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

   This model would explain why a subset of athletes develops protracted, refractory cases of MTSS that cannot be explained as a self-limiting inflammatory condition of the periosteum or crural fascia. For those athletes who recover in a normal time frame, it is likely that these reparative processes occur rapidly enough to accommodate ongoing tibial loads without triggering this positive feedback loop.9,15

   Further research is needed in this area. However, these studies do shed additional light on the pathophysiology of tibial stress injuries and, more specifically, the relationship between MTSS and TSF.

Essential Diagnostic Insights

   Diagnosing MTSS is relatively straightforward although a well directed history and physical are required to rule out other causes of exercise-induced leg pain.

   Athletes presenting with MTSS will typically complain of an aching pain at the middle to distal medial shin with activity (most commonly running). Medial tibial stress syndrome is similar to many overuse injuries in that athletes initially experience pain at the beginning of an activity. The pain then diminishes and often returns hours after completing the activity. These athletes generally achieve symptom relief with rest but the condition may progress to the point of causing pain even during inactivity.

   Eventually, athletes may experience pain throughout the offending activity to the point of impaired performance. This is often the point where the athlete seeks medical attention. A common scenario is for an athlete to present one to two weeks into a new season or training program. Keep in mind that bone remodeling typically starts five days after stimulation and leaves the bone in a relatively weakened state for approximately eight weeks.7

   The hallmark of the physical exam is tenderness over a 4 to 6 cm area at the posteromedial margin of the middle to distal third of the tibia. This is in contrast to TSF, which presents with well localized point tenderness. Refer to “How To Differentiate Between MTSS And TSF” below) for other diagnostic differences between MTSS and TSF.

   The tenderness with MTSS may be exquisite and can often extend into the adjacent soft tissues. Mild soft tissue swelling and induration may be present. While researchers have described percussion, vibration with a tuning fork or using therapeutic ultrasound as adjunctive diagnostic maneuvers to help identify TSF, studies have shown these diagnostic tools have a low sensitivity.16 Passive stretch of the soleus, heel rises and unilateral hopping may reproduce symptoms. Radiographs are indicated to rule out TSF, infection or neoplasm but findings are generally normal with MTSS. Occasionally, one may observe cortical thickening due to chronic remodeling.

   If the patient is a competitive athlete or if suspicion for TSF is high, obtaining a triple phase 99Tc bone scan (TPBS) is indicated. The triple phase bone scan is highly sensitive for tibial stress injuries with the added advantage of being able to distinguish between MTSS and TSF. MTSS will generally (although not always) be positive, displaying a longitudinally or vertically oriented diffuse uptake on the delayed images only. Whereas false negative findings may occur with MTSS, TPBS is virtually 100 percent sensitive for TSF, demonstrating a focal, intense uptake of tracer on all three phases.

   MRI has become an increasingly utilized modality for assessing tibial stress injuries in athletes. It has also shed new light on the relationship between MTSS and TSF. Tibial stress fractures are clearly delineated on MRI and the sensitivity is similar to that of TPBS. In cases of acute MTSS, MRI will demonstrate findings consistent with tibial stress injury. However, chronic MTSS often demonstrates normal findings. Obtaining a MRI can also be helpful in differentiating MTSS from rarer longitudinal tibial stress fractures. With superior anatomic visualization, decreased radiation exposure and reasonable cost for a limited study, MRI is becoming a first line study for tibial stress injuries in many sports medicine practices.

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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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