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Medial tibial stress syndrome

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Apr 1, 2006.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Risk factors and prognostic indicators for medial tibial stress syndrome.
    Moen MH, Bongers T, Bakker EW, Zimmermann WO, Weir A, Tol JL, Backx FJ.
    Scand J Med Sci Sports. 2010 Jun 18. [Epub ahead of print]
  2. stickleyc

    stickleyc Active Member


    Based on years of treating MTSS and related pathologies in college athletes and then getting into the topic in my research, I am of the opinion that there are likely 2 separate (though likely related in some way) mechanisms causing pain in the lower leg (along the tibia) exacerbated with exercise and alleviated with rest. One of these mechanisms is likely related to tibial bending as you describe, however, I believe there is evidence both empirically and anecdotally to suggest that a soft tissue mechanicsm exists that creates an almost identical clinical picture. These 2 distinct mechanisms producing the same clinical picture would provide some explanation why some people progress from shin pain to tibial stress fracture despite very aggressive treatment while others can continue to push the exercise volume while symptomatic and still not progress to a stress fx (ie. because the bone is not involved in the same manner - tibial bending - in creating the pain). The exact soft tissue mechanism is still a subject of debate but I have come to subscribe to a fascia-mediated cause.

    So for now, I'm a fan of using the term exercise related lower leg pain (ERLLP) as the term describing the clinical symptomatology with MTSS referring to ERLLP with a soft tissue mechanism at its core and tibial stress fx referring to the likely outcome of ERLLP mediated by tibial bending. Granted, this is largely a semantics issue but clarifying terms related to these pathologies have been recognized as an important aspect of the discussion going all the way back to the time when only "shin splints" was used.

    I also know my thoughts/theories on the matter are no more definitive than any others in this area since it seems like every study I read attempting to clarify the debate on these issues seems to only muddy the waters even more.

    We summarize our thoughts a bit here if you're interested:

    Crural fascia and muscle origins related to medial tibial stress syndrome symptom location.
    Stickley CD, Hetzler RK, Kimura IF, Lozanoff S.
    Med Sci Sports Exerc. 2009 Nov;41(11):1991-6.
  3. Chris:

    I agree with you that the injury we call medial tibial stress syndrome (MTSS) is likely both caused by abnormal tibial bending and abnormal medial fascial traction forces as I recently outlined in an article for Podiatry Today: Current Concepts in Treating Medial Tibial Stress Syndrome.

    However, I believe the term "exercise related lower leg pain" is too general a term to use in describing the very specific diagnosis of medial tibial stress syndrome, since there are very many causes of exercise related leg pain, which I discuss in my article. Anterior tibial muscle strain, chronic exertional compartment syndrome, and fascial herniation are all forms of "exercise related lower leg pain" which are quite separate and distinct from MTSS. At this point in time, I think the vast majority of experts on this subject are continuing to use MTSS as the proper term for tenderness along the medial tibial border that is not due to medial tibial stress fracture (MTSF).

    Tibial bending, to me, seems the most likely explanation for the vast majority of MTSS and MTSF given the current research evidence and my clinical experience in treating these patients. A close review at the scientific literature reveals that females are much more likely to develop MTSS than their male counterparts even though they would normally be expected to have less fascial tensile force than men athletes due to their decreased mass relative to boys/men. Tibial bending is a much better explanation for the female to male prevalence of this injury due to the decreased bone density and decreased area moment of inertia of the tibia in females vs male athletes. But I do agree with you that the crural fascia is a much more likely culprit for a cause of this injury in some individuals rather than traction force on the tibia from any of the extrinsic muscles of the foot.

    What is also quite obvious to me is that treatment with varus wedged foot orthoses with varus forefoot extensions seems to be, in my hands, the most successful form of treatment for MTSS in the hundreds of running and jumping athletes I have seen with this condition over the past quarter century. Further research hopefully will shed more light on how much tibial bending vs fascial traction are the causes for these common running and jumping injuries. A copy of your article would be greatly appreciated. Thanks for sharing.:drinks
  4. stickleyc

    stickleyc Active Member

    Kevin - I enjoyed the article. It would seem we are generally of the same opinion though I would raise a couple of questions:

    Of those you list, it seems there are differentials for many of those (mostly based on slight differences in symptomatology) that make them less enigmatic than the clinical picture presented by what I would consider the big 3 of ERLLP: CECS, MTSS, TSF. I would not subscribe to using ERLLP to include all lower leg pain (as the generality of the name implies) but many have used it as an operational definition for the clinical picture presented by MTSS, TSF and CECS which can be difficult (if not impossible) to differentiate without diagnostic testing. Since we often cannot truly differentiate between these three based on clinical exam (if there are no neurologic changes from CECS), would you propose calling it MTSS until it has been definitively diagnosed as TSF through bone scan or CECS through pressure study? Granted, MTSS uses the word syndrome and therefore may be an appropriate label for a group of symptoms that may include separate distinct underlying pathologies. However, if so, then doesn't that remove the ability of a distinct diagnosis for this symptom pattern in the presence a negative bone scan and negative pressure study? In this case I think an argument can be made for a distinct pathology caused (at least predominantly) by soft tissue/crural fascia traction which needs a diagnosable name. I think it serves to confuse the issue to use MTSS to describe the clinical picture then, if a bone scan or pressure study comes back positive we change the name of the diagnosis (as we should) but if these studies are negative, we continue to call it MTSS even though the study results suggest a differing mechanism which likely will dictate a different treatment approach. Your thoughts?

    I would agree with the TSF portion of that statement but as above, it seems there has to be a mechanism that is significantly different in those cases where patients never progress to focal tibial pain associated with TSF and in many of my college athletes who are able to maintain all but full training and never progress beyond diffuse pain along the entire distal half of the medial tibial edge.

    Though I could add other thoughts, I must end quickly since the U.S. just scored in stoppage time and why spend time addressing important professional issues when there is celebrating to do.:D
  5. Griff

    Griff Moderator


    Attached Files:

  6. I would agree that I cannot necessarily differentiate MTSS from MTSF since both types of injuries will produce tenderness along the medial tibial border, most commonly in the distal 1/2 of the tibia. However, to lump in chronic exertional compartment syndrome (CECS) with MTSS and MTSF is a bit of a stretch, in my opinion.

    CECS can occur in any of the four compartments of the leg and I have never seen it cause the type of medial tibial border tenderness that is produced in MTSS or MTSF. In addition, I have never had a patient with MTSS or MTSF describing the sensation of "tightness" or "fullness" in the leg whereas this is a common description with CECS. Patients with CECS will typically describe a more gradual "tightness", "fullness" in their legs as the run progresses which will resolve nearly completely with a five minute rest and then starts up again in a few minutes after rest again. MTSS and MTSF will either prevent any running, and resting during the run will not reduce pain significantly so that they can run pain free again for a few minutes (history taking is key here). Finally, in my clinic, for every patient with medial-posterior compartment CECS I will see about 40 patients with MTSS or MTSF so medial-posterior CECS is not a common injury in my area.

    My theory on this clinical observation, which I have also seen numerous times, is that the tibias that are more dense and have greater cross-sectional area will be more likely to develop MTSS and never develop MTSF while the tibias that are less dense and have lesser cross-sectional area will progress fairly rapidly from MTSS to MTSF. Let's take an example of a thicker oak board versus a thinner pine board. If identical magnitudes of bending moments are placed across the thinner pine board as are placed across the thicker oak board, the pine board will start to splinter on the edge sooner and break sooner than will the thicker oak board which will still splinter on the edge, but may never break, if the bending moments are low enough. Therefore, the patients that develop MTSS and never develop MTSF may be thought, in my opinion, to have "stronger tibias" than the patients that go from MTSS to MTSF in weeks. When I was training heavily (70-90 miles per week) for distance running during the 1970s and 1980s, my medial tibial borders were always tender to palpation, but I never once had medial tibial pain with running. Therefore the bending was occurring also in my tibia, but since I had been running since childhood and I have thick tibias, I probably didn't have enough injury to cause symptoms with running.

    Saw that great performance also.....GO USA!!!!
  7. stickleyc

    stickleyc Active Member

    Kevin - I'm enjoying the discussion and appreciate the feedback.

    A couple of thoughts...

    Agreed that CECS that presents classically as you describe is a smaller percentage of patients I have seen (though highly concentrated in female soccer players for some reason - anatomically smaller compartments and lots of exercise that hypertrophies the deep posterior compartment muscles?)

    However, I have worked with 2 ortho's as team physicians at 2 unrelated schools who both proposed to me that recalcitrant MTSS with negative bone scan and negative pressures may still be related to a compartment syndrome type mechanism where expansion of the muscles of the deep compartment cause fascial traction (and pain) but not always the neurologic findings in classic cases. Additionally, if the increased pressure on the fascia within the compartment was due to a greater extent to chronic hypertrophy as opposed to the transient pressure changes associated with exercise onset, then I could see there being no report of "fullness that dissipates with a short rest" that classic CECS describes. Both of these physician based their belief on the noted improvements they had seen in people with very chronic MTSS (and no indications of CECS) who they stripped the fascia (opening the deep posterior compartment) during surgery. Interestingly, after the article I listed was published, another ortho I've never met emailed me with the following observation:

    "most interesting, is what is found at surgery. I learned from [my mentor] that chronic MTSS can be cured surgically. You strip off all the medial fascia, remove it from the muscle and cauterize the muscle and bone to (theoretically) kill any pathologic nerve endings."

    It is possible though that this type of atypical CECS would be much less likely to develop in a non-athletic population who doesn't do lots of repetitive exercise to hypertrophy those muscles.

    Also, I know all of this is anecdotal and just individual opinions but I find it interesting to consider.

    Your thicker vs. thinner tibiae argument is compelling. I'll have to think about that one a bit more.

    I would ask this though: The previously mentioned ortho who emailed me made this statement regarding his clinical assessment of MTSS:

    "The bending theory for the diffuse lower 1/3 pain is unlikely as 3-point bending of the tibia in physical exam in negative for MTSS and positive for stress fracture (as proved by bone scan)."

    Would you disagree based on your experience with clinical exam of these patients? In your oak board analogy, wouldn't the thicker tibia which experiences more diffuse pain still be positive (for pain) during 3-point bending if the underlying mechanism for pain is still tibial bending?

    The likely answer has nothing to do with the thickness of your tibias but more so related to the fact that you were wearing shoes and couldn't find a pair of five-fingers anywhere.

    I find this area particularly interesting because it is so enigmatic...look how unclear this whole thing is even before adding tibial torsion and free moment differences in TSF and MTSS into the picture.
  8. The resolution of symptoms with fasciotomy does tend to point toward a fascial cause of MTSS. This is why I stated in my article that these injuries are probably caused by a combination of both fascial traction and tibial bending.

    However, I don't think that even the most lumberjack-like orthopedic surgeon could put enough "three point bending force on the tibia" to mimic the high magnitudes of ground reaction forces seen in running or jumping activities....and I've worked in orthopedic surgeon groups for the past 25 years. It is the bending during running (2.5-3.0 times body weight) or jumping (up to 7.0 times body weight in high jumping) that produces the injury of MTSS and MTSF, not 1.25 times body weight experienced during walking. In other words, the three point test is useless for diagnosing these conditions, in my experience.

    Great discussion, Chris.....you need to hang out here on Podiatry Arena more often!!:drinks
  9. Likewise, Chris.

    I see very little chronic exertional compartment syndrome (CECS), but, when I do, it is much more common in females, in my experience.

    It would be very interesting to do a study where you took a group of control athletes versus those that had this surgery and allowed the control athletes to rest from running the same amount of time that the surgical patients needed to rest to recover from surgery. I'll bet that the non-surgical controls would also show significant improvement. That is not to say that fascial stripping doesn't help some athletes. If the medial tibial fascia is involved in these injuries (I think it may involved to some extent in some patients) the medial tibial fascial stripping would certanly make sense. I would think, however, that these are variants of medial tibial stress syndrome (MTSS) if their primary pain/tenderness is localized to the medial tibial border and not in the deep posterior compartment.

    CECS is due to more strenuous exercise with the volume of the muscle increasing signficantly to the point where the intracompartmental pressures are high enough to cause nerve compression, arterial compression or muscle compromise/damage. To my knowledge, CECS has never been reported within the medical literature for walking or standing. If they get walking pain, then we think more intermittent claudication than CECS. People with CECS will have very tight muscle compartments upon clinical examination done in a non-weigthbearing manner, where these compartments will be more supple, not full and non-compressible if CECS is present. This is best appreciated, of course, after 10-20 minutes of some more vigorous exercise, such as running, but won't happen even with fast walking usually.

    The example of comparing beams from wood species with different densities and of different cross-sectional diameters is a very good one. If you consider it closely, you will likely find that it offers a very mechanically sound explanation of why some patients with MTSS go on to develop medial tibial stress fracture, while others do not.

    A wood board or a tibia will bend more (greater bending strain) at a single 1 mm x 4 mm fracture site that is on one of its edges than will a board with 10 microfractures of .01 mm x .02 mm over a 10 cm length over the edge of the board or tibia. The stress fracture, therefore, would be expected to be more painful than the multiple microfractures that exist over a longer surface area when either weightbearing activities or manual three-point bending maneuvers are performed. I really don't see any problems here since it make perfect mechanical sense, at least to me.

    I have had the good fortune to be involved in cadaver research with the Penn State Biomechanics lab and Steve Piazza, PhD and Neil Sharkey, PhD, two very smart guys. Neil coauthored a book on bone physiology and does a lot of work on the microscopic structure of bone and the mechanics/physiology of fractures and I have learned a lot from him on this subject. In fact, there were plans at one time to do a tibial strain/orthosis study on their dynamic gait simulator which can mimic running a few years ago. Hopefully some day we can do that study since this would be a great study to investigate the effects of foot orthoses on tibial strains to test the "bone bending theory" of MTSS. I'll keep my fingers crossed.
  10. physiocolin

    physiocolin Active Member

    Hi Kevin

    As a physiotherapist having worked for many years with athletes and the miliotary, I find the MTSS pathology probably one of the most exacting challenges in the female athlete. Certainly when working in the military it wasn't unusual to take them off all impacting related activities for 3 - 6 months.

    The question I have is there any research to perhaps look at the nutritional advice to support improvement in bone structure? Is there perhaps a trabeculae insufficiency in these prone individuals?


    Colin Campbell
  11. Dear All
    The posts on this topic are fascinating and so well researched.
    My humble contribution is to refer readers to the work done by Janet Travell on Myofascial Pain and Dysfunction.
    Indeed the Fascia has always been to Osteopaths a very important area of study.
    The Fascia Congress last year in Amsterdam was a mine of information on a neglected anatomical structure. I look forward to your comments Brian
  12. Colin:

    Sorry I haven't replied sooner. I've been very busy lately.

    There is, of course, the problem that many female athletes may not have normal menstrual cycles which may over time affect bone density. In addition, many teenage females may not have enough calcium in their diets, especially if they think that milk will make them fat. Certainly, any clinician that has a female athlete as a patient should inquire regarding menstrual cycles and dietary habits in addition to all the normal questions regarding their sport, training history, shoes, etc.

    Here is a nice pdf from Harvard on tibial stress injuries and the multifaceted approach the clinician should consider in these athletes.
  13. jensglynne

    jensglynne Member

    ("I tell my patients that these varus forefoot extension orthoses have been "tuned" specifically for running and should not be used for walking since I am worried about potential problems with first ray/first MPJ mechanics in walking with large amounts of varus forefoot extensions. I don't worry about this being a factor in running since the requirements for first MPJ dorsiflexion seem to be much less for running than for walking and I don't think the windlass is as big of a factor for running as it is for walking.") Originally posted by Kevin Kirby

    Kevin, Would you use this type of forefoot Varus Extention for a patient presenting with MTSS Symptoms, who is not a "runner" but a high level Basketball player?

    My concern is that in basketball the individual not only runs in a straight line, but moves from side to side, walks, jogs, jumps, etc...

    Can we ignore windlass in cross-training activities such as this. Tennis, Basketball, Netball etc??


    Jens :eek:
  14. physiocolin

    physiocolin Active Member

    Hi Kevin

    Much appreciated. Thanks also for the informative PDF, which was comforting in supporting most of what I have applied.


  15. Jens:

    Good question!

    Yes, as you have noted, side to side sports (e.g. football, basketball, netball, tennis, racketball, squash, etc) are a little more tricky when a varus forefoot wedge is used since these varus wedges may increase the risk of inversion ankle sprains. I still may use varus forefoot wedges in treating medial tibial stress syndrome in athletes participating in these sports but will try to avoid their use initially and see if the symptoms improve with just the use of a well-made full-length foot orthosis
  16. Deansargeant

    Deansargeant Member

    I don't worry about this being a factor in running since the requirements for first MPJ dorsiflexion seem to be much less for running than for walking and I don't think the windlass is as big of a factor for running as it is for walking.")

    In reponse to your reply to Jens' question, how much importance do you place on the windlass mechanism when treating athletes who perform cross training like activities ie. basketball or tennis?

  17. Dean:

    I believe the windlass mechanism is an over-rated mechanism to allow normal foot function in many sports activities since patients with 1st MPJ arthrodeses can still play these sports with little to no problem. The windlass mechanism of the first metarsophalangeal joint (MPJ) probably has its greatest effect during walking activities where, during first MPJ dorsiflexion, the center of mass (CoM) of the body is falling toward the ground. In running or jumping activities, the CoM is rising away from the ground while 1st MPJ dorsiflexion is occurring so that the demand on hallux dorsiflexion is decreased during running and jumping. Since side to side sports like basketball, tennis, racketball, squash, etc. require more lateral movement which doesn't necessarily require much 1st MPJ dorsiflexion, then the windlass is probably not all that important in these sports either. That is not to say that proper windlass function doesn't affect foot function. However, from what I have seen in my patients that end up having successful 1st MPJ arthrodesis surgeries and are able to function quite well with no windlass function whatsoeve, the windlass probably isn't as important in running and jumping sports as we had previously thought it was.

    Hope this helps.
  18. NewsBot

    NewsBot The Admin that posts the news.

    Just picked up this pearl:
    Medial Tibial Stress Syndrome….It’s not what you think !
    from Functional Anatomy Seminars - Functional Anatomic Palpation Systems™ | Functional Range Release™ by Dr. Andreo Spina

  19. Craig Payne

    Craig Payne Moderator

    This just turned up on You Tube.
    Interesting dry needling teachnique....also notice half way through when he tests the 'bending moments' we discussed earlier in this thread.

    Last edited by a moderator: Sep 22, 2016
  20. NewsBot

    NewsBot The Admin that posts the news.

    Biomechanical and lifestyle risk factors for medial tibia stress syndrome in army recruits: A prospective study.
    Sharma J, Golby J, Greeves J, Spears IR.
    Gait Posture. 2011 Jan 17. [Epub ahead of print]
  21. LMadeley

    LMadeley Member

    Just interested in the practical design parameters in Kevin's article:

    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

    What angulation of forefoot varus wedging do you normally use that is practical? Have you tried extending the padding to the plantar hallux which would assist windlass activity when the heel unweights?
  22. Thickness plantar to the first metatarsal head starts out at 3 mm, beveled down to 0 mm thickness at lateral 4th metatarsal head. May add or subtract from that varus wedging thickness depending on gait examination and patient symptomatic response. May also continue this varus forefoot extension to plantar to the hallux but I always bevel the sub-hallux pad distally to prevent dorsal shoe upper irritation.

    The proper amount of forefoot varus extension often is what makes the most difference for runners in the orthosis, especially for midfoot to forefoot striking runners.

    Hope this helps.
  23. NewsBot

    NewsBot The Admin that posts the news.

    The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study.
    Moen MH, Bongers T, Bakker EW, Weir A, Zimmermann WO, van der Werve M, Backx FJ.
    J R Army Med Corps. 2010 Dec;156(4):236-40.
  24. Romeu Araujo

    Romeu Araujo Active Member

    Hi all,

    I looked for a study that included Q-angle as a factor for MTSS, but didn't found it.
    Do you know any? Or an opinion article?

    Thank you.

    Best regards,
  25. Heres some reading re Q angle and MTSS - no significant relationship but Navicular Drop was -
    The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athlete

  26. Romeu Araujo

    Romeu Araujo Active Member

    @M Weber,

    Thanks for the papers!

  27. NewsBot

    NewsBot The Admin that posts the news.

    Risk factors and prognostic indicators for medial tibial stress syndrome
    M. H. Moen et al
    Scandinavian Journal of Medicine & Science in Sports; Volume 22, Issue 1, pages 34–39, February 2012
  28. Craig Payne

    Craig Payne Moderator

    At the very start of this thread we had the discussion about the role that tibial bending moments might play in MTSS. It is assumed that the bending moments are greater in running, due to the narrower base of gait (ie runners varus). The suggested treatment based on that hypothesis is the use of medial wedging in the shoe to adjust the location of centre of force, so that the bending moments are reduced. The feedback I get is that more and more people are doing this and find it helpful.

    I was just reading Anatomy for Runners by Jay Dichary, based on a recommendation from the author of Tread Lightly. Anatomy for Runners has its flaws and does promise the second coming of the messiah, but one comment jumped out at me in relation to MTSS:

    "Slightly widen the stance so that the second toe lands on the edge of the white line on track or bike lane"

    While I have some issues with "second coming of the messiah" stuff in the book, I assume that the clinical experience of the author is that changing the running gait to a wider stance helps with MTSS ....what is he doing by that? .... reducing the runners varus and hence the bending moments in the tibia!!! .... don't you love it when a plan comes together!
  29. The base of gait of running should affect tibial bending moments but will also affect subtalar joint pronation moments also, both of which may have an effect in causing medial tibial stress syndrome (MTSS) and medial tibial stress fracture (MTSF). In addition, widening the base of gait during running will alter the frontal plane orientation of the ground reaction force vector relative to the center of mass of the body, which may cause a decrease in the metabolic efficiency of running or create tissue stresses on other structures. Therefore, it seems more mechanically sound and practical to me to "bring the ground up to the foot" with a varus-wedged foot orthosis to treat MTSS and MTSF than to instruct runners to try to train themselves to run with a wider base of gait. However, it is an interesting clinical observation that widening the base of gait may help prevent or reduce the symptoms of MTSS and/or MTSF.
  30. Samuel Ong

    Samuel Ong Member

    I have a 26 year old male patient with MTSS. He plays basketball twice a week. He used to do many other sports, but only started getting the pain when he started playing basketball.

    He has forefoot supinatus with high supination resistance and functional hallux limitus.

    On his first visit I gave him OTC vasyli with a 4 degree rearfoot and forefoot varus post. When he returned 2 weeks later he reported that his symptoms has gotten worse. Instead of having pain on the distal 1/3 or the tibia, he now has pain on the distal 2/3 of his tibia. I changed his forefoot varus post into a forefoot valgus post instead.

    Should I have persisted with the forefoot varus posting? Has anyone encountered the same problem as me?
  31. Timm

    Timm Active Member

    Hi Samuel,

    I have had 2 similar experiences in Bball players with MTSS.
    The change of approach from forefoot varus wedging to forefoot valgus wedging made a big difference in both cases. One of the guys found he actually couldn't dunk with the forefoot varus wedge in and the moment who took the wedge off he could..

    My theory - the similarities between these 2 patients - they both running had a large degree of out-toe, with the varus wedge seemingly 'blocking' their natural path of least resistance (stress has to go somewhere). The forefoot valgus wedge reduced their pain and also improved 1's jumping performance by lowering the Windlass force and facilitating 1st MPJ function as opposed to limiting it.

    I'd have my orthotic prescription aimed at lowering the Windlass force and seeing how that goes...

    Hope that helps and best of luck!

  32. Samuel Ong

    Samuel Ong Member

    Hi Tim,

    Thank you for your reply and insights .

    I was wondering if perhaps I had done my forefoot varus post wrongly? (ie. do I need to bevel the anterior edge of the forefoot varus post just proximal to the MPJs?)

    It would be interesting to have Kevin and Craig's thoughts on treating MTSS with a reafoot varus and forefoot valgus post.

    Just when I'm starting to get a hold of biomechanics, it throws a curveball at me :craig:!!! (I am using baseball terminology in hope that this will draw Kevin's attention to this post)

  33. Sam:

    Sounds like an interesting case.

    In runners, I will always use a varus forefoot extension in treating medial tibial stress syndrome (MTSS) along with an orthosis that provides a medial heel skive and good medial longitudinal arch support. This type of orthosis seems to relieve the pain from MTSS in 75-80% of cases. By the way, the varus forefoot extensions I use on these orthoses end distally at the sulcus and are beveled at the sulcus so that the digits are not supported by the varus forefoot extension.

    However, when treating athletes who are involved in side-to-side sports, such as basketball, soccer (football) and tennis, one must be careful of adding varus forefoot extensions to orthoses since excessive varus influences under either the rearfoot or forefoot may increase the likelihood of inversion ankle sprains. Your idea of adding a varus influence at the rearfoot and a valgus influence at the forefoot is an orthosis modification that I have used for the past 20 years in athletes competing in side-to-side sports, but only if I am worried that a varus forefoot extension may cause lateral ankle instability.

    In other words, I still use small amounts of varus forefoot extensions on orthoses for side-to-side sport athletes in treating MTSS, but, if the athlete feels as if this modification makes them feel "laterally unstable", I may switch the varus forefoot extension to a valgus forefoot extension, just as you did.

    Hope this helps.:drinks
  34. Samuel Ong

    Samuel Ong Member

    Hi Kevin,

    Thank you for an excellent reply.

    What did you do in the other 20-25% of cases which did not get relief from the orthosis?

    I too believe that MTSS is caused by bending of the tibia. But is there a possibility that in this case MTSS is caused by the solues muscle , flexor digitorum longus muscle or crural fascia? In your opnion, what are the percentages of MTSS that occur not from bending of the tibia?

    Finally, if MTSS is caused by strain in the soleus muscle or flexor digitorum longus muscle or fasciitis from the crural fascia, would a varus rearfoot post and valgus forefoot post potentially help relieve the pain?

    Thanks in advance :drinks

  35. Since most cases of MTSS get better with orthoses, I will try other things such as stretching, physical therapy and even different shoes and running styles in those that don't respond 100% to orthoses. I don't think I have seen anyone in the last five years that didn't get at least some better with foot orthoses, but not everyone gets 100% pain relief.

    MTSS is likely caused both by valgus tibial bending and traction on the soleal fascia, FDL etc. It may be a combination of both of these stresses on the medial tibial cortical wall that causes the symptoms of MTSS. I don't have a clue whether valgus forefoot posts help one type of MTSS from the other because, honestly, I really don't know whether it is the tibial bending or soft tissue traction that is causing the majority of the pain in the patients I see with MTSS.

    Hope this helps.:drinks
  36. NewsBot

    NewsBot The Admin that posts the news.

    The knowledge of medial tibial stress syndrome of parents and coaches of adolescent athletes
    by McShane, Joseph J., M.S.,
  37. Peter1234

    Peter1234 Active Member

    Hi there,
    this paper seems to sum it up: its the deep crural fascia that is partly to blame for the surrounding symptoms (MRI) seen at the medial tibia- apart from excess tibial bending. None of the muscle attachments or insertions have connections with the distal 2/3 of the medial tibia as has been suggested on occasion. Hope this provides some clarity.

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    The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial
    Maarten H Moen, Leonoor Holtslag, Eric Bakker, Carl Barten, Adam Weir, Johannes L Tol and Frank Backx
    Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2012, 4:12
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    Medial tibial pain pressure threshold algometry in runners
    Osama Aweid, et al
    Knee Surgery, Sports Traumatology, Arthroscopy; June 2013
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    Review of Medial Tibial Stress Syndrome: A Comparison of In Vivo and Computational Methods
    Wesley R and McCullough M
    Austin J Biomed Eng. 2014;1(5): 1025. (full text)

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