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Medial tibial stress syndrome

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  #31  
Old 6th March 2007, 02:02 PM
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Default Re: Medial tibial stress syndrome

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Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: A case-control study.
J Sci Med Sport. 2007 Feb 28;
Madeley LT, Munteanu SE, Bonanno DR
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Medial tibial stress syndrome (MTSS) is a common overuse leg injury seen in athletes and can be recalcitrant to management. This cross-sectional study aimed to determine if there are differences in the isotonic endurance of the ankle joint plantar flexor muscles in athletes with MTSS compared to athletes without MTSS. The isotonic endurance of the ankle joint plantar flexors was measured in 30 participants diagnosed with MTSS, and 30 reference participants that were matched to MTSS participants on the basis of age (+/-5 years), gender, BMI (+/-5%) and type of sporting activity. The number of heel-rise repetitions of the participants in each group was compared for differences. There were no significant differences between participants with and without MTSS for age (p=0.34), height (p=0.40) or BMI (p=0.27). The mean number of heel-rise repetitions performed by participants in the MTSS group was significantly less than the reference group (mean 23, S.D. 5.6, versus mean 33, S.D. 8.6; p<0.001). These results suggest that athletes with MTSS have endurance deficits of the ankle joint plantar flexor muscles. Rehabilitation of athletes with MTSS should comprise training designed to enhance endurance of the lower limb musculature, including the ankle joint plantar flexors. It is not known whether a lack of endurance of the ankle joint plantar flexor muscles is the cause or effect of MTSS.

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Old 6th March 2007, 08:18 PM
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Default Re: Medial tibial stress syndrome

Excellent article. I have argued that weak muscles would cause MTSS by the fact it would change eccentric to concentric loading. I was wondering if there is a possible mechanism to explain the weak muscle as a result of MTSS.

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  #33  
Old 22nd March 2007, 11:31 PM
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Default Re: Medial tibial stress syndrome

Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors.
Plisky MS, Rauh MJ, Heiderscheit B, Underwood FB, Tank RT.
J Orthop Sports Phys Ther. 2007 Feb;37(2):40-7.
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STUDY DESIGN: Prospective cohort. OBJECTIVE: To determine (1) the cumulative seasonal incidence and overall injury rate of medial tibial stress syndrome (MTSS) and (2) risk factors for MTSS with a primary focus on the relationship between navicular drop values and MTSS in high school cross-country runners.

BACKGROUND: MTSS is a common injury among runners. However, few studies have reported the injury rate and risk factors for MTSS among adolescent runners.

METHODS AND MEASURES: Data collected included measurement of bilateral navicular drop and foot length, and a baseline questionnaire regarding the runner's height, body mass, previous running injury, running experience, and orthotic or tape use. Runners were followed during the season to determine athletic exposures (AEs) and occurrence of MTSS.

RESULTS: The overall injury rate for MTSS was 2.8/1000 AEs. Although not statistically different, girls had a higher rate (4.3/1000 AEs) than boys (1.7/1000 AEs) (P = .11). Logistic regression modeling indicated that only gender and body mass index (BMI) were significantly associated with the occurrence of MTSS. However, when controlled for orthotic use, only BMI was associated with risk of MTSS. No significant associations were found between MTSS and navicular drop or foot length.

CONCLUSIONS: Our findings suggest that navicular drop may not be an appropriate measure to identify runners who may develop MTSS during a cross-country season; thus, additional studies are needed to identify appropriate preseason screening tools.
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  #34  
Old 12th May 2007, 06:07 AM
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Default Re: Medial tibial stress syndrome

Have seen a patient with shin pain. 17 year old girl who has a history of 6 knee operations, both knees, between the age of 11 and 16. Has been through rehab and now recently started playing sport (netball) for first time in a long while. The knee surgery was regarding the alignnment of the patellae.
She has a pes planus foot type and tight gastrocsoleus complex. Have discussed calf stretching and footwear. I want to prescribe some orthoses for her but am a little hesitant about whether polypropolene will be to hard, due to the surgical history of the knee. I am thinking maybe full length Polypropolene device with a soft cushioning cover. From experience what do you think? Is a plastic device definitely a no no due to her knee history? Any ideas welcome. Thanks.
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Old 12th May 2007, 06:45 AM
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Default Re: Medial tibial stress syndrome

I think you have to change your focus when you look at a patient.

It is not about what orthotic should be made, but rather what is going on biomechanically, and how can it be treated.

Equinus will make both legs toe out from the foot upwards increasing the Q angle and making a patient prone to chondromalacia (the patella tracking problem) Here in the States when I first got involved in Sports Medicine, the orthopedic surgeons would take out the patella for this condition, so don't let the fact she had surgery scare you off. All it means is that the orthopedic surgeon doesn't understand the cause of the condition, so how could he fix it?

Equinus will also cause shin splints, and it will also make orthotics intolerable. You are dealing with an extrinsic pronatory condition,and you cannot expect the orthotic to correct something that is not in the foot.

We can correct four things between the foot and the ground: Leg length, equinus, Pronation, and Metatarsal heights. Do not limit yourself to just the pronation aspect. In this case measure your dorsiflexion and place the heel lifts that are appropriate on your orthotic.

I don't mean to sound harsh, but for you to really succeed in sports medicine you have to use all the tools in the orthotic tool kit.

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  #36  
Old 14th May 2007, 03:58 AM
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Default Re: Medial tibial stress syndrome

Excellent. Thanks. I must agree, I overlooked the equinus aspect of the orthoses in this case.
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  #37  
Old 14th May 2007, 02:08 PM
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Default Re: Medial tibial stress syndrome

You are very welcome. By the way, all you need to do is add a heel lift to the orthotic until you can get the gastroc stretched out (stretching, manipulation of the ankle, night splints, &/or whatever other techniques there are).

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  #38  
Old 23rd September 2007, 05:23 PM
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Default Re: Medial tibial stress syndrome

I have a MTSS case (20yo female - hockey, volleyball and other sports) who gets bruising along the medial tibial border. She's sure that the bruising is a part of the 'shin splints'. She has suffered with MTSS for many years.

I have had some success with arch supports and heel raises but spoke to her in an informal setting on the weekend and the pain and bruising is back again after only a few weeks relief. On reading Kevin's past posts, I think I'm going to try a varus FF extension next but I don't know what to make of the bruising.

What's the story with MTSS and bruising - is it coincidental?

Rebecca
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  #39  
Old 7th November 2007, 01:22 PM
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Default Re: Medial tibial stress syndrome

Association Between Foot Type And Tibial Stress Injuries: A Systematic Review.
Barnes A, Wheat J, Milner C.
Br J Sports Med. 2007 Nov 5; [Epub ahead of print]
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OBJECTIVES: To systematically review published articles investigating the association between structural foot characteristics and tibial stress injuries. Furthermore, to suggest possible future avenues of research in this area.

METHODS: Literature was identified, selected and appraised in accordance with the methods of a systematic review. Articles potentially relevant to the research question were identified by searching the following electronic databases: Amed, Cinahl, Index to UK theses, Medline, Pubmed, Scopus, Sports discus, Web of science. Duplicates were removed, and based on the title and abstract, the full text of relevant studies retrieved. Papers were independently assessed by two reviewers; this formed the basis for the inclusion of the most appropriate trials.

RESULTS: From the 479 articles originally identified, nine were deemed appropriate for inclusion in the review. In general, specific data relating to this relationship was limited. Outcomes of the nine investigations were difficult to compare due to differing methods used across studies. Results have proved conflicting, with limited evidence found to implicate any specific foot type as a potential risk factors for tibial stress injuries.

CONCLUSIONS: No definitive conclusions can be drawn relating foot structure or function to an increased risk of tibial stress injuries. Extremes of foot types are likely to pose an increased risk of tibial stress injuries compared to normal arched feet.
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  #40  
Old 18th April 2008, 01:33 AM
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Default Re: Medial tibial stress syndrome

Hi all,

Resume:

Female, 34 year old, MTSS, used to do long walks through forests. Extreme tenderness in soft tissues in lower leg (medial side mostly), plantar fascia and presented and lower leg edema. When she came to me had already been in a vascular surgeon who ruled out any kind of vascular pathology – he prescribed her compression socks (for the hole limb) and physiotherapy - she felt a little better (edema control), but nothing more. Allthis in her right leg. In the left one a "insignificant disconfort".

After that, she arrived to me (after 3 months). I asked for a RX (negative), I thought in a MRI but the healthcare plan she has does not cover it…
I’ve applied ortothics (I do not prescribe – I do it…) with a rear foot varus post, an heel raise (“functional equinus”); stretching is being done. She improved a lot immediately and then slowly - not as much as I wanted. She’s doing now anti-inflammatory therapy.

She cannot stop her job for a few weeks – will be fired – she works all day standing and sometimes does repetitive movements in a machine pedal…

One of these days she walked for 45m and the pain got worse. She also refers that she feels better with the compression socks.

Any suggestions? Some specific physiotherapy treatment, anti-inflammatory therapy, in water exercising?
I apologize for my English – I hope I haven’t been too confusing…

My best regards to you all from a long time reader,
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  #41  
Old 18th April 2008, 04:45 AM
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Default Re: Medial tibial stress syndrome

Quote:
Originally Posted by Romeu Araújo View Post
Hi all,

Resume:

Female, 34 year old, MTSS, used to do long walks through forests. Extreme tenderness in soft tissues in lower leg (medial side mostly), plantar fascia and presented and lower leg edema. When she came to me had already been in a vascular surgeon who ruled out any kind of vascular pathology – he prescribed her compression socks (for the hole limb) and physiotherapy - she felt a little better (edema control), but nothing more. Allthis in her right leg. In the left one a "insignificant disconfort".

After that, she arrived to me (after 3 months). I asked for a RX (negative), I thought in a MRI but the healthcare plan she has does not cover it…
I’ve applied ortothics (I do not prescribe – I do it…) with a rear foot varus post, an heel raise (“functional equinus”); stretching is being done. She improved a lot immediately and then slowly - not as much as I wanted. She’s doing now anti-inflammatory therapy.

She cannot stop her job for a few weeks – will be fired – she works all day standing and sometimes does repetitive movements in a machine pedal…

One of these days she walked for 45m and the pain got worse. She also refers that she feels better with the compression socks.

Any suggestions? Some specific physiotherapy treatment, anti-inflammatory therapy, in water exercising?
I apologize for my English – I hope I haven’t been too confusing…

My best regards to you all from a long time reader,
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.
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  #42  
Old 18th April 2008, 05:13 AM
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Default Re: Medial tibial stress syndrome

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.

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  #43  
Old 18th April 2008, 07:27 AM
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Default Re: Medial tibial stress syndrome

Quote:
Originally Posted by Romeu Araújo View Post
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,
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.
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  #44  
Old 19th April 2008, 02:46 PM
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Default Re: Medial tibial stress syndrome

Kevin,

Quote:
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.
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...

Quote:
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.
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,
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Old 19th April 2008, 09:40 PM
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Default Re: Medial tibial stress syndrome

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.
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Old 21st April 2008, 03:30 PM
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Default Re: Medial tibial stress syndrome

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.”

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Old 22nd April 2008, 09:19 PM
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Default Re: Medial tibial stress syndrome

A wise Sports Physician once said to me 'an unusual presentaiton of a common problem is more likely than an unusual problem'.
Quote:
“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.”
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.
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Old 23rd April 2008, 07:30 AM
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Default Re: Medial tibial stress syndrome

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 by Ella Hurrell : 23rd April 2008 at 07:31 AM. Reason: typo
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Old 5th June 2008, 09:49 AM
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Default Re: Medial tibial stress syndrome

Medial tibial stress syndrome: evidence-based prevention.
Craig DI.
J Athl Train. 2008 May-Jun;43(3):316-8.
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CLINICAL QUESTION: Among physically active individuals, which medial tibial stress syndrome (MTSS) prevention methods are most effective to decrease injury rates? DATA SOURCES: Studies were identified by searching MEDLINE (1966-2000), Current Contents (1996-2000), Biomedical Collection (1993-1999), and Dissertation Abstracts. Reference lists of identified studies were searched manually until no further studies were identified. Experts in the field were contacted, including first authors of randomized controlled trials addressing prevention of MTSS. The Cochrane Collaboration (early stage of Cochrane Database of Systematic Reviews) was contacted. STUDY SELECTION: Inclusion criteria included randomized controlled trials or clinical trials comparing different MTSS prevention methods with control groups. Excluded were studies that did not provide primary research data or that addressed treatment and rehabilitation rather than prevention of incident MTSS. DATA EXTRACTION: A total of 199 citations were identified. Of these, 4 studies compared prevention methods for MTSS. Three reviewers independently scored the 4 studies. Reviewers were blinded to the authors' names and affiliations but not the results. Each study was evaluated independently for methodologic quality using a 100-point checklist. Final scores were averages of the 3 reviewers' scores.

MAIN RESULTS: Prevention methods studied were shock-absorbent insoles, foam heel pads, Achilles tendon stretching, footwear, and graduated running programs. No statistically significant results were noted for any of the prevention methods. Median quality scores ranged from 29 to 47, revealing flaws in design, control for bias, and statistical methods.

CONCLUSIONS: No current evidence supports any single prevention method for MTSS. The most promising outcomes support the use of shock-absorbing insoles. Well-designed and controlled trials are critically needed to decrease the incidence of this common injury.
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Old 12th February 2009, 01:02 AM
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Default Re: Medial tibial stress syndrome

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]
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PURPOSE:: To conduct a prospective, multisite, cohort study investigating the possible risk factors for medial tibial stress syndrome (MTSS) in college athletes.

METHODS:: One hundred and forty-six healthy, collegiate athletes from NCAA Division I and Division II institutions participated in the study. Subjects first completed a health history questionnaire to establish previous history of injury and underwent a physical examination to assess their ankle/foot strength, ankle/foot range of motion, tibial varum, and navicular drop before the start of their respective athletic season. Athletes were instructed to report to a certified athletic trainer if they developed pain on their tibia. If MTSS was present, subjects were then placed into the symptomatic group. Independent t-tests and chi-square analyses were used to determine whether differences existed between MTSS and healthy athletes for the continuous and the discrete dependent variables, respectively. The significant dependent variables were then used in the discriminant function analysis.

RESULTS:: Twenty-nine subjects developed MTSS during this study. Athletes that had been participating in athletic activity for fewer than 5 yr were significantly more likely to develop MTSS (P = 0.002). Additionally, athletes with a previous history of MTSS (P = 0.0001), a previous history of stress fracture (P = 0.039), and the use of orthotics (P = 0.031) were more likely to develop MTSS compared with those who did not develop MTSS.

CONCLUSION:: This study established that the factors most influencing MTSS development were previous history of MTSS and stress fracture, years of running experience, and orthotic use. These data demonstrate the importance of establishing a thorough history before the start of the season so that athletes who might be at risk for MTSS development can be identified.
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Old 28th September 2009, 09:32 PM
Jaimee Brent Jaimee Brent is offline
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Default Re: Medial tibial stress syndrome

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
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Old 29th September 2009, 01:59 AM
matthew malone matthew malone is offline
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Default Re: Medial tibial stress syndrome

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.
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Old 29th September 2009, 02:02 AM
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Default Re: Medial tibial stress syndrome

stress model
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Old 30th September 2009, 05:11 AM
Jaimee Brent Jaimee Brent is offline
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Default Re: Medial tibial stress syndrome

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?
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Old 30th September 2009, 11:24 PM
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Default Re: Medial tibial stress syndrome

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
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Old 1st October 2009, 09:29 AM
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Default Re: Medial tibial stress syndrome

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Originally Posted by Jaimee Brent View Post
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
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.
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Old 1st October 2009, 10:00 AM
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Default Re: Medial tibial stress syndrome

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.
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Old 1st October 2009, 10:32 AM
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Default Re: Medial tibial stress syndrome

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Originally Posted by Ian View Post
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.
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!!
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Old 1st October 2009, 11:14 PM
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Default Re: Medial tibial stress syndrome

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
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Old 2nd October 2009, 04:05 AM
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Default Re: Medial tibial stress syndrome

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Originally Posted by matthew malone View Post
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.
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).
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E-mail: kevinakirby@comcast.net
Website: www.KirbyPodiatry.com

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