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Medial tibial stress syndrome

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Apr 1, 2006.

  1. Romeu:

    If she does have medial tibial stress syndrome (MTSS), then the pain should improve with increased varus support in the orthosis. However, MTSS doesn't normally present with lower leg edema and doesn't normally respond much to compression hose. Where exactly is she most tender or experience the most symptoms in the leg? Unless one knows the exact anatomical structure involved, it is very difficult to make a diagnosis without more information.
     
  2. Romeu Araujo

    Romeu Araujo Active Member

    Hi Kevin,

    Thanks for your reply.

    When I referred edema I meant a small one, inflammatory. However, she spoked about a larger edema when that happened – I believe it may have been significant because the physician that saw her initial suspected of an allergic reaction. Then discarded it and sent her to the vascular surgeon. The physiotherapist sent her to me.
    Has been a few weeks since then and he traveled abroad- he’ll be back next week– I’ll try to speak with him then to get more information.

    But let’s go back to what I’ve seen and done:

    Both anterior and posterior tibialis muscle and fascia hurt in palpation and also the whole medial/anterior quadrant.

    The pain did really improved with increased varus support in the orthosis. She now can work all day with an occasional discomfort. But, for me, it’s not enough… 3 weeks have passed and the situation seems to be steady…

    I forgot to tell an important fact. It happened a day after a 30 km walk (a usual walk for her) in the woods.

    Best regards,
     
  3. Romeu:

    It sounds like she is getting better. You could try putting her into a hiking boot for her long walks with the orthoses since this may help stabilize the ankle and further relieve some of her discomfort. Her work activities sound fairly vigorous also so you may ask her about whether she feels something she is doing at work is injuring her also.

    Did you use a medial heel skive or other varus heel cup wedging technique in the orthosis? Additional varus heel cup support will further decrease the internal stress on the posterior tibial muscle and anterior tibial muscle.

    In addition, in cases like these, even though the orthosis seems to fit the foot well in the medial longitudinal arch (MLA), possibly she is deforming the MLA of the orthosis excessively in the shoe when walking. I will often take adhesive felt and fill the plantar MLA of the orthosis plate to increase the MLA stiffness and see if this makes the patient less symptomatic. The combination of a higher/stiffer MLA and medial heel skive often makes the difference in these patients between some pain and no pain.

    One other thing, in these more difficult cases I like to do a test where I will take the orthoses out of the shoes and have the patient stand on the devices then walk forward over the orthosis to evaluate how much the orthosis MLA deforms under simulated walking. For example, if I am interested in the left foot, I will have them stand their left foot on top of the left orthosis, then with their right foot first behind their left foot, have them step forward with their right foot to see how the left orthosis deforms under weightbearing loads from the left foot. This may give you valuable additional insight into how your orthosis design is helping to limit the abnormal moments/motion that are causing your patient's painful pathology.

    Hope this helps. Have a nice weekend.
     
  4. Romeu Araujo

    Romeu Araujo Active Member

    Kevin,

    Yes I did and she feels fine with the orthotics – just a modest pain at the end of a hard working day. It’s just I’ve never seen such an exuberant MTSS and it’s not evolving as fast as I want… Maybe I’m being too demanding...

    Thanks for the hint.

    I’ll evaluate with more detail though, initially, I’ve already “reinforced” the plantar MLA of the orthosis plate to increase the MLA stiffness.

    Regards,
     
  5. CraigT

    CraigT Well-Known Member

    Has compartment syndrome been ruled out??
    This type of pain which responds positively, but only partially is one thing i find with this.
    The only thing that I would not be sure of in this case would be the positive effect from the compression socks.
    I would probably like to see the results of a compartment pressure test.
     
  6. Romeu Araujo

    Romeu Araujo Active Member

    Craig T,

    I ruled out Compartment Syndrome due to the clinical presentation.
    Does not present “pain resulting from an exercise-induced compartment syndrome is usually described as a deep ache in the muscle area, rather than near the bone. Over time, the symptoms may progress to numbness and muscle weakness. The pain will usually subside after discontinuing the activity.”

    Regards,
     
  7. CraigT

    CraigT Well-Known Member

    A wise Sports Physician once said to me 'an unusual presentaiton of a common problem is more likely than an unusual problem'.
    What you have described is indeed classical compartment pain. However I have seen many cases which do not have these classical symptoms. Often the pain is diffuse and not as intense as this description... particularly if it is low grade.
    The other confounding thing is that you may have both a periostitis combined with compartment pressure- you get a good response from the periostitis, but the compartment sysmptoms persist.
    The other thing i find with MTSS is often you simply need some time to rest. You can manage them perfectly, but there is inevitable load through this area of the leg. In an irritated condition, this can be enough to prevent full resolution. Often these patients will be very happy with their orthoses, but their pain persists.
    Is she still having Physio?? If not, this may be much more effective now that you have taken care of one of the major causes. Anti inflammatories also may be useful.
     
  8. Ella Hurrell

    Ella Hurrell Active Member

    I have just been reading through Romeu's postings and I have to agree with Craig - I too wondered about compartment syndrome. I have seen one or two patients that have had similar symptoms that have turned out to be compartment syndrome rather than MTSS. I would see if some pressure studies could be done?

    Ella
     
    Last edited: Apr 23, 2008
  9. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Medial tibial stress syndrome: evidence-based prevention.
    Craig DI.
    J Athl Train. 2008 May-Jun;43(3):316-8.
     
  10. admin

    admin Administrator Staff Member

    Contributing Factors to Medial Tibial Stress Syndrome: A Prospective Investigation.
    Hubbard TJ, Carpenter EM, Cordova ML.
    Med Sci Sports Exerc. 2009 Feb 6. [Epub ahead of print]
     
  11. Jaimee Brent

    Jaimee Brent Active Member

    I was wondering if anyone has had a patient that presents with MTSS yet isnt associated with running or jumping activities?

    From the possible aetiology of "Bone Bending" and the fact that pain often presents at the most slender point of the diaphysis could ppl with decreased bone integrity/structure (ie osteoporosis/osteomalacia) actually be diagnosed with MTSS?

    Furthermore, could increasing muscular support around these areas decrease pain?

    and can MTSS predispose to stress fractures?

    Any thoughts would be great

    Jaimee
     
  12. matthew malone

    matthew malone Active Member

    can MTSS predispose to stress fractures?

    Jaimee MTSS is a condition that exists on a continuum of sorts that can starting with normal remodelling of bone and ending with a stress reaction / fracture. MTSS is somewhere in the middle. A good source of info is clinical sports medicine book by Bruckner and Khan. So in theory and clinically those who may present with early periostitis can progress further.

    Furthermore, could increasing muscular support around these areas decrease pain?

    Dysfunction to the lower limb muscles of the leg has been highlighted as playing a role in MTSS (Burnet et al, 2004; Clement, 1974). Devas (1958) demonstrated that contraction of the Triceps Surae can cause the tibia to bow. Lanyon et al (1975) expanded on this as he suggested an overly strong Triceps Surae muscle may contribute to tibial bending. Indeed Ghelsen and Segar (1980) also observed greater plantar flexion strength in individuals with MTSS compared to controls. A reduction in dorsiflexion at the ankle joint has also been associated with tibial stress fractures and MTSS (Andrish, 1974; Fredericson, 1996; Rasmussen, 1974). If this is applied to the bowstring theory then muscles who’s length reduces the amount of dorsiflexion at the ankle, will relate bending loads onto the tibia (Beck, 1998).

    Treatment could therefore be aimed at stretching exercises for the Gastrocnemius / Soleus complex, according to Beck (1998) this should be commenced prior to starting an exercise programme. He went to state that once a tibial stress injury had occurred then no stretching exercises should be done. The reason behind this as Beck suggests is because stretching of the Triceps Surae does impart cause a tibial bowing, which will increase tibial strain.

    However..
    Andrish (1974) assessed a stretching exercise programme for ‘shin splints’ in 2777 naval recruits. The study found no statistical evidence to suggest stretching improved the symptoms of ‘shin splints’, infact the incidence of shin splints occurred higher in those recruits who were doing stretching exercises as compared to the control group. Currently no new studies in the past 5 years has looked at stretching exercises and MTSS!!

    In contrast to this Clement (1974) proposed a treatment plan consisting of modifying training methods as well as utilising isometric muscle rehabilitation in order to reduce tibial stress and improve muscular strength and endurance to the anterior tibial and Gastrocnemius group. Clement reported that both the Tibialis Anterior and Gastrocnemius muscles of 6 athletes with MTSS were thinner in circumference of up to 1.46cm in the symptomatic legs. They devised a structured treatment plan for 12 athletes, with Phase II of the treatment plan involving isometric and isokinetic exercises.
     

    Attached Files:

  13. matthew malone

    matthew malone Active Member

    stress model
     
  14. Jaimee Brent

    Jaimee Brent Active Member

    Thankyou

    thats about what i thought. So if MTSS is a say mid-way sign in a stress continueum this would more likely relate to a stress fracture occurance and not typically an insufficiency fracture in someone who is not as active. (Assuming that stress and insuffieciency fractures are of different aetiologies).

    However, wouldnt someone with insuffieiency have decreased bone density and therefore even less resistance to tibial bowing? which could again present as MTSS like symptoms under normal stress and strain?
     
  15. matthew malone

    matthew malone Active Member

    So if MTSS is a say mid-way sign in a stress continueum this would more likely relate to a stress fracture occurance and not typically an insufficiency fracture?

    NO, because a stress reaction only tells you that a stress has been placed on a specific bone which in turn has responded to this i.e the periostitis formation seen with MTSS. Stress reaction and fracture are completely different.

    However, wouldnt someone with insuffieiency have decreased bone density and therefore even less resistance to tibial bowing?
    Yes

    which could again present as MTSS like symptoms under normal stress and strain?

    YEs and NO. People with decreased BMD are obviously more prone to fractures, breaks etc.. but in the majority of cases the mechanism of injury is completely different. Take an old women who has a mild fall, low and behold she sustains a fracture due to osteoporosis. Take away the history of osteoporosis and mechanism of injury and IN CERTAIN SITUATIONS (not a fall more low grade stuff like prolonged walking etc) then yes your symptoms may mimic MTSS, but add both these factors together and your clinical alarm bells should differentiate.

    the above type of injury wouldnt occur in a fit athlete as the energy input from the fall would have to be a lot higher. MTSS involves a process of normal / abnormal remodelling of bone. They done not get a reduced BMD, When a person begins to embark upon exercise the bone undergoes metabolic changes. Initially in the tibia; bone porosity occurs due to osteoclastic activity on the posteriomedial border. New bone formation then occurs in order to resist the compressive forces of exercise and to strengthen the bone (Anderson and Greenspan, 1996). There is evidence the affected area of the tibia is 15% more porous then in control groups and 23% more porous in athletic subjects (Magnusson et al, 2001). Porosity is different from bone mineral density!

    It has been postulated that bone in athletes especially those who participate in running or jumping sports do not remodel at a fast enough rate to adapt to the changes induced by mechanical loading, and as such possibly progress to a stress related injury / fracture (Beck, 1998). The important thing to note though is the mechanism of injury and underlying pathology that is different in people with MTSS then those people who are prone to fracture because the overall composition of the bone is severly reduced (osteoporosis). I hope it makes sense.

    Matt
     
  16. Jaimee and Matthew:

    Nearly all cases of medial tibial stress syndrome (MTSS) occur in running and jumping athletes. I have seen only two cases of individuals that developed MTSS with no history or running or jumping activities in my 25 years of clinical experience, so these cases do occur, but are rare. MTSS is 6-10 times more common in females than males, and in runners, accounts for between 13-17% of all injuries. Currently, I am treating approximately 10 runners with MTSS in my practice.

    The two current competing theories of how MTSS occurs is either as a soft tissue traction injury where either the soleus fascia or attachments of the posterior tibial or flexor digitorum longus muscles are "pulling away" from the medial border of the tibia or as a bone bending injury where the valgus bending moment on the tibia causes sufficient bending strain on the medial tibial border to cause bone injury and pain.

    I gave quite a fairly comprehensive lecture on MTSS about four years ago at the 2005 Australian Conference of Science and Medicine in Sport in Melbourne in which I described my belief that MTSS is probably more likely a bone bending injury but could also be caused by pulling of soft tissue on the medial tibial border. Certainly, there is good clinical evidence that MTSS may lead to medial tibial stress fracture (MTSF) so that there is a bone stress reaction continuum that occurs from MTSS to MTSF. The MRI study by Fredricson et al is one of the most impressive on the subject and certainly supports the idea that MTSS is a precursor to MTSF (Fredericson M, Bergman AG, Hoffman KL, Dillingham MS: Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system, Am J Sports Med, 23:472-481, 1995).

    In my 2005 Melbourne lecture, and in my latest book (Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 141-150), I offered the theory that MTSS is most commonly caused by eccentric loading forces occuring at the tibial shaft and the resultant increase in valgus tibial bending moment due to increased lateral location of the loading forces on the forefoot during running and jumping. If the loading of the forefoot is lateral enough, the intensity of exercise is great enough, the bone is weak enough, the area moment of inertia of the tibia is small enough, then MTSS or MTSF will likely occur.

    In my book and in an article I will be writing for Podiatry Today magazine in the coming months, I will describe how adding fairly large varus rearfoot and forefoot wedging to the orthoses of these athletes has given the best clinical results in the treatment of MTSS. Basically, the idea with the foot orthoses is to try to bring the relatively large magnitudes of the ground reaction force vector that occurs during the initial 50% of the stance phase of running and jumping into being more in line with the long axis of the shaft of the tibia, rather than lateral to the long axis of the tibial shaft and causing excessive loading of the tibia and, in turn, excessive valgus bending moment on the tibia. The varus forefoot wedges may need to be as high as 10 mm in thickness under the first metatarsal head (skiving down to no thickness under the 5th metatarsal head) in order to allow the runners to train and race without pain. Obviously, these orthoses are not used during walking activities, only with running.

    Good discussion.:drinks
     
  17. Griff

    Griff Moderator

    Hope you don't mind Kevin but thought I'd upload a few of your pics which massively helped me understand the theory you describe above (mainly for the benefit of those who haven't bagged themselves a copy of your book yet). I scanned these from your book for a presentation I gave to some Physiotherapists - referencing you fully of course ;)

    First pic showing loading forces acting away from central axis causing bending moment on structure with consequent compression and tension stresses.

    Second pic showing the action of the orthoses you describe.

    Once again can't thank you enough for your teachings on this Kevin.

    Ian.
     
  18. Ian:

    My wife keeps telling me that I need to put my initials on all my drawings since I see them used in lots of other people's lectures. I guess I should do that...one of these days...problem is I have done over 1,000 drawings with CorelDraw over the past 20 years and that would be a whole lot of work.

    I'm happy to share these, and my other drawings, with you and others that are using them to help advance the knowledge of others. That is why I spend so much of my time doing them. Thank you for referencing me for my illustrations since many who use my drawings for their lectures do so.

    Drawing was always something that I enjoyed doing and was fairly easy for me as a child and teenager. However, it helped being around some very talented people to compete with in my art classes during my teen years. My best friend in junior high, and high school, David Marek, is now the Chief Designer for Honda Research and Development. In addition to many other things that Dave and I did, Dave and I did a lot of drawing together in our early teen years. Dave has been designing vehicles for Honda for the past 22 years and has been drawing cars and customizing car models ever since I first met him in 1969. How many 13 year olds do you know that could draw any car from any year from memory? Amazing talent!!
     
  19. matthew malone

    matthew malone Active Member

    Thanks for chipping in Kevin, Ian.

    I look forward to reading your article in coming months on foot orthosis treatment in MTSS patients. I think this is a massive area still (amongst others) where there is very little evidence on the use of orthosis in MTSS. It will be very interesting to see a new current approach.

    old studies on orthosis for MTSS:

    Schwellnus, Jordan and Noakes (1990) conducted a RCT amongst 1748 South African military recruits during a 9 week training period. 237 participants were elected to receive Orthoses and 1511 in the control group. Neoprene impregnated flat insoles were given to the experimental group to be worn with standard shoes. The study found that the rate of injury amongst the control group with no Orthoses was higher (31.9%) compared to the experimental group with shock absorbing insoles. In the control group 20.4% of participants reported MTSS whilst this number was only 12.8% in the experimental group. The critical finding from the study was that shock absorbing insoles can help prevent injuries and in particular tibial stress syndrome.

    Andrish, Bergfoeld and Walheim (1974) undertook a RCT looking at the effect of 5 differing treatments on ‘shin splints’. They assessed the effectiveness of heel pads in preventing ‘shin splints’ in naval recruits. There outcome highlighted that heel pads were not found to be a preventative measure or useful in naval recruits who had developed ‘shin splints’, in fact a higher incidence was found in those recruits wearing heel pads (4.36) to the control group (2.96).

    Ekenma et al (2002) assessed the use of functional foot Orthoses in reducing / preventing tibial stress fractures / strains. The study used subjects who were part of the Swedish Special Forces. The participants were asked to run and walk in both military boots and running trainers on a treadmill. This study showed that the use of biomechanical foot Orthoses used in running shoes and military boots did not significantly change tibial stress. This study was based with a very low sample of only 9 people which in part is not a big enough sample to reflect the true population, however they did standardize the running shoes to ensure every participant wore exactly the same brand of trainers.

    In conclusion- would you expect a gel heel pad or soft flat bed of neoprene to improve MTSS Symptoms??

    Kevin i look forward to your paper.

    Matt
     
  20. Matt:

    Thanks for your excellent post. The paper I will be writing on MTSS in the near future will contain much of the same information I have already published in my newsletters from 3 years ago on MTSS which is now available in my third book (Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009). The only thing that has changed is that there has been some new research in the last few years and I have become even more convinced that MTSS is a bone bending injury rather than a soft tissue traction injury in the majority of cases. In addition, in regards to MTSS being a "periostitis", there is actually evidence that MTSS is not a periosititis since Johnell et al found evidence of periostitis in only 1 of 33 soft tissue biopsies in patients with MTSS (Johnell O, Rausing A, Wendeberg B, Westlin N: Morphological bone changes in shin splints. Clin Ortho Rel Res, 167:180-184, 1982) and Detmer showed no evidence of periostitis in 10 patients that had fasciotomy for MTSS (Detmer DE: Chronic shin splints: Classification and management of medial tibial stress syndrome. Am J Sp Med, 3:436-446, 1986).
     
  21. Peter1234

    Peter1234 Active Member

    Stanley, I think you would be very interested in the MRI study and histology studies I listed in my lecture since both seem to point to MTSS being a possible precursor or early stage of MTSF. Fascinating stuff![/QUOTE]

    Kevin,
    Very interesting discussion, thank you for sharing your immense knowledge on this subject. Could you please provide a link for the lectures that you refer to?
     
  22. Peter:

    Look at post #3 in this thread. This contains the text from the PowerPoint lecture I gave at the Australian Sports Medicine Conference in Melbourne from a few years ago.
     
  23. Peter1234

    Peter1234 Active Member

    Thanks Kevin,
    am I right in thinking that MTSS occurs partly as a result of 'bending' movements of the tibia and traction by attachments from Soleus or other muscle groups on the periosteum of the tibia?

    My left leg has had MTSS and I am convinced it has to do with prolonged and abnormal traction on my tibia. I have rear foot varus and plantar flexed first ray(s). My left foot is especially 'stiff' around the midtarsal joint and I have slight hallux limitus on the same side. ~Intuitively it seems that in my case there is a prolonged pronation moment through midstance- which is prematurely converted into a forced supination moment due to the 'limitus' of my left hallux.

    Moreover my thought is that abnormal 'twisting' is occurring in my tibia (transverse plane) as there is an abnormal coupling mechanism between my foot and leg. As a result propulsion occurs to a great extent through the second MTPJ. I would be very interested to see a study of the rear- and fore foot varus wedges you are suggesting for this condition.

    Thanks, Peter
     
  24. Peter:

    Without seeing your feet and lower extremities and watching you run, I wouldn't have any idea of what is causing your history of having had MTSS. However, you must remember, MTSS may also be transient and may depend on tibial bone density and will be determined by tibial diameter and cortical density and thickness. In other words, theoretically, MTSS may occur more commonly in those athletes with tibias that are more compliant and less commonly in those athletes with more stiff tibias when bending within the frontal plane. Certainly the 5 to 1 female to male predominance of MTSS points to the fact that increased tibial frontal plane bending compliance will predispose the athlete toward MTSS.
     
  25. Peter1234

    Peter1234 Active Member

    hi Kevin,

    a great deal of what has been written makes sense, such as the rear-foot varus-when I run, for some reason I have a genu varum- which would add to the shear/bending of the tibia. My left tibia is also slightly smaller in circumference than the right.

    I did have a problem when I was in my teens and would run a lot- and often up steep hills. This did go away. However as I get older I have put on weight- something that is bound to effect the amount of force going through the tibia.

    Thanks very much for a great thread, and again Kevin for being so generous with your time!

    Peter
     
  26. Peter1234

    Peter1234 Active Member

    Just to add a small point - I found that stretching before runnning has helped a lot!!!
     
  27. carolethecatlover

    carolethecatlover Active Member

    Thanks all, this is my assignment (500 words....LOL) this week. Carole, still a student.
     
  28. physiocolin

    physiocolin Active Member

    MTSS is an interesting subject, causes lots of frustration for both patient and practitioner alike. Well now there is the shoe to deal with it, the Newton Runner'!!
    The blurb says it has revolutionised the way athletes run - making them more comfortable, particularly for forefoot strikers. Anyone out there got any first hand experience with the 'Newton Runner'?
    Colin
     
  29. Griff

    Griff Moderator

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=24111
     
  30. DaVinci

    DaVinci Well-Known Member

    I have no idea how a Newton shoe will alter the bending moments in the tibia nad actually help MTSS?
     
  31. David Smith

    David Smith Well-Known Member

    Kevin

    Just had a runner in who is doing the London marathon and has MTSS. I was a wondering how to treat this particular patient since he has a short left leg with a cavus f/f equinus foot. The right side is the most painful and this foot is a more normal posture but both have stiff ankle dorsiflexion and valgus f/foot that gives a supinated stance phase in walking.

    When running at any speed, on ground or treadmill, he is a toe striker with no heel contact. The pain is along the origin of FDL and only comes on after running but is tender to palpate at any time. Interestingly the left is more tender to palpate but the right is the one that is painful after running. He's been having physiotherapy with no resolution.

    Just had a read thru the early posts in this thread and there are some pearls right there.Good stuff thanks :drinks

    Do you think the low 1st mpj and valgus f/foot cause him to use the low gear push of and utilise the FDL muscle more and so increase tibial stress this way or do you still think that increased tibial varum at foot strike is the problem or perhaps a combination? From you post 2nd Oct 09 11.05 am I guess you would say bending due to strike angle during running.

    Regards Dave
     
  32. Dave:

    Try using varus forefoot wedges on his running shoe sockliners. Even better, make him a varus wedged orthosis with a slight increase in heel height to see if you can also get some medial pressure under the arch and medial heel and medial forefoot during runnning. This should greatly help reduce both the valgus tibial bending moments and the medial soft tissue tensile forces on the tibia during the first half of the support phase of running that is the most likely cause of this patient's symptoms during his training and racing activities.
     
  33. physiocolin

    physiocolin Active Member

    thanks to all those replies regarding the Newton Runner- I'm now better informed.

    physiocolin
     
  34. David Smith

    David Smith Well-Known Member

    Kevin, Slo mo video proved that the foot is in significantly varus position at fore foot strike and fully pronated before heel strike. Open chain measurement of STJ eversion was 11 dgs and at heel strike the relative STJ eversion constantly exceeded 11 dgs: using the software to measure the angle. I can see the tension in the medial tissues in stance phase and can intuitively see the bending moments about the lower shank. When running the heel does just come to the ground and so I have designed the EVA orthoses as suggested.

    Cheers Dave
     
  35. Dave:

    You describe a common scenario for those runners with medial tibial stress syndrome (MTSS). If initial response isn't good, don't be afraid to add more forefoot varus wedging to the running orthosis, no matter what the experts tell you otherwise. Forefoot varus wedging is very effective in treating many cases of MTSS. Please keep us informed of your patient's progress.:drinks
     
  36. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Anatomical and Biomechanical Assessments of Medial Tibial Stress Syndrome
    Katherine E. Bartosik, Michael Sitler, Howard J. Hillstrom, Howard Palamarchuk, Kellie Huxel and Esther Kim
    Journal of the American Podiatric Medical Association Volume 100 Number 2 105-110 2010
     
  37. CraigT

    CraigT Well-Known Member

    :eek::D
     
  38. Griff

    Griff Moderator

    A cross-sectional design cannot show causation. So what this study showed was that people who already had MTSS walked slower (and had more pain) than those who did not have it?
     
  39. Been working on my lecture on medial tibial stress syndrome for the Rome, Italy seminar in early May and thought a nice illustration of how the tibial stresses may be changed with varus wedged foot orthoses would be helpful.
     

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