Journal of Physical Medicine Rehabilitation & Disabilities Category: Medical Type: Research Article
Medial Tibial Stress Syndrome: Who’s at risk? A Systematic Review
*Corresponding Author:
Singh RDepartment Of Physical Therapy, The Sage College, Troy, New York, United States
Tel:+1 5182444550,
Email:singhr@sage.edu
Received Date: Jul 13, 2016 Accepted Date: Sep 13, 2016 Published Date: Sep 27, 2016
Abstract
The purpose of this review is to identify risk factors in the athletic population for the development of Medial Tibial Stress Syndrome (MTSS). MTSS is a lower extremity pathology that frequently impacts athletes and disrupts their ability to participate. Identifying risk factors and other direct causes of this condition can provide insight regarding treatment techniques and methods of prevention.
Methods
An extensive search of the literature was conducted. Databases used included PubMed, ProQuest Nursing, Cinahl and Allied Health, Proquest Health and Medicine, and Google Scholar. 11 articles were found meet inclusion and exclusion criteria. Critically Appraised Topic (CAT) analyses were completed for each include article. Quality assessment via Physiotherapy Evidence Database scale (PEDro) was also completed, average quality score being 6.
Results
Significant risk factors for MTSS development include high body mass index, female gender, navicular drop, foot pronation, limited hip internal rotation range of motion, increased plantarflexion range of motion, limited straight leg raise, cortical thickness of the tibia, bilateral ankle strength, impaired standing heel-rise test, decreased foot balance, increased miles run per week, less significant exercise history, higher pain level, and longer duration of symptoms.
Discussion
Overall it can be inferred that there is lack of agreement in the current literature regarding the cause of MTSS, the associated risk factors, and the best way to treat it. Based on the results provided by this systematic review, different healthcare providers may be able to better develop appropriate plans of care. Future studies may want to focus on risk factors consistently contributing to MTSS, larger sample sizes, analyzation based on type of impact sport, or running mechanics in relation to MTSS development.
INTRODUCTION
The formal definition of MTSS varies throughout the existent literature. It was first qualified as “a symptom complex seen in athletes who complain of exercise induced pain along the posteromedial border of the tibia†[1]. The exact pathophysiology of MTSS remains unknown, however until recent research emerged, inflammation of the periosteum as a result of increased traction was viewed as the most viable explanation. Studies have now shown that it is more likely that MTSS is a bone stress reaction that progresses to a painful state as opposed to an inflammatory process [1]. The metabolic changes in bone that occur when an individual begins an exercise program result in an increased porosity on the posteromedial border of the tibia. In a normal individual, new bone is laid down in order to resist compressive forces and to increase the strength of the bone. However, in an individual who has suffered from longstanding MTSS, the tibia will remain more porous by approximately 15% according to one study [1].
In order to diagnose MTSS, a thorough clinical history and physical examination must be conducted. It will often present as “diffuse, palpable pain, localized to the posteromedial tibial borderâ€. The pain can be located anywhere along this border, however it is commonly found from the middle to distal thirds. It is described as a dull ache after exercise. It may last for several hours up to days [1]. MTSS is often diagnosed as shin splints, shin pain, periostitis, and exercise related lower leg pain [3]. Imaging and diagnosis MTSS with radiograph is not appropriate however, Magnetic Resonance Imaging (MRI), has increasingly been used for studying MTSS.
Currently, there is no accepted successful treatment plan that consistently alleviates the symptoms of MTSS in all populations. Many studies describe conservative options for treatment including ice application, aspirin, heel cord stretching and walking casts. Other researchers suggest more exercise based interventions such as graded running programs, strengthening, and stretching exercises specifically targeting the calf muscles. Sports compression stockings are also frequently used in athletic populations [2]. However, despite the volume of research that has been conducted on interventions for MTSS, there is a lack of agreement upon the most effective method. One reason for such lack of consensus might be the multitude factors leading to development of MTSS. With the several different risk factors known, treatment for and prevention of MTSS as a single problem is difficult and may encompass a wide range of options. This has led to a focus on attempting to determine the most relevant risk factors that contribute to the development of this condition. It is the intention of many medical professionals to identify these risk factors in individuals most known for developing MTSS, such as athletes, in order to implement prevention strategies.
Thus far, what is known about risk factors is that there are both intrinsic and extrinsic aspects that can possibly play a role in the development of MTSS. Additionally, some of the known risk factors are preventable, while others are inherent and may increase susceptibility. What are still under debate however, are the most common biomechanical risk factors or other direct causes. Understanding the most prevalent risk factors for MTSS may lead to better understanding of the best intervention and prevention approaches. Therefore, it is the purpose of this review to identify the most common risk factors of MTSS, specifically in the athletic population.
METHODS
Search strategy
Search Engine | Key Works | Relevant Articles | Filters | Relevant articles |
PubMed | Shin splints and physical therapy | 31 |
Athletic population, symptoms of MTSS, non case study or systematic review, English |
1 |
Shoes and shin splints | 12 |
Athletic population, symptoms of MTSS, non case study or systematic review, English |
0 | |
Shin splints risk factors | 43 | Athletic population, symptoms of MTSS, non case study or systematic review, English | 8 | |
Prevention of shin splints in athletes | 7 | Athletic population, symptoms of MTSS, non case study or systematic review, English | 1 | |
ProQuest Nursing and Allied Health | Shin splints and physical therapy | 286 | Full text, peer reviewed, not published prior to year 2000, athletic population, symptoms of MTSS | 2 |
Medial tibial stress syndrome risk factors | 982 | Full text, peer reviewed, not published prior to year 2000, athletic population, symptoms of MTSS | 1 | |
Medial tibial stress syndrome and physical therapy | 792 | Full text, peer reviewed, not published prior to year 2000, athletic population, symptoms of MTSS | 0 | |
ProQuest Health and Medicine | Shin splints and footwear | 289 | Full text, peer reviewed, not published prior to year 2000, MTSS symptoms | 0 |
Medial tibial stress syndrome prevention | 1782 | Full text, peer reviewed, not published prior to year 2000, MTSS symptoms | 1 | |
Athletes and medial tibial stress syndrome | 1578 | Full text, peer reviewed, not published prior to year 2000, MTSS symptoms | 1 | |
Google Scholar | Medial tibial stress syndrome and risk factors | 30800 | Not published prior to year 2000, athletic population, MTSS symptoms, non case-study or systematic review, within first 5 pages of search sorted by relevance | 11 |
Medial tibial stress syndrome and athletes | 18000 | Not published prior to year 2000, athletic population, MTSS symptoms, non case-study or systematic review, within first 5 pages of search sorted by relevance | 7 | |
Shin splints risk factors | 20700 | Not published prior to year 2000, athletic population, MTSS symptoms, non case-study or systematic review, within first 5 pages of search sorted by relevance | 3 | |
Cinahl | Medial tibial stress syndrome and risk factors | 31 | Full text, peer reviewed, not published prior to year 2000, MTSS symptoms | 0 |
Study selection
Data extraction and quality assessment
The methodological quality of each article was analyzed using the Physiotherapy Evidence Database (PEDro scale) [4]. Each paper was individually assessed for interval validity, external validity, and statistically sufficiency. A point was awarded for each question if there was sufficient evidence that the requested information was clearly stated. A maximum possible score for methodological quality was 11. A strong score was considered >6, fair 4-6, and poor
RESULTS
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:
Limitations:
|
Sharma et al., |
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
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:
Limitations:
|
Subject description
Overall, our results displayed varying risk factors for developing MTSS. The most common risk factors include general demographics and history, navicular drop, range of motion, pain level, miles ran per week, bilateral ankle strength, exercise history, cortical thickening of tibia shown with MRI, decreased repetition completion during standing heel rise test (decreased plantarflexion strength), presentation of symptoms, foot balance and duration of symptoms which were found significant in ten of the eleven studies analyzed.
Demographics and history
Biomechanical characteristics
Training characteristics
Symptom presentation
DISCUSSION
Higher BMI and female gender were shown to be associated with an increased incidence of MTSS symptoms. With a higher BMI, increased stress is automatically placed on the lower extremities. Adding in high-impact activity too significantly increases the chance of stress-related injuries because the bones cannot handle the additional stress and will not adapt to it quickly, if at all. The relationship between female gender and the development of MTSS has been examined primarily in studies with military populations. Results have shown that the incidence of injury is increased when women train with men and are therefore expected to demonstrate equivalent fitness levels. This is due partly to the fact that women are often smaller in stature than men. Therefore, when attempting to train at the same level as men, women are susceptible to overstrenuous gait changes, such as long stride lengths. This can increase the risk for development of MTSS. Current studies are investigating the separation of men and women during naval-training programs and its effect on incidence of MTSS [1].
Altered biomechanics, such as navicular drop and increased plantarflexion range of motion may also contribute to the development of MTSS symptoms. These factors have a detrimental effect on an individual’s overall lower extremity posture, leading to improper forces placed on anatomical structures during activity. The forces can impact structures that are typically loaded during physical activity, however in a manner that will place an increased stress upon them. When examining these altered mechanics in the ankle/foot complex, in particular the talocrural and tarsal bones, it is evident that increased levels of stress on the structures and cyclic loading produce symptoms [9]. Specifically, navicular drop, measured by the amount of pronation occurring at the subtalar joint, contributes to the altered biomechanics of running, and changes the normal stresses placed on the tibia [6]. This tendency of altered biomechanics to predispose structures to anatomical damage is characteristic of stress injuries, including MTSS.
The results of this review suggest that exercise history and a sudden increase in running distance may place the individual at increased risk for development of MTSS as they are at an increased risk for incurring a stress injury. It has been past suggested that with more experience in athletic activity the tibia has been able to adapt and adjust according to the forces applied a concept that is based on Wolff’s law. However, when increases in athletic participation are sudden, this law is not able to be applied because the body does not have adequate adjustment time. With a longer history of athletic participation, individuals are also in better overall physical fitness. Consequently, muscles and bones will both be able to act accordingly to normal impact forces placed on them during athletic activities [9]. Additionally, it should be taken into account that when a sudden change occurs in the type of exercise, biomechanics of the actions completed are altered and muscle imbalance may play a role in MTSS development secondary to their pull on bone [10].
Finally, higher pain levels and longer duration of symptoms were found to be associated with both the initial onset of the syndrome as well as recurrence in the future. This may be due to the fact that MTSS causes chronic inflammation of the tibia. If athletic participation is not discontinued with symptom onset, the injury site is prevented from healing adequately. Without adequate rest and rehabilitation of the underlying issues that predisposed each athlete to developing MTSS, such risk factors will continue to be present and these individuals will have a continued chance of MTSS symptoms and possible stress fractures. In fact, it has past been concluded that an inverse relationship is present between stress fractures and bone mineral density [12]. The inflammation present with MTSS not only causes pain but inhibits osteoblast cell activity, weakening the bone. If activity is not significantly decreased when such pain occurs, the bone becomes gradually weaker and microfractures occur from the increased stress that the demineralized bone cannot handle. If stress fractures develop and activity is still continued, the athlete might even develop a full fracture. On the other hand, if activity is discontinued at the onset of pain, osteoblastic activity is allowed to resume and bone density is capable of increasing [9].
This systematic review has provided preliminary evidence regarding the prevalence of certain risk factors in the incidence of MTSS. As stated these are primarily related to baseline characteristics (age, gender and BMI), biomechanical factors (range of motion, strength, navicular drop, foot balance, and tibial measures), exercise regimes and history (miles run per week) and presentation of symptoms (such as pain level and duration of symptoms). Although these factors were identified in peer reviewed literature, there was a lack of consistency and agreement amongst the research. Despite the examination of a fairly representative sample of the athletic population, a significant variety of factors were found to play a role in the development of MTSS.
Previous research on MTSS has concluded many of the same things as our review has found. Many relate the limitation of this realm to the small number of studies completed on the subject matter and the wide range of methods used. Both of these create issues with coming to sound conclusions secondary to the insufficiencies. In particular, the impact of foot structure on the possibility of developing MTSS has been reviewed, and adds only that very high and very low foot arches are at increased risk for developing stress injuries on the tibia [9]. When significant findings were found by other reviews, those risk factors were of great similarity to those outlined above. Such significant risk factors include female gender, high BMI, navicular drop, and hip external rotation in males, previous history of MTSS, use of orthotics, and less experienced runners. Based on these findings, it was also suggested that males and females be evaluated separately when evaluating the risks for MTSS as the different body compositions, bony structure, and resulting kinematics may play significant roles in potentiating factors [7]. Overall, all studies that have looked at MTSS and the associated risk factors have not been able to definitively state reasons for development or propose prevention strategies based on gathered information.
Several limitations were encountered throughout this systematic review. One such limitation is that of low PEDro scales of a majority of the studies. It would have benefited this systematic review more to include studies all of which had strong scores based on the PEDro scale. Thus, the results of this study should be interpreted with caution. A second limitation of this systematic review is the variability of subjects, as not all athletes were participants of the same sport and were of different levels of competition. Such differences may impact the interpretation of the results and how they can be applied to different populations. Additionally, several of the studies used within this review had small sample sizes, which limit the generalizability of the results, as does the overall small number of studies used in this review. Of the studies included, many limitations were common between them, including limited blinding (subjects, therapists, or assessors), lack of randomization (for subject recruitment, group allocation, or order of assessments completed), self-reporting of symptoms, subjects entering studies at different stages of MTSS development, attrition, and lack of control groups.
Despite all of the limitations to this review, several aspects were conducted appropriately and led to some basic conclusions about the subject area. The review can serve as a comprehensive summary of the current and available research that exists regarding this topic. Although the resulting list of studies included was less than optimal, it provides a decent overview of the risk factors for MTSS. This was accomplished in part due to the strengths that were evident in many of the individual studies. One of the key aspects of the research that has been conducted thus far in this area is the inclusion of a definition of MTSS for the purpose of the research. This improves the accuracy and consistency of the results that are obtained. In addition, many of the studies operationally defined their samples as well as their outcome measures. These samples were typically representative of the population that of interest. Furthermore, many of the studies included time frames that were adequate in order to capture the outcomes of interest, populations with similar demographic and baseline characteristics, and reliable statistics. Finally, the current research being conducted on this topic generally requires limited to no equipment, improving the opportunity for clinical application.
Although this review successfully revealed a multitude of factors that are associated with the development of MTSS, instead of identifying a definitive list of those that can be addressed through treatment and prevention, it highlighted gaps in the information regarding this topic. Future research should focus on narrowing the group of potential risk factors to a more precise collection that have been consistently correlated with the development of MTSS and can be used in clinical practice for prognostic purposes. It may be beneficial to continue studies addressing the athletic population initially as this is the population that is most affected by MTSS. Future studies should also attempt to use larger sample sizes, from more diverse populations of athletes. Subjects could also be analyzed within groups based on the type of impact sport, such as ballistic movement versus cyclic high-impact activity. Running mechanics could also be analyzed using advanced technological resources, such as a gait mat or other computer software to analyze specific areas of the lower extremities receiving increased force or abnormal loading. Once conclusive evidence is achieved regarding the consistent risk factors that contribute to the incidence of MTSS, they can be applied to the clinical treatment and prevention of this condition to ultimately achieve a decreased impact on the quality of life of those impacted.
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Citation:Singh R (2016) Medial Tibial Stress Syndrome: Who’s at risk? A systematic Review. J Phys Med Rehabil Disabil 2: 014.
Copyright: © 2016 Singh R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
