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Help for patient with MTSS

Discussion in 'Biomechanics, Sports and Foot orthoses' started by TeKsTeR, Jun 3, 2009.

  1. TeKsTeR

    TeKsTeR Member


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    Can anyone out there who can help me with a particular pt. I encountered recently. Her c/o and findings are: pt is a 48 yr old woman who runs 30min/per and does aerobic training 3x/week. c/o chronic pain on the postero-distal 1/3 of L tibia that increases w activities and reduces w rest. Palpation in the area showed pain & tenderness. Biomechanical assess: tibial varum, windlass +ve at insertion on ILA, genu valgum, reduced hamstring flex. and ankle JROM, flexible forefoot varus. X-rays showed cortical thickening along the mid tibial shaft.
    Pdx: chronic MTSS ( post tib. m.m test WNL).
    Rx so far: stretches calves, hammies, ITB's in addition to physio manipulation of the prescrided muscles, trigger points released have also tried. Prescription orthoses w medial skive and f/foot varus ext. was given with no success.
    Now this is my dilemma? the patient's G.P referred her to an orthopaedic surgeon for a second opinion, however the patient do not want to go because she had enough, and have asked me for advice re. her diagnosis. ANy inputs from you guys are greatly appreciated.
     
  2. Re: HELP !!! MTSS revisited

    Sounds like you need to get some more testing done.

    MRI to see exactly wants going on with the medial aspect of the tibia ie stress fracture, periosteoma stress, muscle overuse or all of the above.

    Maybe a compartment pressure test would be also recommended as well.

    Have you tried ice massage, simple and I find with myself and patients great results.

    20 min ice over area, then 2 ice blocks gently rub up and down area until melted then repeat.

    I kown that new research says icing doesn´t help etc but my body and cronic tibial stress problems say otherwise.

    thats my 2 cents hope that it helps

    Michael Weber
     
  3. Re: HELP !!! MTSS revisited

    Hmmm. What are the patients activity levels? It might be that a period of rest is needed. She has to be realistic about her rehab, the things you have used can reduce the tissue stress but if its still too high its not going to get better!

    Otherwise I would look to the orthotics. Are they being worn? Are they right for the day shoes AND the sports shoes and are they being worn in both? Have they sunk in either?

    Oh and check the planal dominance. If its a transverse planal dominance (ie lots of drift, not much drop) you might need to rethink your prescription variables or, as Craig suggests, refer them to your enemies!

    Regards
    Robert
     
  4. Re: HELP !!! MTSS revisited

    I have no idea what this means; or this:
    What kind of shoes is she running in, where is she running, how heavy is she and other questions that spring to mind...........

    Robeer, nice teaching opportunity for you here, you said something like:

    Planal dominance of which joint and when? How does this influence our prescription variables and why should I refer these cases to Dennis :rolleyes:
     
  5. Admin2

    Admin2 Administrator Staff Member

  6. Mr./Mrs./Ms./Miss Tekster:

    It is not often that a correctly made foot orthosis doesn't help at all for MTSS, unless it is a stress fracture of the tibia. How do you know you are not dealing with a tibial stress fracture that hasn't healed yet?? A three-phase technetium bone scan and/or MRI will be the best tests for determining if you are dealing with a bad case of medial tibial stress syndrome (MTSS) or a medial tibial stress fracture.

    Also, I'm sure your custom foot orthoses were ordered with more variables other than a "medial skive and f/foot varus ext". If you want further help, it would help your case if you gave all of us more information to work with.
     
  7. CraigT

    CraigT Well-Known Member

    You would have to be suspicious of stress fracture or at the very least a stress reaction.
    Either way, my experience is that you can do all the correct things with these, and have no result until they actually have some rest from activity. Then your treatment should stop the problem returning.
    Has she done this?
    I you are punching a wall and break your hand, you can pad your hand, but it won't heal if you then keep punching the wall...
    One other consideration would be have her assessed for osteoporosis.
    I would send her to a Sports Physician rather than an Orthopod for a second opinion.
     
  8. Nice analogy. I'm stealing that one. :drinks

    Mine now.

    Regards
    Robert
     
  9. Love that analogy, am going to borrow that one too!:boxing::

    Have had many cases that resemble this one lately(seems to be catching at the moment). You need to double check the PDx with further imaging.

    Generally, MTSS (muscle overuse) resolves in 6-8 weeks when a patient is absolutely compliant with:

    RICER
    a change in activities,
    modification of exercise,
    correct stretching program,
    correct strengthening program,
    correct proprioception strengthening program
    orthoses(semi customised or fully customised) and
    change in footwear.

    If this isnt happening then you need to reconsider the PDx. DDx: tibial stress reaction/ stress fracture(bone scan or MRI), anterior compartment syndrome(pressure measurement in anterior compartment), inflammation/injury of other structures or other reasons for boney/ muscle etc inflammation/strength vs weakness(history, blood tests, biopsy). You have to isolate the injured structures through further imaging and then once diagnosis is specific then you must assess aetiology and hone treatment in on aetiology.

    Unfortunately, a large part of these patients can be compliance.:bash:
    (not not doing exercises but doing the exercises they choose to do, the way they want to do them, and then over doing it) Compliance extends into not doing stretches correctly, avoiding a reduction in training, resisting a change or modification of activities and training errors, not to mention only wearing orthoses when they choose too, or transitioning to GP vs Physio vs orthopod vs sportsmed Dr vs personal trainer vs........... which allows them to continue the way they were etc....no wonder frustration/being over it all weighs in to the equation!!.

    It is always worthwhile to go with your patient into their exercise environment and assess them there. Usually there are some basic training mistakes that need to be eliminated. (That the patient never thought to mention/ or in fairness was unaware of,in terms of importance)

    I did have one case lately who was a perfect patient who did as instructed (yes, im sure;)) without significant relief. Blood tests looking for a reason for xs inflammatory muscle reaction revealled hypothyroidism which has a high incidence of chronic musculoskeletal pain. Once her thyroid levels were sorted and the above tx put into place symptoms resolved, which was amazing since she had suffered from a version of MTSS for over 15 years. I think now of it a bit like trying to heal a diabetic ulcer with uncontrolled BGL's. Given her time of life it may be worth considering(post pregnancy also affects the thyroid).

    Hypermobility also seems to fit into these cases along with poor proprioception. Proprioceptive strengthening training i have also found to be helpful. Patients get so focused in on improving strength and stretching of muscles/ tendons we sometimes forget about the joints and the fact that the muscles are reacting to protect the joints. This is controlled by proprioception.

    If symptoms are worse on exercise i would assume you are past MTSS and into atleast tibial stress reaction/ fracture territory which requires a min of 6-8 weeks rest. Swimming allows them to keep their cardio up without over loading anything. Then you will need to help her out with a rehab program(one that you have devised for her with the help of other health professionals, that considers strengthening, stretching and proprio) and then monitor her closely. Ensure you have compliance 24/7 with orthoses and footwear.

    Often these feet are poor dissipators of vibration forces(tight posteriors usually), shock attenuation is crucial in shoe so let your orth do the correcting and the shoe focus in on shock absorption.

    Footwear is usually best off neutral in these patients focusing in on the control from the orthoses and max. shock absorbing properties in shoe particularly a stable lateral crash pad( not too soft or you will set the achilles off) and max. shock absorption at heel strike. This is also an important feature in the orthotic and topcover. Fit to rearfoot is also crucial to eliminate proprio signals re: ankle instability at heel strike.

    I agree that often these patients with non responsive "MTSS" often have a similar clinical presentation. Poor core stability, poor gluteal strength, Internal hip position, flexed knee position during gait cycle and tibial varum. They often have generalised hypermobility and poor proprioception and a foot with a high STJ axis and marked navicular drift over drop. The MTJ is often locked longitudinally and the 1st ray plantarflexed maximumly(granted clinical experience only)
    I'll take traditinal pes planus MTSS any day!!

    Again, i agree that the stage of the gait cycle should be considered here. Often these cases have a rapid velocity of pronation ( ie the foot is trying to pronate as it is unstable at heel strike)..... Ankle instability seems to cause the peroneals to fire early and quickly and therefore changing the subsequent 1st ray mechanics. The hip flexion and internal rotation as well as the knee flexion mean that by this stage the max. body weight is being transfered above meaning max. force is translating down the leg increasing the corkscrew effect by the time it reaches the foot. This would produce max. ground reactionright over the tib ant insertion point/ navicular.(poor tib ant:empathy:)

    I also focus on midfoot support and midtarsal orientation over RF support as an increase in RF support usually triggers peroneals to increase their fire as we are resisting RF pronation that the foot is trying to achieve to restabilise itself. So should we be thinking in these non responsive cases about creating RF pronation(usually to 0 deg) and MTJ supination around the longitud. axis? I have found this approach seems to bare results as it seems to unload tib ant and satisfy peroneals. :drinks

    Also, you have to consider if your pt is running as a heel striker or a midfoot striker?, generally most of these pts are restricted posteriorly which means they are usually a midfoot striker thereby increasing the velocity of gait and the above mechanics (otherwise they would be presenting with Achilles symptoms):dizzy:
    It is important that their footwear also addresses this!

    If there is minimal STJ change, a coalition/boney restriction needs to be considered especially if the orths are increasing symptoms. In the mean time check her thyroid levels and get further imaging to be more specific about diagnosis.

    The great thing about these patients is that they are usually really motivated to get better. (so they can fit more into an even shorter time frame even though they are already doing more than is humanly possible) The main problem is that they are usually too motivated and do every thing too hard, too much, too fast, too far (that bit takes a psych degree- the tortoise and the hare syndrome).

    This is one condition that i have often thought should be considered more and defined by stages of progression rather than simply MTSS vs tibial stress fractures vs anterior compartment syndrome. Treatment does change depending on diagnosis!, or stage of pathology?.

    Sorry to bore you all, just rambling on as it has been a decidedly interesting day!
    Hope that sheds some light
    xx
     
  10. Palin Podiatry you wrote :
    Poor core stability, poor gluteal strength, Internal hip position, flexed knee position during gait cycle and tibial varum. They often have generalised hypermobility and poor proprioception and a foot with a high STJ axis and marked navicular drift over drop. The MTJ is often locked longitudinally and the 1st ray plantarflexed maximumly(granted clinical experience only)

    What´s a HIGH STJ axis ? Ive not heard of this before ? With the muscles involved do you mean medial deviated.

    Michael Weber
     
  11. Can someone tell me what this:

    And this:
    mean?

    I really haven't got a clue and I assume that the rest of you must know? :bash:
     
  12. So.....

    Can I assume from the lack of replies that no-one else knows what the above means either (save possibly for Mr./Mrs./Ms./Miss Tekster).

    While this makes me feel somewhat better for the fact that I appear to be not alone and in urgent need of some CPD relating to the use of acronyms, it saddens me that no-one else seemed too bothered by the meaning of this information. With the exception of Kevin who requested more information, everyone else seemed happy to give advice without knowledge of what this meant or its implications.:morning::hammer:

    OK this bits the edit to the post: I'm guessing that: "post tib. m.m test WNL" is supposed to say post tibial manual muscle test within normal limits" like I said, what does this mean? You could at least use Kendall's grading system. What are the normal limits of strength for a 48 year old female?

    I still haven't got a clue what "windlass +ve at insertion on ILA" is, please put me out of my misery. ILA? Something longitudinal arch? For the sake of saving a few seconds by not typing it in full Mr./Mrs./Ms./Miss Tekster has left me dumbfounded for a few days. As far as I can work out the plantar fascia doesn't insert into anything that could be represented by the acronym ILA. Indeed, what does windlass +ve mean? And who's teaching this crap?:mad::craig:
     
    Last edited: Jun 5, 2009
  13. Simon:

    Same old story here on Podiatry Arena. :deadhorse: All the posters want (or even expect) free expert advice. However, a good number of them don't take the time to spell their acronyms out, don't take the time to give a complete history or physical exam and don't have the common courtesy to use proper punctuation and grammar and proofread their postings so that we can justify spending our valuable time in answering their queries that they have so hastily thrown up onto Podiatry Arena. :craig:

    What can we do about it? Maybe, in order to improve the quality of postings here on Podiatry Arena, we should simply stop offering any free advice unless the above conditions are met by the poster that is asking the questions?! I believe that this rule may be the best way to go. What say you??
     
  14. efuller

    efuller MVP

    I think there is a natural consequence of a poorly written question. If you use obscure acronyms, no one will understand what you are saying and you probably not get your question answered. It is helpful to people to know that what they write in their chart, and when written is understood by the writer, is not understood by the profession as a whole nor anyone else, like lawyers or auditors, who might be reading the chart at a later date. Another natural consequence is that poor writing reflects on ones image. If someone writes well enough that I can understand what they are saying, I will help them if I feel that I can add something and I'm not too tired and cranky. I've had my spelling corrected in a post and the more relevant point in the debate completely ignored. (By someone who often ignored questions and whined about how little time they had to spend on the arena). I'd rather read posts that addressed issues. I'd also rather read well written posts about issues, but we don't always get that choice. Sometimes people think better than they write. I wouldn't want to drive away people who can think better than they can write. We can always choose not to respond. Sometimes, it's helpful to have discussions on definitions.

    However, I'm still wondering what a positive windlass test is. Is it positive when a patient is standing and you can't lift the hallux off of the floor, or is it positive when you see resupination when you attempt to lift hallux off of the floor. Or, is it how Jack (push up test of Jack) described it where you see rearfoot adduction when you attempt to dorsiflex the hallux. I could come up with many more possibilities for what a positive windlass test could be. Who is teaching that crap anyway?


    Cheers,

    Eric Fuller
     
  15. TeKsTeR

    TeKsTeR Member

    Have you tried ice massage, simple and I find with myself and patients great results.

    20 min ice over area, then 2 ice blocks gently rub up and down area until melted then repeat.

    I kown that new research says icing doesn´t help etc but my body and cronic tibial stress problems say otherwise.

    thats my 2 cents hope that it helps

    Michael Weber

    Sorry SIMON SPOONER for taken so long to reply, cause I been taking in all your feedbacks and treament regime all at once in my head (hmm very confusing).
    However I have tried using Mark Weber's 2 cents hope with ice, but the prob still persist.
    So I agreed my Craig Payne's idea of referring this patient to a sports physician for for second opinion and perhaps an MRI for possible stress reaction.
     
  16. TeKsTeR

    TeKsTeR Member

    I will Keep you guys up to date after the MRI results, but thank you very much for all your help, its been very interesting putting all your ideas together.
     
  17. Medial tibial stress syndrome is a stress reaction of the tibia that needs to be differentiated from the very similar clinical condition of medial tibial stress fracture (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).
     
  18. TeKsTeR

    TeKsTeR Member

    Sorry Guys for taking so long to reply back esp to Mr SIMON SPOONER. Originally Posted by TeKsTeR
    windlass +ve at insertion on ILA,

    And this:

    Quote:
    Originally Posted by TeKsTeR
    Pdx: chronic MTSS ( post tib. m.m test WNL).

    mean?

    I really haven't got a clue and I assume that the rest of you must know.
    WIndlass +VE means I hav manage to reproduce pain at the inner long arch at the insertion site. I have tests the tibialis posterior muscle strength to be normal.

    Anyway I hav taken particular to Mr MArk Webers's 2 cents hope re. Ice 4 20min ... but to no availability. I hav told to patient to rest for 1 week but the same results. However I must agreed with Craig Payne's suggestion re. referral to sports phycian for 2nd opinion and MRI scan to rule out possible stress reaction. I will keep you guys posted when she gets her results back. Thank you for all your help!
     
  19. Maybe It´s a generation thing. Too stressed to stop and think.

    PS MY NAME IS MICHAEL NOT MARK.

    Michael Weber
     
  20. Freeman

    Freeman Active Member

    Re the comment " It is not often that a correctly made foot orthosis doesn't help at all for MTSS, unless it is a stress fracture of the tibia" from Kevin, I agree, what I have found, along with minimizing frontal plane motion and subsequent arch drop, is using poron arch fill on the dorsum of the orthotic shell. Some people cannot tolerate a rigid poloypro appliance packed up into their medial long arch as well as "poron to taste", as it were. Listen carefully to the comments of the patients when they try a variety of additions and mods. I put them on the treadmill or send them, out for a short run and get them right back for their input and comments and make decisions based on how they seem to find the changes and adjustments

    Additionally, you get best results with the best patients, meaning if people cannnot give these things adequate rest, which is alearnign thing on its own, then they will not get better.

    Best reagrds

    Freeman
     
  21. AtomAnt

    AtomAnt Active Member

    What about PRICER?
    P = Preparation or Prevention
     
  22. Hi,

    i always like threads on MTSS, as its the reason why i got into podiatry in the first place. that and the threads always seem to get messy!

    TeKsTeR, you have'nt provided much info re the mechanics of the pt and your orthotic perscription as asked for already, as this info i am sure would really genarate some discussion. In my experiance MTSS can be a stubborn condition that can persist, but it often only takes something simple or a small change to get it right. for example: i had a case recently where i was treating a resistant case, which resolved when i surgested that the pt wear his orthoses under the shoe sock liner, as opposed to above...the comparably firm eva sole of the shoe offering more resistance than the soft sock liner material. just an example to keep the discussion going:drinks

    regards
    Gareth
     
  23. TeKsTeR

    TeKsTeR Member

    Many thanks for your reply, i have pretty much exhausted all avenue, furthermore her GP keep on insisting the patient should seek orthopaedic opinion as the GP thinks she have tibial stress fracture. Once she get the MRI, I will keep you posted re. the pt. outcome. Thnks again
     
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