Comparison of optimized machine learning approach to the understanding of medial tibial stress syndrome in male military personnel.

PURPOSE: This study investigates the applicability of optimized machine learning (ML) approach for the prediction of Medial tibial stress syndrome (MTSS) using anatomic and anthropometric predictors. METHOD: To this end, 180 recruits were enrolled in a cross-sectional study of 30 MTSS (30.36 ± 4.80 years) and 150 normal (29.70 ± 3.81 years). Twenty-five predictors/features, including demographic, anatomic, and anthropometric variables, were selected as risk factors. Bayesian optimization method was used to evaluate the most applicable machine learning algorithm with tuned hyperparameters on the training data. Three experiments were performed to handle the imbalances in the data set. The validation criteria were accuracy, sensitivity, and specificity. RESULTS: The highest performance (even 100%) was observed for the Ensemble and SVM classification models while using at least 6 and 10 most important predictors in undersampling and oversampling experiments, respectively. In the no-resampling experiment, the best performance (accuracy = 88.89%, sensitivity = 66.67%, specificity = 95.24%, and AUC = 0.8571) was achieved for the Naive Bayes classifier with the 12 most important features. CONCLUSION: The Naive Bayes, Ensemble, and SVM methods could be the primary choices to apply the machine learning approach in MTSS risk prediction. These predictive methods, alongside the eight common proposed predictors, might help to more accurately calculate the individual risk of developing MTSS at the point of care.

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.

The prevalence and effect of the sites of pain in female soccer players with medial shin pain.

BACKGROUND: Female soccer players are often diagnosed with medial shin pain, which includes tibial stress fracture, medial tibial stress syndrome, and chronic exertional compartment syndrome. As the possibility of varied sites of pain affecting sports activities has not been fully researched, an urgent discussion and evidence is required. This study investigates the prevalence and effect of sites of pain on the sports activities of female soccer players with medial shin pain. METHODS: A questionnaire survey was conducted for 196 female soccer players with medial shin pain to assess symptom duration, the effect of practice and performance, and sites of pain. The players were classified into three conditions (tibial stress fracture, medial tibial stress syndrome, or medial shin pain with neurological symptoms) and compared based on sites of pain. RESULTS: We observed that medial tibial stress syndrome had a lower impact on performance compared to that of tibial stress fracture and medial shin pain with neurological symptoms. While participants with tibial stress fracture had to suspend practice sessions more frequently, the difference in symptom duration between the classified groups was not statistically significant. The effect of sites of pain on sports activities was not significantly different in participants with medial tibial stress syndrome. CONCLUSIONS: Medial shin pain should be evaluated carefully to differentiate between medial tibial stress syndrome and medial shin pain with neurological symptoms. Restriction of sports activities may help improve the patient's condition early, regardless of the presentation.

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.

An Elastic Foot Orthosis for Limiting the Increase of Shear Modulus of Lower Leg Muscles after a Running Task: A Randomized Crossover Trial.

BACKGROUND: Excessive foot pronation may be attributed to an increasing burden on leg muscles during running, which might be a factor in medial tibial stress syndrome. We developed an elastic foot orthosis (EFO) that can decrease foot pronation and aimed to identify whether this orthosis could limit the increase in lower leg muscle hardness after running. METHODS: Twenty-one healthy volunteers participated in this randomized crossover trial with an elastic or sham foot orthosis (SFO). All volunteers ran on a treadmill for 60 min while wearing either orthosis. Muscle hardness of the posterior lower leg was assessed using shear wave elastography before and after running. The Wilcoxon signed rank test was used to compare muscle hardness between the two orthotic conditions. RESULTS: No significant differences were observed between the two orthotic conditions before running (p > 0.05). After running, the flexor digitorum longus (FDL) hardness in the EFO group was significantly lower than that in the SFO group (p < 0.01). No significant changes were observed in the other muscles. CONCLUSION: The results suggest that the EFO can restrict the increase in FDL hardness with running. The EFO may be an effective orthotic treatment for medial tibial stress syndrome.

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.

Difference in the foot intersegmental coordination pattern between female lacrosse players with and without a history of medial Tibial stress syndrome; a cross-sectional study.

BACKGROUND: Medial tibial stress syndrome is a common sports related injury. Altered foot kinematics can be a risk factor for the injury. Since foot segments can move independently, intersegment coordination is important for proper foot function. This study aimed to compare the foot intersegmental coordination pattern and single segment kinematics between female lacrosse players with and without a history of medial tibial stress syndrome during drop jump. METHODS: Twelve players with a medial tibial stress syndrome history and 12 players with no history were enrolled. Foot kinematics, including angle at landing and peak angle and excursion at the rearfoot, midfoot, and forefoot during single-leg drop jumps were analysed. Each segment motion data from landing to leaping was time-scaled to 100% to analyse the intersegmental coordination with a modified vector coding technique. Instant intersegmental coordination of every 1% was classified into four patterns (in-phase, two segments rotate in the same direction with similar amplitudes; anti-phase, two segments rotate in opposite directions; proximal phase, proximal segment dominantly rotates in the same direction compared to the distal segment; and distal phase, distal segment dominantly rotates in the same direction compared to the proximal segment). The percentage of intersegmental coordination pattern and kinematics in each segment were compared between the groups using the Student's t test. RESULTS: Groups with a history of medial stress syndrome showed a significantly higher percentage of proximal phase between the rearfoot and midfoot in the sagittal (Mean ± SD; history, 52.2 ± 17.9%, no history, 29.3 ± 16.7%; p = 0.004) and coronal planes (history, 40.3 ± 22.0%, no history, 15.9 ± 9.1%; p = 0.004). Dorsiflexion excursion (history, 34.5 ± 4.5°, no history, 29.6 ± 2.1°; p = 0.003) were significantly larger in a history of medial tibial stress syndrome group compared to no history group. CONCLUSIONS: Rearfoot dominant motion pattern relative to the midfoot may be related to medial tibial stress syndrome. Intersegmental coordination analysis may be useful for detecting abnormal foot coordination patterns. Also, stabilization for the rearfoot may be required rather than the midfoot for intervention.

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.

Distance travelled by military recruits during basic training is a significant risk factor for lower limb overuse injury.

INTRODUCTION: Military initial training results in a high incidence of lower limb overuse injuries (stress fractures and medial tibial stress syndrome). This study aimed to determine whether the distance travelled by recruits, both on and off duty, was a risk factor for overuse injury. METHODS: 14 male airborne infantry recruits from three training platoons carried global positioning system receivers throughout the first 19 weeks of basic military training. Total distance travelled each day was recorded. This was compared with time of clinical manifestation of 52 lower limb overuse injuries (stress fractures and medial tibial stress syndrome) collected from the 276 airborne infantry recruits in the period immediately preceding the study. RESULTS: Recruits travelled significantly farther than the UK average male population in 17 of 18 measured weeks. Pearson correlation between distance travelled per week and injuries was not significant (p=0.4448); however, correlation between distance travelled per week and injuries two weeks later was significant (p=0.0263). A generalised linear model found distance travelled as a significant covariate (p=0.0144) to the expected number of injuries two weeks later. CONCLUSION: Recruits travel long distances during basic training, particularly in the first few weeks when they are not yet conditioned. This distance travelled is likely a contributing risk factor to the high incidence of overuse injuries seen during training, and strategies to reduce this distance should be explored.

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.

Efficacy of kinesiology taping on the management of shin splints: a systematic review.

BACKGROUND: Shin splint is one of the most common sports injuries after strenuous exercise. Kinesiology taping (KT) is a popular noninvasive remedy used in sports-related disorders, with the potential effects of relieving pain, facilitating proprioception, modulating muscle activation and correcting abnormal movement patterns. However, the exact efficacy of KT on shin splints is still unknown, and previous findings are inconsistent. Hence, this study aimed to conduct a systematic review to evaluate the current status of relevant evidence on its efficacy. METHODS: The review was performed according to the PRISMA guidelines, and a systematic search of the literature was conducted in December 2020. Electronic databases, Embase, Scopus, Medline, Web of Science, PubMed and Biomed Central were searched for the identification of pertinent studies with pre-defined key terms on shin splints and KT. RESULTS: Four studies with a total sample size of 141 participants were included and analyzed. Two studies had within-subject designs, whereas the other two were randomized clinical trials. Although the positive results of KT were reported by the studies, methodological quality varied from poor to moderate according to the Physiotherapy Evidence Database Scale or Non-Randomized Studies-of Interventions. CONCLUSION: In conclusion, this review revealed that the efficacy of KT on shin splints remains not clear. Evidence that supports its effectiveness in individuals with shin splints is currently limited. Further studies with good methodological quality and study design are warranted.

Foot Orthoses Enhance the Effectiveness of Exercise, Shockwave, and Ice Therapy in the Management of Medial Tibial Stress Syndrome.

OBJECTIVE: Our aim was to assess the effects of adding arch-support foot-orthoses (ASFO) to a multimodal therapeutic intervention on the perception of pain and improvement of recovery from medial tibial stress syndrome (MTSS) in recreational runners. DESIGN: A prospective randomized controlled trial. SETTING: Sport training and medical centers. PARTICIPANTS: Fifty female recreational runners with MTSS were randomized into 2 groups. INTERVENTIONS: Runners either received ASFO or sham flat noncontoured orthoses. Both groups received a multimodal therapeutic intervention, including ice massage, ankle muscle exercises, and extracorporeal shockwave therapy. MAIN OUTCOME MEASURES: Pain during bone pressure using a numerical Likert scale (0-10), MTSS severity using an MTSS scale, perceived treatment effect using the global rating of change scale, and quality of life using the short Form-36 questionnaire were determined at week 6, 12, and 18. RESULTS: Pain intensity and MTSS severity were lower, and the perceived treatment effect and physical function were better in the ASFO than in the sham flat noncontoured orthoses group at week 6 and week 12. Cohen's dz effect size for between-group differences showed a medium difference. However, arch-support foot-orthoses did not add to the benefits of multimodal therapeutic intervention on pain, MTSS severity and perceived treatment effect at week 18. CONCLUSIONS: Adding ASFO to a therapeutic intervention leads to an earlier diminishment of pain and MTSS severity, and improved PF and perceived therapeutic effects.

Lower leg muscle structure and function are altered in long-distance runners with medial tibial stress syndrome: a case control study.

BACKGROUND: Medial tibial stress syndrome (MTSS) is a common lower leg injury experienced by runners. Although numerous risk factors are reported in the literature, many are non-modifiable and management of the injury remains difficult. Lower leg muscle structure and function are modifiable characteristics that influence tibial loading during foot-ground contact. Therefore, this study aimed to determine whether long-distance runners with MTSS displayed differences in in vivo lower leg muscle structure and function than matched asymptomatic runners. METHODS: Lower leg structure was assessed using ultrasound and a measure of lower leg circumference to quantify muscle cross-sectional area, thickness and lean lower leg girth. Lower leg function was assessed using a hand-held dynamometer to quantify maximal voluntary isometric contraction strength and a single leg heel raise protocol was used to measure ankle plantar flexor endurance. Outcome variables were compared between the limbs of long-distance runners suffering MTSS (n = 20) and matched asymptomatic controls (n = 20). Means, standard deviations, 95 % confidence intervals, mean differences and Cohen's d values were calculated for each variable for the MTSS symptomatic and control limbs. RESULTS: MTSS symptomatic limbs displayed a significantly smaller flexor hallucis longus cross-sectional area, a smaller soleus thickness but a larger lateral gastrocnemius thickness than the control limbs. However, there was no statistical difference in lean lower leg girth. Compared to the matched control limbs, MTSS symptomatic limbs displayed deficits in maximal voluntary isometric contraction strength of the flexor hallucis longus, soleus, tibialis anterior and peroneal muscles, and reduced ankle plantar flexor endurance capacity. CONCLUSIONS: Differences in lower leg muscle structure and function likely render MTSS symptomatic individuals less able to withstand the negative tibial bending moment generated during midstance, potentially contributing to the development of MTSS. The clinical implications of these findings suggest that rehabilitation protocols for MTSS symptomatic individuals should aim to improve strength of the flexor hallucis longus, soleus, tibialis anterior and peroneal muscles along with ankle plantar flexor endurance. However, the cross-sectional study design prevents us determining whether between group differences were a cause or effect of MTSS. Therefore, future prospective studies are required to substantiate the study findings.

Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries.

ABSTRACT: Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

Biomechanical analysis of two runners who developed leg injuries during a six-week transition to maximal running shoes: A case series.

Achilles tendinopathy (AT) and medial tibial stress syndrome (MTSS) are two of the most common running-related injuries. In a previous study investigating running biomechanics before and after a six-week transition to maximal running shoes, two runners dropped out of this study due to Achilles pain and shin pain, respectively. The purpose of this case series was to investigate running biomechanics in those two runners, identifying potential causes for injury in relation to maximal shoe use. Running biomechanics were collected in a laboratory setting for these two runners wearing both a maximal running shoe and traditional running shoe before the six-week transition using an 8-camera motion capture system and two embedded force plates. Both runners displayed prolonged eversion in the maximal shoe, which has been previously cited as a potential risk factor for developing Achilles tendinopathy and medial tibial stress syndrome. Relatively high loading rates and impact forces were also observed in the runner with shin pain in the maximal shoe, which may have contributed to their pain. More prospective research on injury rates in individuals running in maximal shoes is needed.

The effectiveness of PROLOTHERAPY for recalcitrant Medial TIBIAL Stress Syndrome: a prospective consecutive CASE series.

BACKGROUND: Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option. OBJECTIVE: To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport. METHOD: The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment. INTERVENTION: An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area. MAIN OUTCOME MEASURES: Pain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman's non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods. RESULTS: Patients reported a significant (p < 0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as 'much improved' at medium-term follow-up and the median return to sports score was 'returned to desired but not pre-injury level' at medium-term and long-term follow-up. No adverse events were reported. CONCLUSIONS: Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls. CLINICAL RELEVANCE: Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.

The Protective Effect of Neuromuscular Training on the Medial Tibial Stress Syndrome in Youth Female Track-and-Field Athletes: A Clinical Trial and Cohort Study.

CONTEXT: Few reports have analyzed the effects of neuromuscular (NM) training programs on the injury incidence among youth female track-and-field athletes. OBJECTIVE: To determine the effects of NM training on reducing lower limb injury incidence and to establish its effects on countermovement jump performance, balance, 30-m sprint, and joint position sense in youth female track-and-field athletes. DESIGN: Single-blind, randomized controlled clinical trial. SETTING: Sports research laboratory. PARTICIPANTS: Twenty-two female athletes were allocated into 2 groups: Conventional (CONV) training (n = 11; age = 15.3 [2.1] y) and NM training (n = 11; age = 15.0 [2.7] y). INTERVENTIONS: Interventions were performed during the preseason of 6 weeks. The CONV training included anaerobic, strength, and aerobic training. The NM training consisted of a multicomponent program that integrated jumps, landings, and running with strength, endurance, agility, balance, and CORE training. MAIN OUTCOME MEASURES: A follow-up of the cohorts was carried out through the evaluation of lower limb injuries (main outcome) during a regular season (weeks 7-18). Secondary outcomes were measured before and after the intervention: Y-balance test, active joint repositioning, ground reaction force, and countermovement jump height. RESULTS: The injury incidence rate was 17.89 injuries per 1000 hours athlete-exposure in CONV training, and 6.58 in NM training (relative risk = 0.38; 95% confidence interval,  0.18 to 0.82; P = .044). Particularly, the medial tibial stress syndrome incidence rate was 5.96 injuries per 1000 hours athlete-exposure in CONV training and 0.82 in NM training (relative risk = 0.17; 95% confidence interval, 0.02 to 1.12; P = .012). In addition, a significant training × time interaction was noted, favoring improvements in 30-m sprint and countermovement jump height after NM. CONCLUSION: The NM training may improve youth female athlete's physical fitness and reduce their injury relative risk of medial tibial stress syndrome injury.

Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in athletes.

PURPOSE: Medial tibial stress syndrome (MTSS) represents a common diagnosis in individuals exposed to repetitive high-stress loads affecting the lower limb, e.g., high-performance athletes. However, the diagnostic approach and therapeutic regimens are not well established. METHODS: Nine patients, diagnosed as MTSS, were analyzed by a comprehensive skeletal analysis including laboratory bone turnover parameters, dual-energy X-Ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT). RESULTS: In 4/9 patients, bilateral pseudofractures were detected in the mid-shaft tibia. These patients had significantly lower levels of 25-hydroxycholecalciferol compared to patients with MTSS but similar levels of bone turnover parameters. Interestingly, the skeletal assessment revealed significantly higher bone mineral density (BMD) Z-scores at the hip (1.3 ± 0.6 vs. - 0.7 ± 0.5, p = 0.013) in patients with pseudofractures and a trend towards higher bone microarchitecture parameters measured by HR-pQCT at the distal tibia. Vitamin D supplementation restored the calcium-homeostasis in all patients. Combined with weight-bearing as tolerated, pseudofractures healed in all patients and return to competition was achieved. CONCLUSION: In conclusion, deficient vitamin D levels may lead to pseudofractures due to localized deterioration of mineralization, representing a pivotal component of MTSS in athletes with increased repetitive mechanical loading of the lower limbs. Moreover, the manifestation of pseudofractures is not a consequence of an altered BMD nor microarchitecture but appears in patients with exercise-induced BMD increase in combination with reduced 25-OH-D levels. The screening of MTSS patients for pseudofractures is crucial for the initiation of an appropriate treatment such as vitamin D supplementation to prevent a prolonged course of healing or recurrence. LEVEL OF EVIDENCE: III.

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.