Conquering Medial Tibial Stress Syndrome

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Conquering Medial Tibial Stress Syndrome
While runners account for the majority of MTSS cases in sports medicine practices, athletes who participate in any running, jumping or cleated sport may be susceptible to these injuries.
This MRI reveals a non-displaced fracture of the distal tibia. The active 45-year-old female initially complained of six weeks of progressive pain that started at the ankle and radiated up the proximal tibia to the mid-shin. (Photo courtesy of Nicholas Ro
This positive bone scan indicates bilateral tibial stress fractures as well as associated right first metatarsophalangeal joint (MPJ) arthritis.(Photo courtesy of Eric J. Heit, DPM, and Richard T. Bouche, DPM)
By John T. Hester, DPM, MSPT

   Biomechanical abnormalities and structural malalignments. Despite the common acceptance of biomechanical/ structural contributions to the development of tibial stress injuries and other exercise-induced leg conditions, there continues to be conflicting data in the current peer-reviewed literature in regard to identifying specific biomechanical risk factors. Researchers have paid much attention to biomechanical abnormalities, particularly excessive subtalar joint pronation (in both degree and velocity) and its relationship to tibial stress injuries. However, only two prospective studies have demonstrated a relationship between excessive subtalar joint pronation and MTSS.5,7 Other studies have been inconclusive or conflicting in this regard.

   Despite the general acceptance and broad use of foot orthoses in treating athletes with tibial stress injuries, the perceived benefits of these devices (reduction of injury frequency, improving skeletal alignment, impact cushioning and sensory feedback) are currently based on limited scientific evidence. Obviously, more research is needed in this area.

What Research Reveals About The Pathophysiology Of MTSS

   Though the anatomic site of MTSS is well known, neither the exact pathophysiologic mechanism nor the specific pathologic lesion are completely understood. Traditionally, researchers believed the underlying mechanism was repetitive microtrauma to the periosteum and fascial attachments as a result of traction forces from the soleus (primarily) and the flexor digitorum longus.12 However, recent MRI and histiologic studies have not supported this periosteal traction-based theory of MTSS. In fact, these studies fail to demonstrate periosteal inflammation.13,14

   There is a growing body of evidence that suggests MTSS, like TSF, is a bone stress reaction caused by chronic repetitive loads that induce tibial bending forces. Keep in mind that maximal tibial bending occurs at the narrowest diaphyseal width (middle to distal third of the tibia), which corresponds to the anatomic site of MTSS. Beck states that “when the tibia experiences chronic and repetitive strain in a pattern that involves abnormal or exaggerated bending, it is stimulated to deposit new bone on its periosteal surface at the level of the narrowest diaphyseal cross-section (junction of the middle and distal thirds) to reduce potentially injurious strains at this site in the future.”9 Beck’s tibial bending theory is gaining increasing acceptance among authors and clinicians who treat exercise-induced leg pain.

   Some authors consider MTSS and TSF to be conditions on a bone stress-failure continuum upon which MTSS is a mild expression and TSF the severe extreme. Why then do some athletes develop chronic refractory cases of MTSS (which never progress to TSF) and others develop TSF without ever demonstrating signs or symptoms of MTSS first? It is not universally accepted that MTSS is simply a mild form of or a precursor to TSF. Many authors believe that although MTSS and TSF may be induced by similar activities, they represent two unique pathologic lesions.

   Beck goes on to state that “persistent and increasing strain on porous (remodeling) bone incites a positive feedback loop that restimulates remodeling. This results in a protracted hypermetabolic state within the bone. This chronic remodeling in cortical bone, mediated via the periosteum (with or without periostitis or periosteal avulsion), probably represents the pathologic lesion of MTSS.”9

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Anonymoussays: July 22, 2010 at 12:35 pm

Excellent Resource. Offers great clarity for this often misdiagnosed malady.

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Anonymoussays: September 17, 2010 at 3:23 pm

very good article.

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Anonymoussays: January 6, 2011 at 2:15 pm

Yes, this was a very good article. Very informative. Thank you.

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