Medial Tibial Stress Syndrome

Other Names

• Medial Tibial Stress Syndrome (MTSS)
• Shin Splints
• Medial tibial periostitis
• Tibial traction of medial periostitis
• Soleus Syndrome
• Tibial periostitis
• Tibial stress syndrome
• Posteromedial shin splints
• Tibial traction periostitis
• Tibial fasciitis
• Shin Soreness

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Background

• This page refers to Medial Tibial Stress Syndrome (MTSS), an overuse injuryseen in the leg due to reptitive stressors

History

• The first case on "shin splints" was published in 1958 (need citation)
• The term medial tibial stress syndrome was first used in the 1970s

Epidemiology

• Can affect up to 35% of runners (need citation)
• Overuse injuries, including MTSS, account for 18.5% of soccer related disabilities
• Exercise-induced shin discomfort is responsible for 10-20% of all runner injuries
• Up to 70% of runners may develop MTSS over a 1 year period

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Introduction

Anterior and medial views of the tibia with the main features shown, with the larger insert demonstrating the deep fascial attachments (A) and schematic section through the tibia illustrating the four compartments of the leg and their fascial coverings (B)The wide subcutaneous medial surface of the tibia can be seen

Crural fascia and muscle origins related to medial tibial stress syndrome symptom location

General

• MTSS is the discomfort and pain in the leg region due to repetitive stressors
• It is one of the most common injuries seen in runners and running sports
• The diagnosis is primarily clinical but can be augmented by imaging
• Treatment is mainly supportive, involving discontinuation of running, physical therapy and a controlled return to activity

Definition

• Exercise-induced pain along the posteromedial border of the tibia
• Typically occurring over a length of at least 5 cm
• Localizes to the distal two thirds of the medial tibial border

Pathogenesis

• Exact cause and pathophysiology remains debated
• Widely considered a stress reaction where bone resorption outpaces bone formation in response to reptitive tibial loading
  • Not considered an inflammatory process of the periosteum (periostitis)
• One possible mechanism
  • Repetitive stress inducing microdamage higher than the repair threshold
  • There is inadequate rest between periods of exercise
• Bending Forces Theory
  • Increased bending forces on the tibia exceeding the opposing strength of leg muscles
• Linked to periostitis and repeated tibial bending and bowing

Contributing Factors

• Increased training intensity
• Hard training surface
• Training errors
• Aging footwear

Anatomy of the Leg involved in MTSS

• The medial border of the distal two thirds of the Tibia is the most common pain location
• Deep Posterior Compartment of the Leg
  • Crural fascia of the deep posterior compartment has been implicated
• Muscles thought to be involved
  • Soleus
    • MRI studies have implicated the soleus
    • For this reason, MTSS is sometimes termed 'soleus syndrome'
  • Tibialis Posterior
  • Flexor Digitorum Longus

Relationship to Chronic Exertional Compartment Syndrome

• Some authors have suggested a relstionship between MTSS and CECS
• Both may present with overlapping symptoms such as exercise-induced lower leg pain
• No definitive pathophysiological relationship has been established
• Some studies have found normal compartment pressure measurements in MTSS (need citation)

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Risk Factors

Factors commonly associated with foot overpronation.

Sports

• Runners
• American Football
• Basketball
• Soccer

Occupations

• Military Recruits

Demographic

• Female gender
  • One Navy study found 53% of females had MTSS, only 28% of males
• Elevated body mass index
  • Significantly associated with MTSS among high school runners (need citation)

Training Related

• Increased training intensity
• Hard training surface
• Training errors
• Aging footwear

Other

• History of MTSS
• History of orthotics use
• Increased hip external rotation
• Increased navicular drop
• Increase plantarflexion of the ankle joint
• Overpronation
• Oversupination

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Differential Diagnosis

Traditional differential diagnosis and classification of medial tibial stress syndrome.

Differential Diagnosis Leg Pain

• Fractures & Dislocations
  • Tibial Shaft Fracture
  • Fibular Fracture
  • Tibial Stress Fracture
  • Fibular Stress Fracture
  • Proximal Tibiofibular Joint Dislocation
• Muscle and Tendon Injuries
  • Calf Strain
  • Calf Tear
  • Peroneal Tendon Injuries
  • Achilles Tendonitis
  • Achilles Tendon Rupture
  • Syndesmotic Sprain
• Neurological
  • Peroneal Nerve Injury
  • Sural Nerve Injury
  • Saphenous Neuritis
  • Acute Compartment Syndrome
  • Chronic Exertional Compartment Syndrome
• Vascular
  • Popliteal Artery Entrapment Syndrome
  • Ruptured Bakers Cyst
• Other
  • Medial Tibial Stress Syndrome
• Pediatric Considerations
  • Tibial Tubercle Avulsion Fracture
  • Tibial Tuberosity Apophysitis
  • Toddlers Fracture (Tibial Shaft Fracture)

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Clinical Features

Typical area of pain

Palpation of the posteromedial aspect of the tibia should elicit pain in MTSS

History

• Bilateral pain or aches on the medial side of the tibia
  • Usually distal two thirds
  • However, any part of the leg can be affected
• Pain is usually dull and often more aching laterally
• Worse with activity, relieved by rest
• Worse at the start of activity, then decreases with further activity
• Often worse the next morning but eases off over time
• In more severe cases, pain is felt at rest
• Uncommonly, pain or parasthesias can radiate to the foot

Physical Exam: Physical Exam Leg

• Inspection should evaluate the shoes to see if they are worn out
• Look for a Leg Length Discrepancy
• Diffuse tenderness over the posteromedial border of the tibia is the most sensitive exame finding (need citation)
• Mild swelling can be present, characterized by subQ thickening at the tibial border
  • This should feel different from palpable callous
• Pain and weakness with passive stretching

Special Tests

• Hop Test: Ask the athlete the hop reptitively on the affected leg
• Fulcrum Test: can be used to exclude tibial stress fracture

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Evaluation

Coronal T2-weighted magnetic resonance imaging images of a 17-year-old female hockey player who was training on a concrete pitch covered with Astro Turf® for approximately 2 mo and was subsequently diagnosed with medial tibial stress syndrome. A white longitudinal line of periosteal oedema on the medial cortex can clearly be seen on the enlarged view (right), which was consistent with the region of pain and tenderness.

Medial tibial stress syndrome evaluated as Grade 4b in the Fredericson classification. a The lateral view of the lower leg X-ray demonstrated cortical thickening and fracture line of the tibial diaphysis (arrow). b MRI showed abnormal signal intensity in the tibial cortex and bone marrow oedema on STIR (arrow)

Radiographs

• Standard Radiographs Leg
  • Useful to rule out other pathology sufch as a stress fracture
  • Note that stress fractures can take a few weeks to be radiographically apparent

CT

• Typically abonormal
  • Type 0: normal
  • Type 1: distributed and slightly reduced cortical attenuation without osteopenia
  • Type 2: osteopenia with or without cavitations or striations
• Gaet et al
  • Majority of asymptomatic runners are type 0
  • All symptomatic MTSS patients have type 2

MRI

• Considered the most sensitivity imaging modality for MTSS
  • Found to be 88% in one study
• Findings
  • Bone marrow edema (64%)
  • Periosteal edema (35%)
• Note that individuals with clinical MTSS can have a normal MRI

Ultrasound

• Role in diagnosing MTSS Remains undefined
• Can detect
  • Periosteal Thickening
  • Periosteal edema
  • Local hyperemia
• However these findings are non-specific

Bone Scintigraphy

• Uncommonly used in modern medicine
• Sensitivity of 74% to 84% (need citation)

Histology

• Biopsy not typically performed
• Findings include
  • Fibrous thickening
  • Rarely, chronic infoammatory cells
• In general, history is inconclusive

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Classification

• Not applicable

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Management

The medial tibial stress syndrome symptoms questionnaire used to assess lower leg symptoms

Prevention

• Avoidance of overstress can be used to prevent MTSS
• Up to 50% of running injuries are due to training related errors
• Educate the athlete about
  • Running‑induced injuries
  • Warm‑up and stretching exercises
  • Suitable footwear
  • Gradual exercise programs
• Evidence is limited on the efficacy of athlete education and prevention

Nonoperative

• Objectives
  • Relieve pain
  • Return to pain free activity
• Acute stage
  • Rest, ice seems to be the most effective
  • Can use Acetaminophen and NSAIDS for analgesia
• Physical Therapy
  • Emphasis on heel cord stretching, calf muscle strengthening
• Subacute management
  • Once pain free, emphasis is on training modification
  • Decrease traning frequency, intensity and running distance by 50
• Not routinely indicated and lacking evidence
  • Corticosteroid Injection, Platelet Rich Plasma, Prolotherapy

Operative

• Indications
  • Failure of conservative measures
• Technique
  • Posterior compartment fasciotomy
  • With or without cauterization of the posteromedial ridge of the tibia

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Rehab and Return to Play

Eccentric calf stretches and strengthening exercises

Rehabilitation: General Principles

• Rest from running/activity is the cornerstone of management
  • Must reduce initial load reduction
  • May require non weight bearing or partial weight bearing until symptoms resolve
• Cross training
  • Other forms of cardiopulmonary fitness like swimming, cycling, rowing etc should be considered
• Manual therapy
  • Fascial distortion model may reduce pain, improve evidence
• Medical Equipment
  • Sleeves and orthotics can be considere don an as needed basis
• Individualized, function based rehabilitation
  • Must address any anatomical, psychological or functional barriers
  • Set clear goals with ongoing assessment
  • Strengthening and flexibility of the posterior leg with emphasis on sport specific conditioning

Rehab Program PDFs

• Medial Tibial Stress Syndrome Exercises PDF
• Pediatric Rehab Medial Tibial Stress Syndrome PDF
• Stress Fracture of the Tibia Rehab PDF
• Stress Fracture Rehab Guideline PDF

Return to Play/ Work

• Progression criteria
  • Pain free during daily activities for 5 days before any return to running
  • Running must be graded, with initial focus on volume, duration, frequency first
  • After those criteria, can consider intensity or speed
• Most athletes can recover within 2-3 months (need citation)

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Prognosis and Complications

Prognosis

• General
  • Most patients have excellent outcomes when treated early and appropriately
• Surgical outcomes
  • Yates et al: surgery ruedced pain in athletes by 72% on the visual pain analog scale
  • Another study found 78% had either good or excellent outcomes following fasciotomy of the posterior compartment

Complications

• In general, complications are uncommon
• Tibial Stress Fracture
• Pseudofractures (looser zones)
• Chronic pain
• Inability to return to sport

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See Also

Internal

• Leg Pain Main
• Leg Anatomy Main
• Physical Exam Leg

External

• https://www.sportsmedreview.com/blog/treatment-medial-tibial-stress-syndrome/

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