Proximal influences in medial tibial stress syndrome

NewsBot · Aug 21, 2012

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LOWER EXTREMITY KINEMATICS IN RUNNING ATHLETES WITH AND WITHOUT A HISTORY OF MEDIAL SHIN PAIN
Janice K. Loudon and Michael P. Reiman
Int J Sports Phys Ther. 2012 August; 7(4): 356–364.

Purpose/Background:
Medial shin pain (MSP) is a common complaint that may stop an athlete from running. No previous study has identified deficits in pelvic, hip or knee motion as potential contributing factors to MSP. The purpose of this study was to investigate the differences in kinematics during running between uninjured athletes and those with MSP. Secondary analyses investigated differences in limbs between groups and differences between sexes.

Methods:
This case-control study investigated fourteen runners aged 18–40 years old with a history of unilateral MSP and fourteen runner controls. Three dimensional lower quarter kinematics were captured as runners ran on a treadmill. Specifically, peak hip internal rotation (IR), frontal plane pelvic tilt (PT) excursion, and knee flexion were examined.

Results:
Groups were similar in age, mass, height, and training mileage. Subjects with a history of MSP demonstrated significantly greater frontal plane PT (P = 0.002, Effect size = 0.55) and peak hip IR (P = 0.004, Effect size = 0.51); and less knee flexion (P = 0.02, Effect size = 0.46) than the control group. No significant difference was found in kinematics of the MSP group during their involved side stance phase as compared to their non-involved side.

Conclusions:
Runners with MSP displayed greater PT excursion, peak hip IR, and decreased knee flexion while running as compared to a control group. These results should help guide treatment for the running athlete that experiences MSP.
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Admin2 · Aug 21, 2012

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drsha · Aug 29, 2012

NewsBot said: ↑

LOWER EXTREMITY KINEMATICS IN RUNNING ATHLETES WITH AND WITHOUT A HISTORY OF MEDIAL SHIN PAIN
Janice K. Loudon and Michael P. Reiman
Int J Sports Phys Ther. 2012 August; 7(4): 356–364.

Full text
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OK, so we have internally placed hips and flexed knees reflecting a collapse in the corresponding closed chain feet either in the rearfoot/the forefoot/or both.

Do we treat the feet, the posture or both?
and can we discuss how we accomplish that?

Dennis

NewsBot · Feb 14, 2013

The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study
Ruth Verrelst, Tine Marieke Willems, Dirk De Clercq, Philip Roosen, Lennert Goossens, Erik Witvrouw
Br J Sports Med doi:10.1136/bjsports-2012-091710

Objective To prospectively identify proximal risk factors contributing to the development of exertional medial tibial pain (EMTP).

Methods Data were prospectively collected on healthy female students in physical education, who were freshmen in 2010–2011 and 2011–2012. 95 female students, aged 18.15±0.84, were tested at the beginning of their first academic year. Testing included isokinetic hip strength measurements of the abductors, adductors, internal rotators and external rotators. The follow-up of the individulas was assessed using a weekly online questionnaire and a 3-monthly retrospective control questionnaire. EMTP was diagnosed by an experienced MD (Doctor of Medicine). Cox regression analysis was used to identify the potential risk factors for the development of EMTP.

Results 21 individuals were diagnosed with EMTP during follow-up. The results of this study identified that decreased hip abductor concentric strength is a predictive parameter for the development of EMTP in females. More specifically, total work (p=0.010) and average power (p=0.045) for concentric abduction strength were found to be significant predictors for this lower leg overuse injury.

Conclusions Hip abductor weakness is a significant predictor for EMTP in women. Preventive screening methods for EMTP should therefore include this proximal contributing factor.
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drsha · Feb 14, 2013

NewsBot said: ↑

The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study
Ruth Verrelst, Tine Marieke Willems, Dirk De Clercq, Philip Roosen, Lennert Goossens, Erik Witvrouw
Br J Sports Med doi:10.1136/bjsports-2012-091710
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OK, so we have internally placed hips (due to hip abductor weakness this time?) and flexed knees reflecting a collapse in the corresponding closed chain feet either in the rearfoot/the forefoot/or both.

Do we treat the feet, the posture or both?
and can we discuss how we accomplish that?

Dennis

NewsBot · May 14, 2013

Hip Muscle Weakness As A Risk Factor For The Development Of Exertional Medial Tibial Pain: A Prospective Study
Ruth Verrelst, Tine Willems, Dirk De Clercq, Philip Roosen,
Presented at 2013 ACSM Mtg

Exertional medial tibial pain (EMTP) is a common and complex overuse problem among civilian, military and athletic populations and is usually induced by repetitive lower leg strain imposed by loading during weight-bearing activities. EMTP is characterised by exertional pain along the posteromedial border of the middle and distal thirds of the tibia and can include diagnostic entities of medial tibial stress syndrome (MTSS), tibial stress fracture, chronic exertional compartment syndrome and muscular an tendon injuries. The treatment of such an injury is often difficult, expensive and time-consuming. Hence, being injured can have a significant effect on a physically active lifestyle, and they can sometimes end activity-related careers entirely. The understanding of injury causation should therefore be of primary concern.

PURPOSE : To prospectively identify proximal risk factors contributing to the development of exertional medial tibial pain (EMTP).

METHODS : Data were prospectively collected on healthy female students in physical education, who were freshmen in 2010-2011 and 2011-2012. 95 female students aged 18.15±0.84, were tested at the beginning of their first academic year. Testing included isokinetic hip strength measurements of abductors, adductors, internal rotators and external rotators. The follow-up of the subjects was assessed using a weekly online questionnaire and a three-monthly retrospective control questionnaire. EMTP was diagnosed by an experienced M.D.. Cox regression analysis was used to identify the potential risk factors for the development of EMTP.

RESULTS: 21 subjects were diagnosed with EMTP during follow-up. The results of this study identified that decreased hip abductor concentric strength is a predictive parameter for the development of EMTP in female athletes. More specific, total work (P=0.010) and average power (P=0.045) for concentric abduction strength were found to be significant predictors for this lower leg overuse injury.

CONCLUSION: Hip abductor weakness is a significant predictor for EMTP. Preventive screening methods for EMTP should therefore include this proximal contributing factor.
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drsha · May 14, 2013

NewsBot said: ↑

Hip Muscle Weakness As A Risk Factor For The Development Of Exertional Medial Tibial Pain: A Prospective Study
Ruth Verrelst, Tine Willems, Dirk De Clercq, Philip Roosen,
Presented at 2013 ACSM Mtg
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Once again, if this proximal factor should be investigated and screened for, what treatment do you recommend once it is discovered to exist?

Dennis

Griff · May 14, 2013

drsha said: ↑

Once again, if this proximal factor should be investigated and screened for, what treatment do you recommend once it is discovered to exist?

Dennis
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Dennis - if hip abductor weakness is shown to be a risk factor for a given pathology, and hip abductor weakness is 'discovered to exist' then what treatment do you think would be recommended??

drsha · May 14, 2013

Ian G said: ↑

Dennis - if hip abductor weakness is shown to be a risk factor for a given pathology, and hip abductor weakness is 'discovered to exist' then what treatment do you think would be recommended??
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Is there anyone else who didn't understand that I was asking for treatments for hip abductor weakness?

Dennis

NewsBot · Oct 8, 2013

The role of proximal dynamic joint stability in the development of exertional medial tibial pain: a prospective study
Ruth Verrelst, Dirk De Clercq, Jos Vanrenterghem, Tine Willems, Tanneke Palmans, Erik Witvrouw
Br J Sports Med doi:10.1136/bjsports-2012-092126

Objective To prospectively determine risk factors contributing to the development of exertional medial tibial pain (EMTP).

Methods Data were prospectively collected on healthy female students in physical education, who were freshmen in 2010–2011 and 2011–2012. Eighty-six female students aged 19.38±0.85 years, were tested at the beginning of their first academic year. Kinematic parameters in the frontal and transverse plane were measured during a single-leg drop jump (SLDJ). For further analysis, the SLDJ task was divided in two phases: touchdown until maximal knee flexion (MKF) and then MKF until take-off, representing landing and push-off phase, respectively. The injury follow-up of the students was assessed using a weekly online questionnaire and a 3-monthly retrospective control questionnaire. EMTP was diagnosed by an experienced medical doctor. Cox regression analysis was used to identify the potential risk factors for the development of EMTP.

Results During injury follow-up (1–2 years), 22 participants were diagnosed with EMTP. The results of this study identified that increased range of motion (ROM) in the transverse plane of hip and thorax during landing (p=0.010 and 0.026, respectively) and during push off (p=0.019 and 0.045, respectively) are predictive parameters for the development of EMTP in women.

Conclusions Increased ROM values of hip and thorax in the transverse plane, which can be interpreted as impaired ability to maintain dynamic joint stability resulting in increased accessory movements, are significant contributors to the development of EMTP in women.Abstract
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NewsBot · Feb 11, 2014

Contralateral Risk Factors Associated with Exertional Medial Tibial Pain in Women
Verrelst, Ruth; De Clercq, Dirk; Willems, Tine M.; Roosen, Philip; Witrouw, Erik
Medicine & Science in Sports & Exercise: 10 February 2014

Purpose: To prospectively analyse the role of factors on the contralateral side of the kinetic chain in the development of exertional medial tibial pain (EMTP).

Methods: Eighty-one female physical education students were tested at the beginning of their first academic year. Within the testing protocol, contralateral isokinetic hip muscle strength and full-body kinematic parameters during a single-leg drop jump (SLDJ) were evaluated. Online questionnaires were administered weekly and personal interviews were conducted every 3 months to assess injury follow-up. EMTP was diagnosed by an experienced MD (Doctor of Medicine). Cox regression analysis was used to identify the potential risk factors for the development of EMTP.

Results: After exclusion of subjects with diagnosed bilateral EMTP, 11 subjects were included in the EMTP group. Fifty-three subjects did not develop any lower extremity overuse injury and were included in the control group. The leg not at risk within subjects who developed EMTP, was compared with an uninjured leg of the control group. Increased transverse plane motion for the contralateral lower leg segment during landing phase was found to be a significant predictor (P=0.012) for EMTP. Analysis of the isokinetic data did not reveal altered hip muscle strength parameters for the leg not at risk within the EMTP group.

Conclusions: Impaired dynamic joint stability (DJS) or accessory movements were found in the transverse plane of the contralateral lower leg segment of EMTP subjects. This contralateral instability might have contributed to altered movement patterns within the kinetic chain function of EMTP subjects. No contralateral hip muscle strength parameters were found to predict EMTP in this study.
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NewsBot · Sep 6, 2014

Differences between hip abductor and adductor strength and medial tibial stress syndrome in collegiate distance runners
Soria, Alex, M.S.,
CALIFORNIA STATE UNIVERSITY, FULLERTON, 2014, 36 pages; 1525738

Running is a sport that is enjoyed by millions of people. But, just like every sport, there is the likelihood of sustaining an injury. The majority of the injuries are overuse in nature. One of the most common injuries in distance runners is medial tibial stress syndrome. They kinetic chain theory states that distal segments of the leg are controlled by proximal muscles of the hips. Therefore, the purpose of this study was to investigate the differences in hip abductor and adductor strength and the occurrence of MTSS in collegiate distance runners.

A total of 25 collegiate male and female cross country and/or distance track runners volunteered for the study. Participants qualified for one of two groups, either an injured group or a noninjured control group. Each participant was put through a series of isometric and isokinetic hip abduction and adduction strength tests.

There were no significant difference four-way or five-way interaction between groups or within groups for the isokinetic data. In addition, there was no significant three-way or two-way interaction for the isometric data.

These findings can be explained through running mechanics (not similar to the testing protocol), the training phase of the participants, muscle groups not being fatigued (as would be during running), and the amount of participants used. Therefore, we conclude that there were no differences between hip abductor and adductor strength in collegiate distance runners with and without MTSS.
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NewsBot · May 28, 2015

Hip Abductor and Adductor Strength and Medial Tibial Stress Syndrome in Collegiate Distance Runners.
Alex Soria, Jared W. Coburn, FACSM, Lee E. Brown, FACSM, Robert Kersey.
Presented at the ACSM Meeting; San Diego May 2015

Overuse injuries are among the most common injuries in distance runners. Of these, medial tibial stress syndrome (MTSS) has been observed to have a high occurrence rate. Though the exact mechanism for the occurrence of MTSS has not been fully determined, its connection with hip muscular strength has been suggested.
PURPOSE: The purpose of this study was to investigate hip abductor and adductor strength in collegiate distance runners with and without MTSS, using isokinetic dynamometry.
METHODS: A total of 25 collegiate distance runners volunteered for the study (15 non-injured, 10 injured). Participants performed isokinetic concentric and eccentric muscle actions of the hip abductors and adductors at 30, 150, and 270·s-1. RESULTS: No significant differences were found for isokinetic (table 1) hip abductor and adductor strength (Nkg-1 body mass) between injured and non-injured runners.
DISCUSSION: The results of the study suggested there are no differences in hip abductor and adductor strength between injured and non-injured collegiate distance runners. Various factors may have contributed to finding no differences, such as dissimilarity between the testing protocol and the way the muscles are used during running, the training/ competition phase during which testing took place, and the testing protocol which measured strength during non-fatigued conditions. Future research that controls for one or all of these factors may be needed to fully understand the complex relationship between strength and MTSS in collegiate distance runners.
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NewsBot · Sep 22, 2015

BIOMECHANICAL FACTORS ASSOCIATED WITH MEDIAL TIBIAL STRESS SYNDROME: A
PROSPECTIVE STUDY

These preliminary results suggest the etiology of
MTSS is multifactorial with muscular strength,
flexibility, and running kinematics all playing a
role. For kinematics specifically, these results
suggest distal kinematics may play a more
prominent role than proximal kinematics, despite
proximal strength deficits. However, since distal
kinematics may be influenced by proximal muscle
strength, the relative importance of proximal and
distal factors as they relate to MTSS still needs to
be clarified. The results agree with previous studies
documenting increase amounts of rearfoot eversion
in runners with MTSS [5]. However, the results
also suggest the duration of rearfoot eversion is an
important parameter, one which should be
considered separately in future studies on this
injury.
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NewsBot · Jul 27, 2018

ALTERED SAGITTAL PLANE HIP BIOMECHANICS IN ADOLESCENT MALE DISTANCE RUNNERS WITH A HISTORY OF LOWER EXTREMITY INJURY.
Lachniet PB et al
Int J Sports Phys Ther. 2018 Jun;13(3):441-452.

BACKGROUND:
Lower extremity overuse injuries, including bone stress injuries (BSI), are common in runners and may result in prolonged recovery and time off from running. Identifying risk factors for running-related overuse injuries may have a clinically relevant role in prevention of these injuries.

PURPOSE:
The purpose of this study was to compare an adolescent and young adult population of male runners known to have a history of BSI with an injury-free cohort and retrospectively assess for kinematic differences that may differentiate the two cohorts.

STUDY DESIGN:
Controlled laboratory case control investigation.

LEVEL OF EVIDENCE:
Level 3.

METHODS:
25 male high school and collegiate cross-country runners were enrolled. Ten self-reported a prior history of BSI consisting of lower extremity stress fracture or shin splints/medial tibial stress syndrome and were categorized as injured (INJ). Fifteen self-reported no prior history of lower extremity injury and were categorized as uninjured (UNINJ). All runners were pain-free at time of testing. Runners ran at a self-selected speed on a treadmill with retro-reflective markers attached to thorax, pelvis, and each lower extremity segment. Three-dimensional kinematic calculations were made during stance phase (initial treadmill heel contact to toe off) and averaged over 20 steps. One-way ANCOVA was used to compare kinematic differences at the hip and knee between the INJ and UNINJ cohort.

RESULTS:
Runners in the INJ group demonstrated greater peak hip flexion during stance phase on both the right limb [INJ = 32.5°(±3.8°) vs. UNINJ = 26.9°(±4.6°); p<0.01] and the left limb [INJ = 31.2°(±4.8°) vs. UNINJ = 26.8°(±3.1°); p = 0.01] when compared to the UNINJ group. No significant difference in step length or step rate between the INJ and UNINJ cohorts was noted when normalized to height and weight (p = 0.39 and 0.39).

CONCLUSIONS:
The results of this study demonstrate increased peak stance phase hip flexion in a population of young adult male runners with a previous history of BSI. This association may represent an important preliminary finding in the development of a clinically relevant tool to identify risk of BSI. Due to the retrospective nature of this study, future prospective investigations are warranted to validate these findings to determine if these alterations are compensatory following an injury or predictive of a future injury.
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