Author, Year, n |
PEDro Scale Score |
Outcomes |
Results |
Strengths & Limitations
|
Yagi et al.,
2013 (n=102) |
6/10 |
Injury incidence, correlation between incidence and physical measurements determined as risk factors |
123 cases of injury: 102 with medial tibial stress syndrome and 21 with tibial stress fracture. Body weight, BMI and limited hip internal roation determined to be risk factors for medial tibial stress syndrome in females. Limited straight leg raise determined to be risk factor for tibial stress fracture in males |
Strengths:
- Investigators operationally defined sample
- Participants were representative of population from which they were drawn
- All participants entered study at same stage of their condition
- Study time frame was long enough to capture outcomes of interest
- Outcomes were operationally defined
- Sample included subgroups
- Detailed description of physical measurements
- Diagnosis was made by sports physician
- Physical measurements taken by sports physical therapists
- Sited other literature
- Multiple radiographs taken to confirm diagnoses of SF
- Included clinical application of results
- Limited equipment needed to replicate
- Large sample size
- Detailed description of diagnoses being investigated
- Utilized appropriate statistics
- Post hoc tests performed
Limitations:
- Some participants had previous leg pain while others did not
- Attrition occurred
- No blinding
- Investigators did not confirm their findings with a new set of participants
- Ambiguous inclusion/exclusion criteria
- Unequal numbers of males and females
- Limited generalizability
- Multiple physicians made diagnoses, possibly decreasing accuracy
- Physical measurements only taken once
- Participants’ typical running distances varied (short-track, middle-distance, long-distance)
- No detailed data regarding individual running distance
- Assumptions for statistical tests not mentioned
- No control group
- Reliability and validity of outcome measures was not addressed
- Power analysis was not completed
|
Sharma et al., 2011(n=468)
|
5 |
Fitness level, foot balance, time to reach peek heel rotation, presence of smoking habit, incidence of MTSS |
Dominant medial plantar presssures, low aerobic fitness, and smoking habit are all risk factors for developing MTSS. The logistic regression model predicted 96.9% of the non-MTSS group, 67.5% of the MTSS group, with an overall accuracy of 87.7% |
Strengths:
- Purpose of study clearly stated
- Definition of MTSS provided
- 1.5 mile timed-run known to be valid measure of aerobic fitness
- Weight calibration completed for pressure plate
- All participants underwent same training, therefore well-controlled study
- Imaging used to confirm or reject clinical diagnosis
- Good and bad definitions for balance data provided
- Post hoc analysis completed
- Smoking known risk factor based on other studies
- Exclusion criteria used
- Results of MTSS percentage comparable to other studies
- First prospective study to look at biomechanical variables with lifestyle variables for MTSS risk factors
- Large sample size
Limitations:
- Blinding unknown
- Possibility of logistical regression model to be biased secondary to limited factors considered in analysis.
- Logistical regression model unable to predict 32.5% of MTSS group members, meaning other important factors (such as nutrition and bone density) that were potential contributors to the development of MTSS were not considered in the analysis
- No inclusion criteria
- Extent (number of cigarettes per day) of smoking not documented in smokers
- Few biomechanical outcome measures looked at other than plantar pressure
- Which 6 right and left steps, pertaining to length of runway, included in analysis unknown
- Number of days into the training period that the injury occurred was not analyzed
- It is unknown if whom the subjects reported their injury to for further clinical diagnosis testing was an expert or not for such evaluation
|
Hubbard et al.,
2009 (n=146) |
7 |
Age, height, weight, previous injury (MTSS, stress fracture), current footwear (orthotic wear, how often shoes are changes, type of shoe), miles ran per week, current tibia pain or leg tightness (surface type of most running), dietary supplementation (including vitamins), info on menstrual cycle, bilateral ankle strength and range of motion (plantarflexion, dorsiflexion, inversion, and eversion), tibialvarum, and navicular drop |
Significant differences between MTSS and healthy groups for plantarflexion ROM, length subjects had been running, previous history of MTSS, previous history of stress stracture, and orthotic use |
Strengths:
- Sample operationally defined
- Long enough time frame to see outcomes
- Outcome criteria operationally defined
- Trial run of measurements with healthy subjects not in study completed for test measurement tool reliability and SE
- All measurement tool ICC’s >0.7, meaning all with good reliability
- SEM values for all measurement tools relatively small, meaning good reliability
- Statistical analysis completed in subgroups (MTSS and healthy)
- Clear definition of MTSS provided
- Extrinsic outcome measures looked at
- Purpose of study clearly stated
- Similar baseline demographics of subjects
- Inclusion criteria provided
- Specific criteria for presence of MTSS used
- Certified athletic trainer completed initial measurements
- Order that the measurements were completed in was counterbalanced to avoid any order effect
- Copy of questionnaire provided
- Results compared with similar studies previously completed
Limitations:
- Participants with varying past medical histories of MTSS and other diagnoses
- No blinding completed
- No exclusion criteria clearly provided
- No interrater reliability for measurements, as all completed by the same athletic trainer
- No training requirements mentioned for either athletic trainers or researchers defining participants with MTSS
- Majority of athletes were cross-country runners (unequal balance of athletes from different sports)
- Why orthotics were used was not examined
- Other intrinsic factors identified to affect MTSS risk were not included as outcome measures in the study (rearfoot varus and valgus, forefoot varus and valgus, isokinetic ankle strength, and bone mineral density)
- Only extrinsic factors included
- Use of athletes from different sports may skew data as training intensity, surface, duration, etc. differs between sports.
- Number of subjects that developed MTSS (n=29) much smaller than the healthy group compared to for statistical analysis (n=117)
|
Madeley et al.,
2007 (n=30 MTSS athletes, 30 reference (control) athletes |
6 |
Age, height, BMI, type of sport, level of competition, training frequency, training duration, competition duration, standing heel-rise test for muscle endurance - MTSS group additionally: presentation of symptoms, duration, pain over previous week, prior treatments in the past 4 weeks, effects of symptoms on sporting and everyday activities |
No significant differences were found for age, height, BMI. Those in the MTSS group completed a significantly less number of heel-rise repetitions (p, 0.001). Additional questioning from the MTSS group revealed 29/30 had bilateral involvement, median duration of symptoms was 15 weeks, mean pain in the past week was 65mm, 23/30 said symptoms limited everday activity, 24/30 said it limited training and competition, and 23/30 had previous treatment. Previous treatments included change of running surface or sporting footwear, massage therapy, addition of foot orthoses, stretching and/or strengthening program, and general physical therapy treatments. Test-retest reliability for both groups was high, with ICCs >0.90 and low SEM values |
Strengths:
- MTSS diagnosis clearly defined
- Data collected for all participants
- Data analyzed separately for the two groups
- First study to investigate endurance of ankle joint plantar flexors in patients with MTSS
- Purpose clearly stated
- Control group used
- Reference participants used in control group matched to MTSS participants
- Random limb selected for testing for reference group and those with equal, bilateral pain
- Practice trial of heel raises completed so accurately completed during testing trial
- Test-retest reliability of standing heel rise known to be excellent in healthy population, with deep vein thrombosis, and congestive heart failure
- Test-retest reliability of standing heel rise calculated to be excellent ( ICCs>0.90, low SEM values) with MTSS using 5 MTSS patients and 5 reference participants after study completion
- Prospective sample size calculated prior to start of study
- Power of study calculated
- Statistical assumptions tested and corrected
- Age and BMI matched for reference group
Limitations:
- No blinding
- Practice trial of heel raises may have caused fatigue
- Only ankle plantar flexor muscle endurance testing (no other muscle groups)
- Retrospective design limits causal determination
- 77% MTSS participants received prior treatment
- Standing heel rise cannot isolate specific leg muscles
- MTSS not confirmed with diagnostic imaging
- Possibility of other pathologies in MTSS group members
- Only one examiner completed standing heel-rise testing
|
Loudon et al.,
2010 (n=23) |
6 |
Sex, age, BMI, duration of symptoms, navicular drop test, talocrural dorsiflexion range of motion, pain level, quality of life |
15/23 had successful treatment outcomes. Duration of symptoms, change in pain, and GRC questionnaire scores were statistically significant between successful and not successful groups, whereas age, ankle dorsiflexion, NDT, and BMI were not significant
|
Strengths:
- Sample defined
- Outcomes defined
- Subgroup analysis
- Bonferonni adjustment
- Purpose clear
- MTSS diagnosis explained
- Participants with MTSS
- Inclusion & exclusion criteria
- NPRS reliable
- Same investigator takes measurements
- BFOs removable
- Good time frame
- HEP
- No other treatments
- GRC valid
- Compared to other studies
- First to document duration
Limitations:
- Two participants unable to complete
- No blinding
- Small sample size
- Only runners/walkers
- No inter-rater reliability
- Possible inaccurate daily log
- Participants unable to complete included in unsuccessful group results
- Mostly students and medical center employees
- Duration not compared to other studies
- No post-intervention NDT & dorsiflexion
- No strength testing
|
Newsham et al.,
2013 (n=15) |
5 |
MRI measures of tibia (tibial length, tibial width both anterio-posterior and medio-lateral, and cortice thickness (anterior, posterior, lateral and medial) and palpation of middle third of medial border of tibia to determine presence of stress reaction in tibia |
Symptomatic tibia had thicker medial cortices, thicker lateral cortices, and thinner anterior cortices than asymptomatic tibiae. MRI images of symptomatic tibia revealed either oedema within the cancellous bone and/or stress fracture. Participation in a ball sport in addition to triathlete training was associated with asymptomatic tibiae |
Strengths:
- Investigators operationally defined sample
- Participants were representative from the population from which they were drawn
- All participants entered the study at the same stage of their condition
- No attrition
- Conducted long-term follow up at 2 years post
- Defined inclusion criteria
- Qualified individuals conducted measurements on MRI images
- Two individuals conducted measurements that were averaged increasing accuracy
- Included detailed description of measurements taken from images
- Included detailed method of taking images
- Outcome measures were reproducible
- Defined criterion for symptomatic tibiae
- Included diagram of MRI positions and measurements
- Participants had similar demographic characteristics
- Included practical/clinical application of results
- Utilized correct statistical measures
- Sited other literature
- Imaging is one of most reliable diagnostic tools
Limitations:
- No blinding
- Sample did not include subgroups of people for whom the prognostic estimates will differ
- Investigators did not confirm their findings with a new set of participants
- Did not repeat measurements at long-term follow up
- Did not define exclusion criteria
- Utilized convenience sampling
- No mention of reliability or validity of outcome measures
- Six athletes were involved in other sports during training
- Limited generalizability
- Observational studies are low level of evidence
- Small sample size
- No mention of statistical assumptions
Unequal number of males and females |
Yuksel et al.,
2011 (n=11 male and female athletes and 11 regularly exercising individuals) |
6 |
Exercise questionnaire (age of beginning sports activities, weekly training schedule frequency and duration and how any months this program was followed, last training level, lifetime cumulative sports activity, total training level, and if an increase in training duration or intensity had been made in the time one month before MTSS symptom onset), Medial Longitudinal Arch (MLA) angle, both Weight Bearing (WB) and Non-Weight Bearing (NWB), MLA deformation, navicular drop, maximum isokinetic strength of inversion and eversion bilaterally |
Baseline measurements were similar between groups (p>0.05). All MTSS group members complained of bilateral symptoms and 9 had increased training duration or intensity within the month before MTSS onset. No statistically significant differences were found between the groups for weekly training days, duration of single training sessions or total weekly trainings, monthly training period, last training level, WB and NWB MLA angles, MLA deformation, and navicular drop measurements. Statistically significant findings between groups included total training level difference (p>0.001), higher average eversion concentric strength in patient group for both 30°/sec and 120°/sec angular velocities (p<0.05), and higher Inversion/Eversion (I/E) strength ratio in the control group at the 30°/sec angular velocity |
Strengths:
- Sample in study operationally defined
- Outcome data collected for all participants
- Outcome measures operationally defined
- Control group used for subgroup analysis
- Definition of MTSS provided in introduction
- Purpose of study clearly stated
- First study at the time that looked at isokinetic invertor and evertor muscle strength in ankles of MTSS patients
- Inclusion and exclusion criteria provided for both groups
- Specific diagnosis criteria for MTSS provided
- Bandholm method for MLA angles with high reliability
- Standardized warm up completed by all participants
- Submaximal testing completed prior to maximal to ensure accurate measurements
- Dynamometer for strength testing calibrated before each test
- Rest breaks given between strength testing trials
- Parametric and non-parametric data with separate analysis
Limitations:
- Stage of MTSS syndrome unknown in MTSS group
- Blinding not mentioned in study other than study type
- Small sample size
- Possible inaccurate reports from participants on exercise questionnaire
- Possibility of technical error secondary to computer measurement of MLA angles
- Submaximal testing prior to maximal possible source of fatigue making measurements inaccurate
- Investigators of unknown qualifications
|
Plisky et al.,
2007 (n=105 high-school cross-country runners) |
6 |
Baseline history (age, gender, height, body mass, limb dominance, history of lower extremity injury or pain, number of years running experience, and orthotic or tape use), navicular drop, full and truncated foot lengths, DIR, post-season questionnaire |
Female gender and higher BMI associated with higher risk of MTSS; when orthotic wear controlled for only higher BMI |
Strengths:
- Purpose clear
- Power analysis
- Approved by review board
- Coaches and ATs trained to use DIR
- Skilled investigators
- MTSS definition
- Well documented procedures
- Pilot study
- High intra-rater-reliable navicular drop & foot length measurements
- Outliers & goodness of fit calculated
- Limited bias based on study design
- Data for all participants
- First study on practices & events
- Navicular drop and height normalized
- Exclusion criteria
Limitations:
- Participant reported height & weight
- Unknown inter-rater reliability of measurements
- Small sample size
- Small DIR sensitivity
- Data collected monthly
- No blinding
- No follow-up
- No cause and effect
- Those with MTSS excluded
- Validity of measurements unknown
- Baseline varied
- Self-reported shin pain
- Training for DIR unknown
- Reliability and validity of outcome measures (except navicular drop and foot length) unknown
|
Bennett et al.,
2001 (n= high school cross-country runners: 15 with MTSS, 21 without injury) |
6 |
Navicular drop, resting calcaneal position, tibiofibularvarum, gastrocnemius length |
Navicular drop and sex two accurate predictors for incidence of MTSS |
Strengths:
- Operational definition of the sample included
- Participant’s representative of population
- Outcome data collected from all participants that met criteria
- Outcome criteria operationally defined (detailed description)
- No attrition
- All groups managed in same way (measurements conducted in same manner)
- Reliability of measurements was tested (pilot study)
- Relatively equal group sizes
- Participants analyzed in assigned groups
- Control group to provide comparison
- Used appropriate statistics
- Limited equipment necessary
Limitations:
- Participants entered study at different stages of their condition
- Researchers were not blinded
- Participants were not sub grouped based on difference in prognostic factors
- Findings were not confirmed with new set of patients
- Small sample size
- Limited generalizability
- Identification of symptomatic patients relied on self-report of medial shin pain
- Measurements fail to account for dynamics of running
- No randomization
- No mention of training of researchers
- No long term follow-up conducted
- Assumptions for parametric tests not tested
- No mention if participants were receiving treatment
- No description of cross-country training
- No description of symptoms experienced by patients
- No pre and posttest measurements
|
Yates et al.,
2004 (n=124 naval recruits (84 men and 40 women) |
7 |
Foot Posture Index (FPI), ankle dorsiflexion, injury incidence, exit interview |
Gender and foot pronation are significant risk factors for development of MTSS; past history of MTSS increased risk for development; BMI, age and ankle dorsiflexion had no effect |
Strengths:
- Large sample size
- Investigators operationally defined sample
- Participant’s representative of population from which they were drawn
- All participants entered the study at the same stage of the condition
- Study time frame was long enough to capture outcomes of interest
- All outcome criteria operationally defined
- Investigator who took physical measurements was blinded
- Included study specific definition of MTSS
- Specific criteria for inclusion in either MTSS group or non-MTSS group
- Specific exclusion criteria
- Detailed description of physical assessment measures
- Mentioned reliability of outcome measures
- Utilized correct statistical measures
- All participants wore the same types of shoes throughout training period
- Explained reasons for participant drop-out
- Sited other literature
- Researchers included suggestions for prevention and treatment of MTSS
Limitations:
- Limited generalizability
- Sample did not include subgroups of people for whom prognostic estimates will differ
- Investigators did not confirm their findings with a new set of participants
- Ambiguous inclusion criteria
- No mention of statistical assumptions
- Differences in amount of exercise completed by recruits prior to study
- Attrition occurred
- Unequal number of males and females
- Possibility of decreased reported injury rate due to hiding of injury in military populations
- No confirmation of diagnosis with imaging
- FPI does not assess dynamic foot function
- No mention of training of investigator taking physical measurements
- Lower level of evidence (not as strong at determining cause and effect)
|
Moen et al.,
2012 (n=74 athletes with MTSS) |
9 |
Number of days from inclusion to completion of graded running program and participant satisfaction |
No significant differences between three treatment groups in either running program completion time or participant satisfaction with treatment |
Strengths:
- Participants were randomly assigned
- Data analyst was blinded
- Groups had similar sociodemographic, clinical and prognostic characteristics at start of study
- All groups managed in same way except for intervention
- Researchers collected follow-up data over a long enough time frame
- Participants analyzed in groups that they were assigned
- Power analysis conducted
- Investigators were trained by sports physician to increase consistency
- Pretest measurements completed
- Inclusion/Exclusion criteria included
- Detailed description of intervention
- Multiple follow-ups conducted
- Measured compliance
- Corrected for attrition in statistical analysis
- Used appropriate statistics
- Sited previous literature regarding topic
- Detailed description of outcome measures
- Equal group sizes
- RCT is strongest design to show cause and effect
Limitations:
- Attrition occurred
- Athletes and investigators were not blinded
- No control group
- Outcome measures were not validated
- Power analysis may have been inaccurate
- Athletes were involved in different sports
- Limited generalizability
- Potential bias in compliance measurements
- Participants began in different phases of running program
- Expensive equipment need for some phases (treadmill)
- Artificiality (running on treadmill may not be applicable to athlete)
- Running surface varied based on phase of running program
|