Fredericson MRI classification of medial tibial stress syndrome

Craig Payne · Jan 20, 2013

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I kind of missed this....

Diagram of classification here

Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system.
Fredericson M, Bergman AG, Hoffman KL et-al.
Am J Sports Med. 23 (4): 472-81. 1995

Medial tibial pain in runners has traditionally been diagnosed as either a shin splint syndrome or as a stress fracture. Our work using magnetic resonance imaging suggests that a progression of injury can be identified, starting with periosteal edema, then progressive marrow involvement, and ultimately frank cortical stress fracture. Fourteen runners, with a total of 18 symptomatic legs, were evaluated and, within 10 days, referred for radiographs, a technetium bone scan, and a magnetic resonance imaging scan. In 14 of the 18 symptomatic legs, magnetic resonance imaging findings correlated with an established technetium bone scan grading system and more precisely defined the anatomic location and extent of injury. We identified clinical symptoms, such as pain with daily ambulation and physical examination findings, including localized tibial tenderness and pain with direct or indirect percussion, that correlated with more severe tibial stress injuries. When clinically warranted, we recommend magnetic resonance imaging over bone scan for grading of tibial stress lesions in runners. Magnetic resonance imaging is more accurate in correlating the degree of bone involvement with clinical symptoms, allowing for more accurate recommendations for rehabilitation and return to impact activity. Additional advantages of magnetic resonance imaging include lack of exposure to ionizing radiation and significantly less imaging time than three-phase bone scintigraphy.
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Validation of MRI classification system for tibial stress injuries.
Kijowski R, Choi J, Shinki K et-al.
AJR Am J Roentgenol. 2012;198 (4): 878-84.

OBJECTIVE:
The purpose of our study was to compare an MRI classification system for tibial stress injuries with semiquantitative MR features of injury severity and clinical outcome.

MATERIALS AND METHODS:
Two musculoskeletal radiologists retrospectively reviewed in consensus the MR findings of 142 tibial stress injuries to quantify the degree of periosteal and bone marrow edema and grade the injuries using the Fredericson classification system (grade 1 = periosteal edema only, grade 2 = bone marrow edema visible on T2-weighted images, grade 3 = bone marrow edema visible on T1-weighted and T2-weighted images, grade 4a = multiple focal areas of intracortical signal abnormality, and grade 4b = linear areas of intracortical signal abnormality). Kruskal-Wallis tests were used to determine the relationship between the grade of stress injury and the degree of periosteal and bone marrow edema and the time to return to sports activity.

RESULTS:
Grade 4b injuries had significantly (p < 0.002) more severe and grade 1 injuries less severe periosteal and bone marrow edema than grades 2, 3, and 4a injuries. Grade 4b injuries had significantly (p < 0.002) longer time and grade 1 injuries shorter time to return to sports activity than grades 2, 3, and 4a injuries. There was no significant difference (p = 0.06-0.79) among grades 2, 3, and 4a injuries in the degree of periosteal and bone marrow edema and the time to return to sports activity.

CONCLUSION:
Grades 2, 3, and 4a stress injuries had similar degrees of periosteal and bone marrow edema and similar time to return to sports activity, which suggests that these three grades can be combined into a single category in an abbreviated Fredericson classification system.
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Admin2 · Jan 20, 2013

Related threads:
Other thread tagged with medial tibial stress syndrome
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Proximal influences in medial tibial stress syndrome
Two simple clinical tests for predicting onset of medial tibial stress syndrome
Midfoot kinematics and muscle activation in patients with medial tibial stress syndrome
Medial tibial stress syndrome and bone marrow edmea
Foot type and tibial stress injuries

Kevin Kirby · Jan 20, 2013

Craig Payne said: ↑

Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system.
Fredericson M, Bergman AG, Hoffman KL et-al.
Am J Sports Med. 23 (4): 472-81. 1995
Click to expand...

I have been mentioning Fredrericson's classifications system on medial tibial stress syndrome/fracture in my lectures on medial tibial stress injuries for quite a few years now.

Here is the lecture I gave over seven years ago in Melbourne on MTSS where I mentioned Fredericson's excellent paper that, I believe, everyone treating athletes should read.

Originally Posted by Kevin A. Kirby, DPM: October 15, 2005: At 2005 Australian Conference of Science and Medicine in Sport, Melbourne

Medial Tibial Stress Syndrome: Biomechanical Etiology and Effective Foot Orthosis Treatment

Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine
Oakland, California, USA

Leg Pain in Athletes

 Pain that occurs in the lower legs during exercise has commonly been called “shin splints” within the medical community for the past 50 years
 As our knowledge has increased regarding the specific pathologies that cause exertional leg pain, it has been recommended to discard the term “shin splints”
 Shin splints is “a nonspecific term used to describe exertional pain from almost any cause”
Anderson MW, Ugalde V, Batt M, Gacayan J: Shin splints: MR appearance in a preliminary study. Radiology 204:177-180, 1997.

Differential Diagnosis of “Shin Splints”

 Tibial or fibular stress fractures
 Chronic exertional compartment syndrome
 Arterial or nerve entrapment
 Deep vein thrombosis
 Fascial herniations
 Muscle strains or tears
 Medial tibial stress syndrome

Medial Tibial Stress Syndrome

 In 1974, the term “tibial stress syndrome” was first reported in the literature by Clement and the term “medial tibial syndrome” was first reported in the literature by Puranen
Clement DB: Tibial stress syndrome in athletes. J Sports Med, 2:81-85, 1974.
Puranen J: The medial tibial syndrome. JBJS, 56B:712-715, 1974.
 “Medial tibial stress syndrome” was first coined as a term by David Drez, MD and first used within the medical literature by Mubarak et al in their 1982 study of 12 patients with leg pain
Mubarak SJ, Gould RN, Lee YF, Schmidt DA, Hargens AR: The medial tibial stress syndrome: A cause of shin splints. Am J Sp Med, 10:201-205, 1982.

Incidence of MTSS

 Running sports and jumping sports are, by far, the most common causes of MTSS
 In aerobic dancers, 22% of all injuries were due to MTSS
Taunton JE, McKenzie DC, Clement DB: The role of biomechanics in the epidemiology of injuries. Sports Med, 6:107-120, 1988.
 In runners, MTSS accounted for between 13.2% to 17.3% of all injuries
Clement D, Taunton J, Smart G, McNicol KL: A survey of overuse running injuries. Phys Sportsmed, 9:47-58, 1981.
Epperly T, Fields K: Epidemiology of running injuries. In O’Connor F, Wilder R (eds), Textbook of Running Medicine. New York, McGraw-Hill, 2001, pp. 1-11.

 Prospective study by Yates and White on 124 Australian military recruits from HMAS Cerberus, Australia’s largest naval training facility, showed that, during basic training, 40 of these recruits (35%) developed MTSS
Yates B, White S: The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sp Med, 32:772-780, 2004.
 Prospective study of 125 high school distance runners showed a 13% incidence of MTSS
Bennett JE, Reinking MF, Pluemer B, et al: Factors contributing to the development of medial tibial stress syndrome in high school runners. J Ortho Sports Phys Ther, 31:504-511, 2001.

Predominantly in Females?

 In a study of 125 high school XC runners, 15 runners developed MTSS, 13 female and only 2 male (6.5 female/male ratio)
Bennett JE, Reinking MF, Pluemer B, et al: Factors contributing to the development of medial tibial stress syndrome in high school runners. J Ortho Sports Phys Ther, 31:504-511, 2001.
 Incidence of tibial stress reaction was .75/1000 in males vs 8.0/1000 in females during basic training (over ten times more likely in female than male recruits)
Reinker KA, Ozburne S: A comparison of male and female orthopaedic pathology in basic training. Military Medicine, 144:532-536,1979.

Clinical Diagnosis of MTSS

 Presents as diffuse tenderness along distal two-thirds of posterior aspect of medial border of the tibia
 Rarely is any single traumatic event reported by patient
 Pain generally worsens with increased duration or intensity of running or jumping activities
 Pain generally ends after exercise ceases

Imaging Studies in MTSS

 Plain film radiographs are almost always normal but may be positive in tibial stress fracture
 Triple phase radionuclide imaging is very sensitive in detecting MTSS (delayed images only) and is thought to become positive due to early bone remodeling in tibia
Roub LW, Gumerman LW, Hanley EN: Bone stress: A radionuclide imaging perspective. Radiology, 132:431-438, 1979.
 Bone scan, however, is not always positive in patients with early stages of MTSS
Milgrom C, Chisin R, Giladi M, et al: Negative bone scans in impending tibial stress fractures. A report of three cases. Am J Sp Med, 12:488-491, 1984.

 MRI is increasingly being used to diagnose MTSS and tibial stress fractures in athletes due to its ability to detect edema within soft tissue and bone

 In 1995, Fredericson et al proposed an MRI grading system for MTSS and tibial stress fractures:
– Grade 1: mild to moderate periosteal edema on T2 images only
– Grade 2: more severe periosteal edema with bone marrow edema on T2 only
– Grade 3: moderate to severe edema of both periosteum and marrow on both T1 and T2 images
– Grade 4: low signal fracture line with severe marrow edema on both T1 and T2 images
Frederickson M, Bergman AG, Hoffman KL, Dillingham MS: Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system, Am J Sports Med, 23:472-481, 1995.

Dynamics of Bone and Stress

 Bone is a dynamic tissue that will strengthen and remodel in response to stress
 Normal repair and remodeling of bone must be balanced or a temporary disturbance in equilibrium between bone reabsorption and bone regeneration may occur
 Excessive stress causes an increase in osteoclastic over osteoblastic activity that weakens bone and may lead to stress fracture
Johnson LC, Strdford HT, Geits RW, et al: Histo-genesis of stress fractures. JBJS, 45A:1542, 1963.

Stress Phenomenon of Bone

 MTSS and medial tibial stress fracture are best classified as points along a continuum of stress phenomenon of bone or stress reaction of bone
Arendt EA, Griffiths HJ: The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sp Med, 16:291-306, 1997.
 Idea of continuum of bone stress injury, which is now evident in MR studies, is in agreement with the continuum of histological changes in bone that was first noted by Johnson et al in 1963 with their histological studies of stress fractures
Johnson LC, Stradford HT, Gets RW, et al: Histogenesis of stress fractures. JBJS 45A:1542, 1963.

Is MTSS Caused by Periostitis?

 Is inflammation of tibial periosteum the cause of the pain in MTSS as many early authors thought?
 Bhatt et al showed that periosteum had fibrous thickening with increased vascularity and bone of medial tibial border had a loss of osteocytes
Bhatt R, Lauder I, Finlay DB, et al. Correlation of bone scintigraphy and histological findings in medial tibial syndrome. Br J Sp Med, 34:49-53, 2000.
 However, Johnell et al found evidence of periostitis in only 1 of 33 soft tissue biopsies in patients with MTSS
Johnell O, Rausing A, Wendeberg B, Westlin N: Morphological bone changes in shin splints. Clin Ortho Rel Res, 167:180-184, 1982. Detmer showed no evidence of periostitis in 10 patients that had fasciotomy for MTSS
Detmer DE: Chronic shin splints: Classification and management of medial tibial stress syndrome. Am J Sp Med, 3:436-446, 1986.

Nature of Bone Weakness in MTSS

 Magnusson et al found 15% decrease in bone mineral density in medial tibia in 18 male athletes compared to 16 controls and found 23% decrease when compared to 18 athletes without MTSS
Magnusson HI, Westlin NE, Nyqvist F, et al: Am J Sp Med, 26:712-125, 2001.
 Magnusson et al also found that there was a 19% increase in bone mineral density in the medial tibial border in athletes that had recovered from MTSS when compared to when they were symptomatic
 Therefore, these researchers speculated that the losses in bone mineral density seen with MTSS are reversible and not inherited
Magnusson HI, Ahlborg HG, Karlsson, et al: Am J Sp Med, 31:596-600, 2003.

Bone Biopsy Study in MTSS

 Johnell et al took 37 tissue specimens from patients with MTSS and these results were compared to bone and soft tissue biopsies from 10 control patients
 In bone biopsies, there were signs of increased metabolic activity in 22/35 samples, not present in controls
 In soft tissue biopsies, there were inflammatory changes in the crural fascia in 13/33 samples and only 1/33 had inflammatory changes in periosteum
 From their results, they felt that the medial tibial pain may be a “stress microfracture” of the tibia
Johnell O, Rausing A, Wendeberg B, Westlin N: Morphological bone changes in shin splints. Clin Ortho Rel Res, 167:180-184, 1982.
 Microcracks are present even in normal bone
 However, microcracks, under continued loading, will multiply and grow into “macrocracks” resulting in stress fracture or a complete fracture

Etiology of MTSS

 Multiple etiologies for MTSS have been proposed within the medical literature over the past thirty years
 Caused by tensile force from muscle on tibia?
– Posterior tibial
– Flexor digitorum longus
– Soleus
 Caused by combined fascial tensile force from one or more of above muscles on medial tibia?
 Caused by frontal plane bending of tibia?

Possible Causes of MTSSosterior Tibial Muscle

 Posterior tibial muscle was thought to be the cause MTSS by many authors since this muscle is known to be active in decelerating pronation
 However, other than the study of Saxena et al in 1990, anatomical studies have not shown that the posterior tibial muscle originates from the area of the tibia where the symptoms of MTSS are most commonly located
Saxena A, O’Brien T, Bunce D: Anatomic dissection of the tibialis posterior muscle and its correlation to medial tibial stress syndrome. J Foot Surg, 29:105-108, 1990.

Possible Causes of MTSS: Flexor Digitorum Longus Muscle

 FDL has been proposed as primary muscle causing MTSS due to its origin from medial tibia
Garth WP, Miller STJ: Evaluation of claw toe deformity, weakness of foot intrinsics, and posteromedial shin pain. Am J Sp Med, 17:821-827, 1989.

Possible Causes of MTSS: Soleus

 Detmer proposed in 1980 that MTSS was caused by traction stress on periosteum applied by medially arising fibers of the soleus muscle
Detmer DE: Chronic shin splints: Classification and management of medial tibial stress syndrome. Am J Sp Med, 3:436-446, 1986.
 The term soleus syndrome was proposed by Michael and Holder in 1985 since their study of 28 cadaver legs showed that the soleus extends distally, via its investing fascia, to insert along the medial tibia where the symptoms and scintigraphic findings of MTSS most commonly occur
Michael RH, Holder LE: The soleus syndrome. A cause of medial tibial stress (shin splints). Am J Sp Med, 13:87-94, 1985.

Possible Causes of MTSS: Fascia of Leg

 In unpublished study by Bouche and Johnson, tendons of PT, FDL and soleus were attached to pneumatic actuators to simulate muscle pull during stance while strain gauges were placed along medial tibial fascia
 There was an increase in visible bowstringing and measured strain in the medial tibial fascia with tensile loads applied to all three muscles
 Because of tibial fascial involvement in medial tibial pain, Bouche called the condition “tibial fasciitis”

Possible Causes of MTSS: Bending of Tibia

 Milgrom et al, in their prospective study of tibial stress fractures in 295 Israeli infantry recruits, found that the recruits with tibias that had the smallest area moment of inertia were also the recruits more likely to experience tibial stress fractures during basic training
Milgrom C, Giladi M, Simkin A, et al: The area moment of inertia of the tibia: A risk factor for stress fractures. J. Biomech, 21:1243-1248, 1989.
 Beck et al found that Marine Corps recruits with tibial stress fracture had significantly smaller tibial cross-sectional areas and widths
Beck TJ, Ruff CB, Mourtnda FA, et al: Dual-energy x-ray absorptiometry derived structural geometry for stress fracture prediction in male US Marine Corp recruits. J Bone Miner Res, 11:645-653, 1996.

Bone Bending as Cause of MTSS

 Long bones with narrow diaphyseal widths will bend more under load than those with wider diaphyses
Martin RB, Burr DB, Sharkey NA: Skeletal Tissue Mechanics, Springer, New York, 1998.
 Adaptation in long bones that are subjected to bending strains is to increase cortical thickness, density and width that will cause bone to better resist bending loads
Beck BR: Tibial stress injuries: An aetiological review for purposes of guiding management. Sports Med, 26:265-279, 1998.

Why Do Runners Get MTSS:
Running Limb Varus?

Running Limb Varus:
A Common Cause of MTSS?

Bending Moment on Tibia Caused by Eccentric Tibial Loading Forces

Structural/Functional Factors Cited in Literature as Causes of MTSS

 Tibial varus
 Rearfoot varus
 Forefoot varus
 Pes planus
 Increased tibial torsion
 Increased femoral external rotation
 Limb length discrepancy
 Excessive foot pronation
 Tight calf muscles

Effect of Foot Mechanics on MTSS

 Combination of either forefoot varus or rearfoot varus alignment correlated with frequency of MTSS in 25 dancers
Sommer HM, Vallentyne: Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sp Exerc, 27:800-804, 1995.
 13 male distance runners without MTSS were compared to 35 male athletes with shin splints (MTSS) and found that those with shin pain had greater Achilles tendon angles, more STJ ROM, and more rearfoot pronation during running
Viitasalo JT, Kvist M: Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sp Med, 11:125-130, 2005.
 Unilateral standing navicular drop was found to be significantly greater in 125 high school XC runners that developed MTSS
Bennett JE, Reinking MF, Pluemer B, et al: Factors contributing to the development of medial tibial stress syndrome in high school runners. J Ortho Sports Phys Ther, 31:504-511, 2001.
 Prospective study of 124 recruits showed that individuals with pronated foot type (using foot posture index) were significantly more likely to develop MTSS than those with normal or supinated feet
Yates B, White S: The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sp Med, 32:772-780, 2004.

 Many treatments have been proposed for MTSS ranging from conservative to surgical measures
– Ice
– Rest or modified rest
– NSAIDs
– Foot and/or leg taping
– Antipronation shoes
– Foot orthoses
– Strengthening, stretching
– PT modalities
– Casting and pneumatic leg braces
– Electrical bone stimulator
– Tibial fasciotomy

Guide for Treatment of MTSS
 Reduce the inflammation in the medial tibia with ice, NSAIDS and/or modalities
 Reduce or eliminate pathological forces on medial tibia that are causing the symptoms of MTSS with foot orthoses and/or shoes
 Advise patient on strengthening, stretching and return to activities protocol
 Design long-term treatment program for patient so that symptoms will be less likely to return once they resume training

Reducing Pathological Forces on Medial Tibia with Foot Orthoses

 Foot orthoses have the potential to allow the patient to train harder, longer and at more speed with less risk of developing MTSS or tibial stress fracture
 Foot orthoses must also be combined with appropriate shoegear and other treatments to allow for optimum orthosis function
 Foot orthoses designed for treatment of MTSS must be highly specialized in order to achieve maximal therapeutic benefit

Mechanical Effect of Foot Orthoses in Treatment of MTSS

 Basic mechanical goal of foot orthoses is to transfer center of pressure (CoP) that acts on plantar foot to a more medial location
 Medial positioning of CoP will cause STJ supination moment in early stance phase that will lessen early STJ pronation moments that may cause traction on medial tibial muscles/fascia
 Medial positioning of CoP will also decrease the valgus (frontal plane) bending moment on the tibia since the CoP will become more aligned relative to long axis of tibia
 Placing orthosis under foot of patient with MTSS will decrease tibial bending moment by shifting CoP medially

Causes of Increased Valgus Bending Moment of Tibia

 Any structural or positional abnormality that moves the CoP more lateral on plantar foot relative to long axis of the tibia will tend to increase the eccentric loading of tibia and increase the valgus tibial bending moment
 Increased varus alignment of tibia, rearfoot or forefoot at footstrike will cause more lateral positioning of CoP on the foot
 Increased foot abduction relative to the tibia displaces the CoP laterally relative to the long axis of tibia, increases eccentric loading of tibia and will increase tibial bending moment

Design of Foot Orthoses for MTSS

 Foot orthosis needs to have increased varus at both rearfoot and forefoot in order to cause decreased STJ pronation moments and decreased valgus tibial bending moments
– Medial heel skive
– Inverted balancing position of cast
– Relatively stiff plate material
– Rearfoot post
– Varus forefoot extension
 Varus forefoot extension and medial heel skive are most helpful orthosis modifications since they both are very effective at shifting the CoP more medial on the foot

Female Runner Patient with MTSS

 28 y/o female distance runner with medial tibial pain, tight calf muscles, pronated feet and varus forefoot

Foot Orthoses for MTSS

Treatment Protocol for MTSS

– TID gastroc/soleus stretching
– 20 min BID icing to tibia
– Antipronation running shoes
– Reduce training mileage and intensity and/or start alternative exercise program
– Initially, OTC full length orthosis with added rearfoot, arch and forefoot varus wedging and heel lifts
– Later, custom foot orthoses depending on response to initial care
– Bone scan and/or MRI if pain is present at rest or during walking and/or induration/warmth is detected on medial tibial border

Summary

 MTSS is likely an early point along a medial tibial stress injury continuum that may, or may not, progress on to medial tibial stress fracture
 Likely etiologies of MTSS include increased tensile forces from medial tibial muscles/fascia and increased valgus bending moment on tibia during running and jumping activities
 Females much more likely to develop MTSS than males
 Decreased tibial diameter, increased varus alignment of forefoot, rearfoot and tibia along with excessive foot pronation may increase tendency to develop MTSS
 Orthoses with increased rearfoot and forefoot varus correction greatly help relieve symptoms of MTSS
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talarius · Jan 22, 2013

Hi
My first post so hope I don't appear to be the 'dork' of the Arena. And I don't know how to change my user name either but my name is Sally so hope this covers the anon problem too.
I get the feeling I am going to be shouted at for not knowing the answer to my question so apologies in advance. But is there any further correlation between this and Type 1 insulin-dependant childhood onset diabetes?

Ella Hurrell · Jan 22, 2013

Hi Sally

Welcome to Pod Arena

Don't mean to be rude, but did you mean to post your question on this thread? Can't say I've ever noticed a correlation between MTSS and diabetes.

talarius · Jan 23, 2013

Well I think that should be my first and last! Know you don't mean to be rude but think this may be a reason why members are reluctant to participate and give their full names! Yes I did mean to post on this thread as was thinking along lines of diabetic muscle infarction and also delayed tendon repair and just wondered if there were any further studies in that vein. Have a patient to has been sent from pillar to post among the 'experts' to no avail so looking 'outside the box'.

Kevin Kirby · Jan 23, 2013

talarius said: ↑

Hi
My first post so hope I don't appear to be the 'dork' of the Arena. And I don't know how to change my user name either but my name is Sally so hope this covers the anon problem too.
I get the feeling I am going to be shouted at for not knowing the answer to my question so apologies in advance. But is there any further correlation between this and Type 1 insulin-dependant childhood onset diabetes?
Click to expand...

Sally:

Medial tibial stress syndrome and medial tibial stress fracture are seen nearly always in running and jumping athletes and has no correlation, to my knowledge, to Type 1 diabetes.

blinda · Jan 24, 2013

talarius said: ↑

Hi
My first post so hope I don't appear to be the 'dork' of the Arena. And I don't know how to change my user name either but my name is Sally so hope this covers the anon problem too.
I get the feeling I am going to be shouted at for not knowing the answer to my question so apologies in advance. But is there any further correlation between this and Type 1 insulin-dependant childhood onset diabetes?
Click to expand...

talarius said: ↑

Well I think that should be my first and last! Know you don't mean to be rude but think this may be a reason why members are reluctant to participate and give their full names! Yes I did mean to post on this thread as was thinking along lines of diabetic muscle infarction and also delayed tendon repair and just wondered if there were any further studies in that vein. Have a patient to has been sent from pillar to post among the 'experts' to no avail so looking 'outside the box'.
Click to expand...

Hi Sally,

:welcome: to the Arena.

Being an `anon` really is not a problem, from my perspective, so long as posters don`t try to hide behind anonymity in order to deliberately provoke animosity and belittle those who come here with the desire to learn. So, don`t apologise for wanting to discuss a pertinent point which you have raised.

I can understand why Ella (who, incidently is the most inoffensive person I have ever had the pleasure to meet) asked if you meant to post your question in this thread as, at first glance, there may not appear to be a connection of MTSS with diabetes....but actually you do have a point.

It may not be a correlation, but there will be some people out there who have DM1 (or DM2) but are not yet diagnosed, or are recently diagnosed and still struggling to maintain blood sugar control. Sometimes these will present as pts with a slow healing injury, such as MTSS, or any other sports injury.

So, stick around and please don`t stop posting here. Asking questions is one of the best ways to learn :drinks

Cheers,
Bel

Ella Hurrell · Jan 24, 2013

Thanks Bel

Sally - I certainly did not mean to offend, or in any way stifle your contribution / belittle question. I merely suspected that you may have accidentally posted on the wrong thread as you did not elaborate on the connection between the two conditions. With your second post, I now understand the angle you were coming from. I apologise if I have caused offence and certainly hope it will not put you off future postings. :drinks

talarius · Jan 28, 2013

Hello Bel and Ella
Thank you both for those comments - feel do now feel better about having posted a question.
I undertand the causes/effects of DM in particular with reference to the feet and the principles of MTSS as detailed by Kevin et al. What I was trying to get to is whether there is any research specifically to the two insofar as there are links between MTSS, decreased bone marrow, bone density ( which can occur with DM) increased tendon injury and so on. I do realise this is 'off the wall' and if there are no links or no research then I''m happy to shut up about it!
It is, as I say, because I have a patient who is not responding to well to treatment so far despite excellent help, support and advice from the Physios, orthopods and other specialists, inc me, involved his care.

Kevin Kirby · Jan 29, 2013

talarius said: ↑

Hello Bel and Ella
Thank you both for those comments - feel do now feel better about having posted a question.
I undertand the causes/effects of DM in particular with reference to the feet and the principles of MTSS as detailed by Kevin et al. What I was trying to get to is whether there is any research specifically to the two insofar as there are links between MTSS, decreased bone marrow, bone density ( which can occur with DM) increased tendon injury and so on. I do realise this is 'off the wall' and if there are no links or no research then I''m happy to shut up about it!
It is, as I say, because I have a patient who is not responding to well to treatment so far despite excellent help, support and advice from the Physios, orthopods and other specialists, inc me, involved his care.
Click to expand...

Sally:

Have you considered that your patient may not have medial tibial stress syndrome and may, in fact, have some other condition?

If you could give us more patient history, lab/xray/mri results and physical examination findings, then we could help you sort out what exactly the diagnosis of your patient is.

NewsBot · Aug 22, 2020

MRI of tibial stress fractures: relationship between Fredericson classification and time to recovery in pediatric athletes
Frederick S. Ditmars, Lynne Ruess, Cody M. Young, Houchun H. Hu, James P. MacDonald, Reno Ravindran & Benjamin P. Thompson
Pediatric Radiology (2020)

Background
Tibial stress fractures are not uncommon in pediatric athletes. The severity of injury may be graded using magnetic resonance imaging (MRI).

Objective
To determine whether Fredericson MRI grading of tibial stress fractures can differentiate times to recovery across different grades in pediatric athletes.

Materials and methods
A medical record search identified all athletes younger than 19 years old who had tibial stress fractures confirmed by MRI and were treated by sports medicine specialists in our clinic system over a 5-year period. Two pediatric radiologists graded MRI exams using the Fredericson system. Time to recovery (in days) was defined in four ways: pain onset to full participation, pain onset to zero pain, first treatment to full sport participation and first treatment to zero pain. Recovery times were compared to tibial stress fracture Fredericson MRI grade and to the use of a recovery device.

Results
Thirty-eight pediatric athletes (age range: 7–18 years, mean: 15.4±2.2 years) had 42 tibial stress fractures while participating in 12 different sports. About half (55%) were track and/or cross-country athletes. The mean time from diagnosis to report of no pain for all patients was 55.6±5.0 days. We found no significant difference in time to recovery across stress fracture grade or with the use of a recovery device.

Conclusion
No differences were noted between Fredericson stress fracture grades and different time periods to recovery or between differences in recovery time and the return to full participation in sports, regardless of the use of assistive devices.
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Fredericson MRI classification of medial tibial stress syndrome

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Fredericson MRI classification of medial tibial stress syndrome

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