toxin injections. Further, the operative treatment has variable approaches and may be combined with conservative modalities. This article reviews the literature on chronic exertional compartment syndrome and elucidates future recommendations.

Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review.

BACKGROUND: Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions. METHODS: Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions. RESULTS: One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2). CONCLUSION: Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation.

Partial mixed neuropathy of the fourth lumbar spinal nerve misdiagnosed as "shin splints."

A case of anteromedial leg pain diagnosed and treated for 10 years as "shin splints" (medial tibial stress syndrome) is described. A history and examination was performed focused on anatomy, biomechanics, and peripheral nerves. Detailed sensory testing was performed in the painful area, and imaging was obtained to confirm the diagnosis. The clinical investigation was consistent with dynamic stenosis of the left L4-5 intervertebral foramen, causing a mixed partial mononeuropathy of the L4 spinal nerve that presented as pain and hypersensitivity in the anteromedial shin. Manual therapy maneuvers intended to open the intervertebral foramen led to resolution of the pain and sensory deficits. After three additional treatments performed within a month, resolution was maintained for >3 years. This case highlights how concepts from preclinical studies, coupled with basic anatomical, neurological, and biomechanical investigations, can be critical for accurate diagnosis and treatment for a case previously considered unresponsive to care.

On décrit un cas de douleur antéro-médiale de la jambe diagnostiquée et traitée pendant 10 ans comme une « périostite tibiale ¼ (syndrome de stress tibial médial). L'anamnèse et l'examen ont porté sur l'anatomie, la biomécanique et les nerfs périphériques. Des tests sensoriels détaillés ont été effectués dans la zone douloureuse et une imagerie a été réalisée pour confirmer le diagnostic. L'examen clinique était compatible avec une sténose dynamique du foramen intervertébral gauche L4­5, provoquant une mononeuropathie partielle mixte du nerf spinal L4 qui s'est manifestée par une douleur et une hypersensibilité dans le tibia antéro-médial. Des manoeuvres de thérapie manuelle visant à ouvrir le foramen intervertébral ont permis de résoudre la douleur et les déficits sensoriels. Après trois traitements supplémentaires effectués en l'espace d'un mois, la résolution s'est maintenue pendant trois ans. Ce cas montre comment les concepts issus des études précliniques, associés aux examens anatomiques, neurologiques et biomécaniques de base, peuvent s'avérer essentiels pour un diagnostic et un traitement précis d'un cas précédemment considéré comme ne répondant pas aux soins.

Biomechanical characteristics of the lower extremities during running in male long-distance runners with a history of medial tibial stress syndrome: a case control study.

BACKGROUND: Medial tibial stress syndrome (MTSS) is a running-related injury of the lower extremities. After returning to competition, there are often recurring episodes of MTSS. Therefore, it is important to prevent the onset and recurrence of MTSS among long-distance runners. This case-control study aimed to compare the kinematics and kinetics of runners with and without previous MTSS during running to clarify the biomechanical characteristics of the lower extremity of runners with previous MTSS. METHODS: Thirteen male long-distance runners aged over 18 years and asymptomatic at the time of measurement were divided into an MTSS group and a non-MTSS group based on their history of MTSS as reported in a questionnaire. The kinetics and kinematics of running were analyzed when participants ran at a speed of 2.0 ± 0.2 m/s by a three-dimensional motion analysis system and two force plates. Data regarding the joint angles, moments, and powers of the ankle, knee, and hip during the stance phase while running were extracted and compared between the two groups using the Mann-Whitney U test. RESULTS: Of the 13 participants, 5 and 8 were included in the MTSS (10 legs) and non-MTSS (16 legs) groups, respectively. The ankle maximum eversion moment was significantly larger in the MTSS group than in the non-MTSS group (p = 0.04). There were no significant differences in other parameters. CONCLUSIONS: This study found that the ankle maximum eversion moment during the stance phase of running was larger in the MTSS group than in the non-MTSS group. Even after the disappearance of the symptoms of MTSS, the running biomechanics of participants with previous MTSS differed from those of participants without previous MTSS.

Chronic diseases and allergies are risk factors predictive of a history of Medial Tibial Stress Syndrome (MTSS) in distance runners: SAFER study XXIV.

BACKGROUND: Medial Tibial Stress Syndrome (MTSS) is one of the most common causes of exercise-associated lower leg pain in distance runners. AIM: To identify risk factors predictive of a history of MTSS in distance runners entering the Two Oceans Marathon races (21.1 km and 56 km). DESIGN: Cross-sectional study. SETTING: 2012 to 2015 Two Oceans Marathon races (21.1 km and 56 km). PARTICIPANTS: Consenting race entrants. METHODS: 106,743 race entrants completed an online pre-race medical screening questionnaire. 76,654 consenting runners (71.8%) were studied. 558 verified MTSS injuries were reported in the previous 12 months. Risk factors predictive of a history of MTSS were explored using uni - & multivariate analyses: demographics (race distance, sex, and age groups), training/racing history, history of chronic diseases, allergies, and medication use. RESULTS: Independent risk factors predictive of a history of MTSS (adjusted for sex, age group, and race distance) were a higher chronic disease composite score (PR = 3.1 times increase risk for every two additional chronic diseases; p < 0.0001) and a history of allergies (PR = 1.9; p < 0.0001). Chronic diseases (PR > 2) predictive of a history of MTSS were: symptoms of CVD (PR = 4.2; p < 0.0001); GIT disease (PR = 3.3; p < 0.0001); kidney/bladder disease (PR = 3.3; p < 0.0001); nervous system/psychiatric disease (PR = 3.2; p < 0.0001); respiratory disease (PR = 2.9; p < 0.0001) a history of CVD (PR = 2.9; p < 0.0001); and risk factors of CVD (PR = 2.4; p < 0.0001) (univariate analysis). Average running speed was associated with higher risk of MTSS. CONCLUSION: Novel independent risk factors predictive of a history of MTSS in distance runners (56 km, 21.1 km) were multiple chronic diseases and a history of allergies. Identifying athletes at higher risk for MTSS can guide healthcare professionals in their prevention and rehabilitation efforts.

Femoral neck stress fracture and medial tibial stress syndrome following high intensity interval training: A case report and review of literature.

BACKGROUND: Femoral and tibial stress injuries are commonly found in long distance running athletes. Stress fractures have rarely been reported in athletes performing high intensity interval training (HIIT) exercise. The objective of this study was to report a case of a patient who presented with medial tibial stress syndrome and femoral neck stress fracture after performing HIIT exercises. CASE SUMMARY: A 26 year old female presented with bilateral medial tibial pain. She had been performing HIIT exercise for 45 min, five times weekly, for a seven month period. Her tibial pain was gradual in onset, and was now severe and worse on exercise, despite six weeks of rest. Magnetic resonance imaging (MRI) revealed bilateral medial tibial stress syndrome. As she was taking norethisterone for birth control, a dual energy X-ray absorbitometry scan was performed which demonstrated normal bone mineral density of her lumbar spine and femoral neck. She was managed conservatively with analgesia and physiotherapy, but continued to exercise against medical advice. She presented again six months later with severe right hip pain. MRI of her right hip demonstrated an incomplete stress fracture of her subtrochanteric region. Her symptoms resolved with strict rest and physiotherapy. CONCLUSION: HIIT may cause stress injury of the tibia and femur in young individuals.

Factores de Riesgo relacionados al Síndrome de Estrés Medial Tibial en Corredores Competitivos: Una Revisión Sistemática / Risk Factors related to Medial Tibial Stress Syndrome in Competitive Runners: A Systematic Review

Introducción. El síndrome de estrés tibial medial (SEMT) tiene una alta prevalencia entre corredores y genera un negativo impacto funcional. Un gran número de factores de riesgo se asocian con el desarrollo de SEMT, sin embargo, no existe claridad de cuales factores desencadenan la lesión en esta población. Objetivo. Identificar los factores de riesgo relacionados al SEMT en corredores sintetizando la información en una revisión sistemática. Métodos. Se realizó una búsqueda de estudios de cohorte y, casos y controles, en idioma inglés y español, en distintas bases de datos tales como Pubmed, EMBASE, EBSCO, SPORTDiscus, Scopus y Web of Science. Se incluyeron estudios con población de corredores de cross-country y track and field. Se analizaron factores de riesgo asociados a SEMT. Además, Se extrajeron datos como diseño y duración del estudio, definición del SEMT utilizada, características de la población y método diagnóstico. Se evaluó la calidad metodológica con el "NIH Quality Assessment Tool". Resultados. Cinco estudios y 43 factores de riesgo fueron analizados. 18 factores de riesgo presentaron una asociación significativa con SEMT. Los estudios tuvieron entre 64,3-85,7% de calidad metodológica. Los factores de riesgo más analizados fueron sexo, caída del navicular, índice de masa corporal, talla, peso, rango de dorsiflexión de tobillo y rotación de cadera en el plano transverso. Conclusión. Nuestra revisión no permitió determinar un factor de riesgo de SEMT, ya que los resultados entre los estudios fueron contradictorios o solo un estudio mostraba resultados significativos.

Background. Medial tibial stress syndrome (MTSS) has a high prevalence among runners and creates a major functional impact. A large number of risk factors are associated with the development of MTSS, which are not conclusive in this population. Objective: To identify the risk factors associated with MTSS in runners summarizing the gathered data through a systematic review. Methods. A search for cohort and case-control studies retrieved from different databases was conducted in English and Spanish. Studies with cross-country, track, and field runners were covered, in which risk factors associated with MTSS will be analyzed. The extracted data included: the design and duration of the study, the definition of MTSS currently used, the characteristics of the population, the analyzed risk factors, and the diagnostic method. The methodological quality was screened through the use of the "NIH Quality Assessment Tool". Results. Five studies and 43 risk factors were analyzed. Eighteen risk factors had a significant association with MTSS. The studies had a methodological quality of 64.3 -85.7%. The most analyzed risk factors were gender, navicular drop, body mass index, height, weight, range of ankle dorsiflexion and hip rotation in the transverse plane. Conclusion. Our review did not allow us to determine a risk factor for SEMT, since the results between the studies were contradictory or only one study showed significant results.

Medial Tibial Stress Syndrome: A Review Article.

Leg pain caused by recurrent stressors is known as shin pain, also known as the medial tibial stress syndrome (MTSS). Athletes, particularly runners, are more vulnerable. As a result, runners devote little time to practice and avoid exercises completely. The precise cause is yet to be identified. Microdamage caused by recurrent stressors has been proposed as the fundamental mechanism in other investigations. Gender, navicular bone loss, higher body mass index, activities of high intensity, and increased range in external hip rotation in males are all risk factors. A common complaint is a bilateral pain in the distal leg, primarily on the anterior and medial sides. Pain is exacerbated by activity and eased by relaxation. Particularly, pain and swelling in the posterior and medial aspects of the tibia, as well as other causative symptoms, may be discovered during the examination. To rule out alternate origins of the same symptoms, imaging modalities such as computed tomography, radiography, bone scintigraphy, and magnetic resonance imaging might be used. Preventative measures include shock-absorbing insoles, repetitive stress avoidance, and effective treatment of repetitive stress disorder and anatomical abnormalities. Rest, ice, and pain medications are the most common treatments.

Systematic Review of Patient-Reported Outcome Measures for Patients with Exercise-Induced Leg Pain.

Background and Objectives: To determine the most commonly used patient-reported outcome measures (PROMs) in exercise-induced leg pain (EILP) and to identify specific PROMs for EILP in order to evaluate their psychometric properties and methodological quality. Materials and Methods: A strategic search was performed in different databases to identify and extract the characteristics of studies based on the use of PROMs in patients with EILP. Specific PROMs were evaluated according to the Terwee et al. and COSMIN criteria. Results: Fifty-six studies were included in the review. The Medial Tibial Stress Syndrome Score (MTSSS), Lower Extremity Functional Scale (LEFS) and Exercise-Induced Leg Pain Questionnaire (EILP-Q) were identified as specific PROMs for EILP. The Visual Analog Scale (VAS) was the most widely used instrument in the assessment of EILP. The methodological quality assessment showed six positive values for the LEFS, four for the MTSSS and three for the EILP-Q for the eight psychometric properties analyzed according to the COSMIN criteria. The evaluation of the nine psychometric properties according to Terwee showed five positive values for the LEFS and MTSSS, and three for the EILP-Q. Conclusions: The overall methodological quality of the PROMs used was low. The VAS was the most widely used instrument in the assessment of EILP, and the LEFS was the highest quality PROM available for EILP, followed by the MTSSS and EILP-Q, respectively.

Effect of Compression Therapy in the Treatment of Tibial Stress Syndrome in Military Service Members.

CONTEXT: Tibial stress syndrome (TSS) is an overuse injury of the lower extremities. There is a high incidence rate of TSS among military recruits. Compression therapy is used to treat a wide array of musculoskeletal injuries. The purpose of this study was to investigate the use of compression therapy as a treatment for TSS in military service members. DESIGN: A parallel randomized study design was utilized. METHODS: Military members diagnosed with TSS were assigned to either a relative rest group or compression garment group. Both groups started the study with 2 weeks of lower extremity rest followed by a graduated running program during the next 6 weeks. The compression garment group additionally wore a shin splints compression wrap during the waking hours of the first 2 weeks and during activity only for the next 6 weeks. Feelings of pain, TSS symptoms, and the ability to run 2 miles pain free were assessed at baseline, 4 weeks, and 8 weeks into the study. RESULTS: Feelings of pain and TSS symptoms decreased during the 8-week study in both groups (P < .05), but these changes were not significantly different between groups (P > .05). The proportion of participants who were able to run 2 miles pain free was significantly different (P < .05) between the 2 groups at the 8-week time point with the compression garment group having a significantly increased ability to complete the run without pain. CONCLUSIONS: Although perceptions of pain at rest were not different between groups, the functional ability of running 2 miles pain free was significantly improved in the compression garment group. These findings suggest that there is a moderate benefit to using compression therapy as an adjunct treatment for TSS, promoting a return to training for military service members.

Association Between Intracompartmental Pressures in the Anterior Compartment of the Leg and Conservative Treatment Outcome for Exercise-Related Leg Pain in Military Service Members.

Objective: To explore the relationship between a single the intracompartmental pressure (ICP) value in the anterior compartment of the leg 1 minute after provocative exercise and the outcome of a conservative treatment program in a cohort of military service members with chronic exercise-related leg pain. Design: Retrospective cohort study. Setting: Department of military sports medicine at a secondary care facility. Participants: In the years 2015 through 2019, the conservative treatment program was completed by 231 service members with chronic exercise-related leg pain, of whom 108 patients with 200 affected legs met all inclusion criteria (N=108). Interventions: All patients completed a comprehensive conservative treatment program, consisting of 4-6 individual gait retraining sessions during a period of 6-12 weeks. In addition, patients received uniform homework assignments, emphasizing acquisition of the new running technique. Main Outcome Measures: The primary treatment outcome was return to active duty. The duration of treatment, occurrence of acute on chronic compartment syndrome, and patient-reported outcome measures were considered secondary treatment outcomes. Potential risk factors for the primary treatment outcome were identified with a generalized logistic mixed model. Results: Return to active duty was possible for 74 (69%) patients, whereas 34 (31%) needed further treatment. The multivariable analysis showed that the absolute values of ICP in the anterior compartment were not associated with the treatment outcome (odds ratio, 1.01; P=.64). A lower Single Assessment Numeric Evaluation score at intake was negatively associated with the potential to successfully return to active duty (odds ratio, 0.95; P=.01). No acute on chronic compartment syndromes were reported. Conclusions: A single postexercise ICP value in the anterior compartments of the lower leg of military service members with chronic exercise-related leg pain was not associated with the outcome of a secondary care conservative treatment program and can be safely postponed.

Recurrent Tibial Periostitis Due to Blunt Trauma.

Periostitis is characterized by periosteal inflammation surrounding tubular bones. The pathophysiology is now considered to be multifactorial and a spectrum of disorders, recently being redefined as medial tibial stress syndrome (MTSS). Current treatment modalities include preventative and conservative measures, such as activity modification and footwear alterations. There is a paucity of literature for more invasive treatments, such as steroid injections. In conflict with the currently available limited literature, this study reports a case of recurrent tibial periostitis due to blunt trauma treated with steroid injections resulting in symptom resolution and no adverse events. While this case may suggest a therapeutic role for steroids in the treatment of MTSS from blunt trauma, it also highlights the need for additional studies to elucidate the safety profile and therapeutic efficacy of steroid injections.

Clinical features of methotrexate osteopathy in rheumatic musculoskeletal disease: A systematic review.

BACKGROUND: There is growing evidence from case reports that methotrexate (MTX) therapy may impair bone metabolism in individual patients leading to low bone mass, atraumatic stress fractures and immobilizing bone pain - referred to as 'MTX osteopathy'. However, the clinical features, risk factors and treatment options of this condition are still elusive. METHODS: A systematic review was conducted according to PRISMA guidelines. Two databases (MEDLINE, Embase) were searched for published cases of MTX osteopathy in patients with rheumatic musculoskeletal diseases (RMD). Data from the included publications were extracted and descriptive statistical analysis was performed. RESULTS: We report data from 32 studies describing 80 adult RMD patients with stress fractures in MTX osteopathy. Most cases were found in elderly women with longstanding RMD, especially rheumatoid arthritis (72.5%). MTX osteopathy commonly presented as stress fracture of the distal tibia (51.3%), calcaneus (35.0%) and proximal tibia (27.5%), mimicking arthritis in some cases. Although a majority of the patients met the densitometric criteria for osteoporosis (58.1%), typical osteoporotic fractures (e.g., vertebral fractures) were rarely seen. Patients frequently suffered from bilateral (55.0%), multiple (71.3%) and recurrent fractures (25.0%). Fractures mainly occurred at low to moderate doses of MTX therapy (45.0%). It should be noted that half (48.8%) of the patients did not receive systemic steroid therapy for at least 3 years. CONCLUSIONS: Low-dose MTX therapy in RMD may result in atraumatic stress fractures of the lower extremity that can mimic arthritis. MTX osteopathy is characterized by a pathognomonic type of stress fractures with band- or meander-shaped appearance along the growth plate.

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.

Lower Leg Muscle Stiffness on Two-Dimensional Shear Wave Elastography in Subjects With Medial Tibial Stress Syndrome.

OBJECTIVES: We aimed to explore, which muscle stiffness changes may be related to medial tibial stress syndrome (MTSS) and the correlation between the medial tibial periosteal thickness and lower leg muscle stiffness. METHODS: This study included 63 subjects distributed into 3 groups: the symptomless group, the MTSS group, and the control group. The lower leg muscle stiffness of the tibialis anterior (TA), extensor digitorum longus (EDL), peroneus longus (PL), soleus (SOL), lateral gastrocnemius (LG), medial gastrocnemius (MG), tibialis posterior (TP), and flexor digitorum longus (FDL) in the 3 groups was obtained by two-dimensional shear wave elastography. Differences in the muscle stiffness and medial tibial periosteal thickness in the 3 groups were determined by one-way analysis of variance (ANOVA) and least significant difference tests. The relationships between the periosteal thickness and the muscle stiffness were assessed using Pearson correlations. RESULTS: The shear wave velocity (SWV) of all lower leg muscles except the EDL was higher in the symptomless and MTSS groups than in the control group (TA, P = .001; PL, P = .006; SOL, P < .001; LG, P < .001; MG, P < .001; TP, P < .001; FDL, P = .013; and ANOVA). A significant difference was found in the SWV of the SOL, TP, and FDL between the control and symptomless groups (P = .041, P < .001, and P = .013, respectively). Moreover, the medial tibial periosteum was thickened after running training, and its thickness was positively correlated with muscle stiffness. CONCLUSION: The medial tibia periosteal thickness is positively correlated with the lower leg muscles stiffness. Changes in SOL, TP, and FDL stiffness may be related to the occurrence of MTSS.

Conceptualisation of a region-based group of musculoskeletal pain conditions as 'tibial loading pain' and systematic review of effects of load-modifying interventions.

OBJECTIVES: Conceptualisation of a clinically-relevant group of conditions as a region-based, load-related musculoskeletal pain condition ('tibial loading pain') to enable identification of evidence of treatment effect from load-modifying interventions. DESIGN: Systematic review and evidence synthesis based on a developed and justified theoretical position. METHODS: Musculoskeletal pain localised to the tibial (shin) region and consistent with clinical presentations of an exercise/activity-related onset mechanism, was conceptualised as a group of conditions ('tibial loading pain') that could be reasoned to respond to load modifying interventions. Five databases were searched for randomized controlled studies investigating any load-modifying intervention for pain in the anterior-anteromedial lower leg (shin). Study quality was evaluated (Risk of Bias Tool Version 2) and level of certainty for the findings assessed. RESULTS: Six studies reporting seven comparisons were included. Interventions included braces, anti-pronation taping, compression stocking and a stretch + strengthening programme. All included studies were assessed as having unclear or high risk of bias. The review found no evidence of beneficial effect from any of the load-modifying interventions on symptoms, physical performance or biomechanical measures, apart from a possible benefit of anti-pronation 'kinesio' taping. There was very low certainty evidence that kinesio taping improves pain and pain-free hopping distance after one week. The braces were associated with minor adverse effects and problems with acceptability. CONCLUSIONS: None of the treatments investigated by the included studies can be recommended. Conceptualisation of the problem as regional, primarily loading-related pain rather than as multiple distinct pathoanatomically-based conditions, and clearer load-modifying hypotheses for interventions are recommended.