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)
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Author(s): 
By John T. Hester, DPM, MSPT

Key Treatment Options For MTSS

   Short-term management of MTSS is centered around relative rest and activity modification. Rest is the most effective, though often prolonged, treatment approach. Athletes must be aware that many cases of MTSS require upward of four months of relative rest or altered training. In my experience, scintigraphically negative MTSS may resolve in as little as three to six weeks with proper treatment but scintigraphically positive MTSS generally takes eight to 16 weeks. Cross training options during this period include cycling, swimming, deep water/pool running or upper body ergometry.

   Institute ice and NSAIDs (for pain control) early on in treatment. If symptoms are present even with daily activities, patients can use a cast boot or pneumatic leg splint for two to four weeks. Physical therapy is a key component of treatment and may include soft tissue management, massage, electric stimulation, ultrasound or iontophoresis. Some clinicians have used bone growth stimulators (electric, pulsed electromagnetic fields or ultrasonic) on tibial stress injuries in athletes. However, keep in mind that the only randomized controlled trial that evaluated the effect of bone stimulators on TSF in athletes found no difference in healing times.17

   Cold laser treatment is a relatively new option although it is largely unproven. Acupuncture is another alternative treatment for particularly refractory or painful cases. Surgery for chronic, refractory cases of MTSS is an option although results are variable at best. Performing a release of the fascial attachments to the posteromedial tibial margin has had reported success rates of 29 to 86 percent.17 However, a recent study reported that only 41 percent of athletes returned to pre-surgery levels of participation.18 There is also an interesting case study describing a college athlete who was able to get through her soccer season following a sympathetic block for refractory MTSS.19

Emphasizing Preventive Measures

   Long-term management of MTSS is centered on prevention. Eliminating training errors is the cornerstone of preventing MTSS. Doing “too much too soon” at the start of a training program or sports season is the most common training error scenario. The highest incidence of bone stress injuries occur in the first month, which corresponds to the most porous phase of the bone remodeling cycle.9

   Practitioners also need to address surface and terrain issues. Grass, sand and road shoulders are not universally preferable to road running due to their irregular surfaces. A level uniform surface of moderate firmness is optimal for minimizing injury risk.15 Shoes should be sport-specific and patients should change running shoes every 250 to 300 miles. Studies have shown that a running shoe may lose greater than 60 percent of its shock-absorbing capacity after as little as 250 miles.3,20

   Establishing normal strength, endurance and flexibility of calf and leg musculature is also important. A tight or overly strong triceps surae can impart an increased bending moment on the tibia. Weak or fatigued leg muscles may also result in up to a 25 percent increase in ground reactive forces.9

   One should also address biomechanical abnormalities and structural malalignments but keep in mind that investigators have found few statistical relationships between alignment measures and overuse injuries. However, two recent studies do support an association between excessive subtalar joint pronation and MTSS in runners.5,7

   Finally, do not overlook hormonal and nutritional factors. The female athlete triad (amenorrhea, disordered eating and osteoporosis) has been linked to decreased bone marrow density and increased risk for bone stress injuries.15 It is important to note that the female athlete triad is not limited to elite athletes and that many athletes with these issues will not always meet the classic definitions or criteria.16

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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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