Current Concepts In Treating Medial Tibial Stress Syndrome

Medial tibial stress syndrome is relatively common in running and jumping athletes. Accordingly, this author offers a thorough review of the literature and shares insights from his experience in treating this condition and facilitating a rapid, pain-free return to full activity.

   Medial tibial stress syndrome (MTSS) is one of the most common injuries that occurs among running and jumping athletes. Even though use of the term “shin splints” started over 40 years ago to describe the leg pain which occurred in athletes with MTSS, “shin splints” has also been in use over the years to describe a number of other diagnoses that cause leg pain in athletes.1

   For this reason, “exercise-induced leg pain” and “exertional leg pain” have become more popular terms.2,3 These terms describe the multitude of diagnoses that may, along with MTSS, cause leg pain during athletic activities. Such terms include tibial or fibular stress fracture, chronic exertional compartment syndrome, muscle strains or tears, focal nerve entrapment, fascial herniation, lumbosacral radiculopathy, vascular claudication and popliteal artery entrapment syndrome.4,5

   Drez first coined the term “medial tibial stress syndrome” in the early 1980s.6 In 1974, researchers first used the terms “tibial stress syndrome” and “medial tibial syndrome” to describe the medial tibial pain that often occurs in the legs of active individuals.7,8 Other names that have been used over the past 30-plus years for this relatively common condition include posterior tibial syndrome, inflammatory shin pain, traction periostitis, tibial periostitis, medial shin splint syndrome, soleus syndrome and tibial fasciitis.9-15

   The vast majority of individuals who develop the pain from MTSS participate in either running or jumping activities, and MTSS represents a significant percentage of all athletic injuries. In runners, MTSS accounts for 9.4 to 17.3 percent of all injuries and accounts for 22 percent of all injuries in aerobic dancers.13,16-18

   In a prospective study of 124 military recruits, 35 percent developed MTSS during basic training.19 In two separate prospective studies of high school cross-country runners, 12 percent of 125 runners and 15.2 percent of 130 runners developed MTSS.20,21 In another prospective study of 146 collegiate athletes who participated in running and jumping sports, 19.9 percent developed MTSS during their competitive seasons.22

   Females also seem to be much more likely than males to develop MTSS. In a study of military recruits during basic training, researchers found female recruits developed MTSS at a rate that was 10 times greater than their male counterparts.23 In another prospective military study, females were only twice as likely to develop MTSS.19 In two prospective studies of high school cross-country runners, female runners were 2.5 to 6.5 times more likely to develop MTSS than their male counterparts.20,21

Essential Diagnostic Insights

   In order to diagnose MTSS properly and rule out other pathologies that may cause exercise-induced leg pain, it is imperative that the clinician takes a good history and performs a proper physical examination of the patient’s foot and lower extremity. Patients with MTSS invariably complain that their medial leg pain developed along with a recent increase in running or jumping activities.

   The pain from MTSS generally only occurs during the activity with the pain diminishing rapidly within five minutes of activity cessation. If the pain persists during walking activities, the clinician should have a high index of suspicion for medial tibial stress fracture (MTSF). These may occur in the same areas of the medial tibial border as does MTSS.24 Clinical examination of the patient with MTSS will show a characteristic diffuse tenderness that occurs along the distal two-thirds of the medial tibial border.25 On occasion, the exam may show localized induration within the soft tissues just posterior to the medial tibial border.26

   Diagnostic testing is indicated in the patient with the symptoms of MTSS, especially if one suspects MTSF. Plain film radiographs are invariably normal in MTSS and will also be normal in early stages of MTSF.27 Triple-phase bone scans are very sensitive in detecting MTSS with a diffuse marker uptake along a relatively long section of the medial tibia. In contrast, MTSF generally demonstrates a more intense and focused marker uptake within the medial tibial border.28-31 However, in those patients with early stages of MTSS, bone scan imaging is not always positive.32,33

   Magnetic resonance imaging (MRI) has greatly enhanced the ability to diagnose MTSS and MTSF in the injured athlete. A MRI allows the determination of the three-dimensional location of edema within the bone and soft tissues of the medial tibia. This has helped researchers and clinicians develop a better understanding of the pathophysiology of both MTSS and MTSF.

   Fredericson and colleagues used both MRI and bone scan studies to develop a new MRI grading system for MTSS and MTSF based on the location and extent of edema within the periosteum and bone marrow of the medial tibia.34 Their research, along with the research from others, clearly indicates that MTSS may actually be, in many patients, a precursor or an intermediate step in the progression toward MTSF.35,36

Understanding The Tissue Stress Physiology Of MTSS

   Over the years, there has been considerable interest as to which structures along the medial tibial border are responsible for the pain of MTSS. Many researchers speculated that the periosteum of the medial tibia was the source of the injury since periosteal thickening, increased vascularity and loss of osteocytes in the medial tibia were present in those patients with MTSS.37

   However, in soft tissue biopsies of the medial tibial tissues in patients with MTSS, Johnell and co-workers found evidence of periostitis in only one of 33 samples.38 Similarly, Detmer showed no evidence of periostitis in 10 patients who had fasciotomy for MTSS.39

   Others have speculated that the bone of the medial tibia itself was the location of the tissue injury in MTSS. In support of this theory, Magnusson and colleagues found a 23 percent decrease in bone mineral density in athletes with MTSS.40 In a later study, which found bone density to increase in athletes who had recovered from MTSS, researchers hypothesized that the bone mineral density losses that occur with MTSS are reversible and not inherited.41 In addition, histological study has confirmed that patients with MTSS had increased metabolic activity within the bone of the medial tibia, which led to speculation that MTSS was due to a “stress microfracture” of the tibia.38

   Since both MRI and histological studies point to a continual process of stress-induced bone injury over time, there is now considerable evidence to suggest that MTSS and MTSF are best classified as points along a continuum of stress reaction of bone.42 This idea that MTSS and MTSF represent different points along a continuum of bone stress injury is in agreement with the classic research by Johnson and colleagues over 47 years ago.43 These researchers showed a continuum of histological changes in bone, including increased loss of bone density with increased bone stress, which ultimately lead to stress fractures.

   Bone is a dynamic tissue that will lose density with increased stress and will gain density over time to strengthen and remodel itself. Given that, the application of too much stress over too short of a period of time, without sufficient time being allowed for the bone remodeling, will result in a stress reaction injury within the bone.44,45

   Therefore, in the specific example of the running or jumping athlete with medial tibial pain, MTSS and MTSF both represent different points along the continuum of stress reaction injury to their medial tibia. This is ultimately due to changes in the microscopic structure within the bone of the medial tibia.38,40,43

Weighing Soft Tissue Traction Versus Bone Bending As Possible Etiologies

   Even though most experts consider MTSS to primarily be a bone injury, there is still considerable debate as to what mechanical factors are most responsible for the bone injury of the medial tibia that results in MTSS. One of the proposed biomechanical etiologies for MTSS is that muscle or fascia exerts excessive traction or tensile forces on the medial border of the tibia. Researchers have implicated the posterior tibial (PT), flexor digitorum longus (FDL) and soleus muscles as being possible sources for a traction injury to the medial tibia that could cause MTSS.14,39,46-49

   The other proposed biomechanical etiology for MTSS and the one that has recently been gaining increasing favor is that the bone injury of MTSS is due to excessive bending of the tibia during running and jumping activities. In engineering, it is a well known fact that when one places eccentric axial loads across a relatively long and narrow structure, bending moments will occur within that structure. These bending moments will, in turn, cause excessive stresses in the area of that structure with the narrowest cross-section. The greater the forces acting on the structure and the further one directs these forces away from the midline axis of the structure, then the greater will be the bending and stress within that structure.50,51

   In support of the idea that excessive tibial bending moments may be responsible for medial tibial stress injuries, such as MTSS or MTSF, Milgrom and colleagues prospectively studied 295 military recruits.52 The researchers found that the recruits with narrowest tibias were also the recruits more likely to experience MTSF during basic training. Another study of military recruits also found that smaller tibial cross-sectional diameters increased the likelihood of tibial stress fractures.53

Pertinent PearlsOn Biomechanical Treatment

   The treatment of patients with MTSS involves not only determining the biomechanical causes of the injury but also instituting mechanical treatments that will enable the athlete to achieve a more rapid recovery toward full activities.

   After making the diagnosis of MTSS, one should instruct the patient to apply ice to the medial tibia for 20 minutes twice daily. Also tell patients to reduce running activities, run on softer surfaces and wear appropriate anti-pronation shoes. At the initial visit, modify shoe insoles or over-the-counter orthoses with adhesive felt padding at the medial heel, medial arch and medial forefoot to simulate the mechanical effects of a custom foot orthosis. Custom foot orthoses are recommended for the vast majority of these individuals unless their symptoms are mild and have resolved quickly with the aforementioned initial therapeutic measures.

   Previous research has indicated that factors such as increased foot pronation and increased varus forefoot and rearfoot alignment are associated with an increased risk of developing MTSS and MTSF. Research has also shown that medial tibial soft tissue traction and tibial bending are the most likely mechanical causes of MTSS.19,54-60

   Due to that research, when it comes to reducing subtalar joint (STJ) pronation and tibial bending, physicians specifically design foot orthoses for MTSS with the following features:

   • 5 to 80 of inverted balancing position;
   • a 2 to 4 mm medial heel skive;
   • minimal medial expansion plaster;
   • a 16 to 18 mm heel cup;
   • 40/40 rearfoot posts;
   • a full length top cover; and
   • a varus forefoot extension plantar to the first, second, third and fourth metatarsal heads only.24

   In effect, one should specifically design custom foot orthoses for MTSS to shift ground reaction force (GRF) toward the medial aspect of the plantar foot. This not only reduces STJ pronation moments but also reduces the abnormal valgus bending moments on the tibia that cause MTSS. By supporting the foot during running or jumping with a varus-wedged foot orthosis, GRF shifts medially. This will align the loads through the tibia more along its long axis, thereby decreasing the bending stress on the medial tibia border.24

   In addition, these specifically designed orthoses for MTSS will also lessen the STJ pronation moments. This will decrease the tensile force from the medial tibial muscles and fascia that also may contribute to the pain of MTSS. In my 25 years of treating athletes, such custom orthoses have proven very effective at allowing a more rapid return to running and jumping activities.

In Conclusion

   Understanding the diagnosis, pathophysiology, biomechanical etiology and effective orthosis treatment methods for medial tibial stress injuries (such as MTSS and MTSF) is the key to allowing active patients to resume their activities as soon as possible.

   Sports medicine podiatrists who can use their knowledge and clinical skills to facilitate quick and successful healing will have the reward of the satisfaction that their efforts will allow these individuals to continue their active lifestyles, pain-free, for years to come.

Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is in private practice in Sacramento, Calif.

Editor’s note: For related articles, see “Conquering Medial Tibial Stress Syndrome” in the January 2006 issue or “How To Triumph Over Shin Pain” in the June 2003 issue. For other articles, please visit the archives at www.podiatrytoday.com.

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