Systematic Review of Treatments for Medial Tibial Stress Syndrome

NewsBot · Aug 29, 2013

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Treatment of Medial Tibial Stress Syndrome: A Systematic Review.
Marinus Winters, Michel Eskes, Adam Weir, Maarten H. Moen,Frank J. G. Backx, Eric W. P. Bakker
Sports Med. 2013 Aug 27.

BACKGROUND: Medial tibial stress syndrome (MTSS) is a common exercise-induced leg injury among athletes and military personnel. Several treatment options have been described in the literature, but it remains unclear which treatment is most effective.

OBJECTIVE: The objective of this systematic review was to assess the effectiveness of any intervention in the treatment of MTSS.

STUDY SELECTION: Published or non-published studies, reporting randomized or non-randomized controlled trials of any treatment in subjects with MTSS were eligible for inclusion. Treatments were assessed for effects on pain, time to recovery or global perceived effect.

DATA SOURCES: Computerized bibliographic databases (MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro and SPORTDiscus) and trial registries were searched for relevant reports, from their inception to 1 June 2012. Grey literature was searched for additional relevant reports.

STUDY APPRAISAL: The Cochrane Risk of Bias Tool was used to appraise study quality of randomized clinical trials (RCTs) whereas the Newcastle Ottawa Scale was used to appraise non-randomized trials. The 'levels of evidence', according to the Oxford Centre for Evidence-Based Medicine, addressed the impact of the assessed trials. Two reviewers independently performed the search for articles, study selection, data extraction and appraised methodological quality.

RESULTS: Eleven trials were included in this systematic review. All RCTs revealed a high risk of bias (Level 3 of evidence). Both non-randomized clinical trials were found to be of poor quality (Level 4 of evidence). RCTs, studying the effect of a lower leg brace versus no lower leg brace, and iontophoresis versus phonophoresis, were pooled using a fixed-effects model. No significant differences were found for lower leg braces (standardized mean difference [SMD] -0.06; 95 % CI -0.44 to 0.32, p = 0.76), or iontophoresis (SMD 0.09; 95 % CI -0.50 to 0.68, p = 0.76). Iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking and extracorporeal shockwave therapy (ESWT) could be effective in treating MTSS when compared with control (Level 3 to 4 of evidence). Low-energy laser treatment, stretching and strengthening exercises, sports compression stockings, lower leg braces and pulsed electromagnetic fields have not been proven to be effective in treating MTSS (level 3 of evidence).

CONCLUSION: None of the studies are sufficiently free from methodological bias to recommend any of the treatments investigated. Of those examined, ESWT appears to have the most promise.
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Admin2 · Aug 29, 2013

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NewsBot · Nov 26, 2018

Acute effect of taping on plantar pressure characteristics in athletes with exercise-induced leg pain: a description and comparison of groups.
Park J, Kim T.
Phys Sportsmed. 2018 Nov 21:1-8.

OBJECTIVES:
Foot pronation is considered as a potential risk factor of lower leg overuse injury. This study aimed to identify plantar pressure characteristics of elite athletes with exercise-induced leg pain in throwing athletic disciplines, and to verify the acute effect of taping for restricting foot pronation by analyzing the plantar pressure characteristics.

METHODS:
This study was designed as a description and comparison of throwing athletic athletes. Participants were divided into exercise-induced leg pain (ELP group, n = 17) and control groups (CON group, n = 14). Plantar pressure variables (contact area, maximum force, and peak pressure) at eight-foot regions in athletes' supporting leg were recorded during standing on one leg and a natural walk before and after applying anti-pronation or sham taping techniques.

RESULTS:
There are significant difference of contact area, maximal force, and peak pressure in some regions of their foot between the ELP and CON groups. But the anti-pronation taping decreased only the peak pressure in lateral midfoot of CON group during a natural walk (p = 0.002).

CONCLUSION:
The anti-pronation taping technique may not be effective preventive strategy from the exercise-induced leg pain, such as shin splints.
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NewsBot · Oct 6, 2019

Treatment of medial tibial stress syndrome using an investigational lower leg device. A randomised controlled trial
W. McNamara et al
October 2019Volume 22, Supplement 2, Page S19

Introduction: Medial tibial stress syndrome (MTSS) is a common and frustrating overuse injury for patients and clinicians. Due to a combination of bone loading, biomechanical inefficiencies and myofascial traction it can be difficult to treat. Fascial traction and increased bone loading secondary to soleus muscle tightening has been well documented in the literature as a predominant risk factor. The purpose of this study was to investigate the effect of an investigational device designed to improve soleus muscle length on MTSS symptoms compared to placebo.

Methods: A prospective double-blinded randomised placebo-controlled trial was conducted to determine the effect of an investigational device on shin pain symptoms exhibited in patients suffering from MTSS. Participants were randomised to the device or placebo groups and were included if they had symptomatic MTSS lasting 6 weeks or more. Excluded were those where other lower limb pathologies (diagnosed or suspected). Participants completed a standardised MTSS Severity questionnaire at the initial assessment and 1-6, 8, 12, and 24 weeks.

The investigational device resembled a sleeve with three rubber ellipsoids compressing the musculotendinous junctions of the soleus muscle. Another component compressed along the posteromedial border of the distal one-third of the tibia. The placebo device appeared identical, however, lacked the functional compressive components.

Results: Fourteen participants formed the study cohort. The placebo group consisted of 4 male and 3 female participants of with a mean age of 28 ± 2.3 years. The device group consisted of 2 male and 5 female participants of with a mean age of 26 ± 1.8 years. Comparison of scores between groups from 0-4 weeks showed no statistically significant difference (p > 0.05). However, from 5-24 weeks the device group maintained a significantly lower score than the placebo group (p < 0.03). Comparison within the placebo group demonstrated no statistically significant difference between any time points (p > 0.05). Comparison within the device group yielded a significant reduction in MTSS severity from 0-5 weeks (p < 0.03), 0 to 12 weeks (p < 0.03), and 0-24 weeks respectively (p < 0.03).

Discussion: The investigational device demonstrated a significant reduction in MTSS symptoms from 5 weeks that was sustained over 6 months compared to the placebo. Clinically, it has potential to benefit patients with MTSS as a useful adjunct to current treatment methods. Further investigation regarding efficacy is indicated.
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NewsBot · Nov 12, 2019

The effect of pads on foot morphology in athletes with medial tibial stress syndrome.
Akiyama K
J Back Musculoskelet Rehabil. 2019 Sep 12

BACKGROUND:
Evaluation of the effect of a pad on foot morphologies in patients with MTSS requires more reliable and objective methods, rather than conventional subjective observations.

OBJECTIVE:
The objective of this study was to investigate the effect of pads on foot morphologies during quiet standing in athletes with medial tibial stress syndrome (MTSS).

METHODS:
We measured three-dimensional foot morphologies in 30 feet with MTSS and 40 healthy feet.

RESULTS:
The analysis showed that Hallux valgus degree, calcaneal angle, arch height, and arch height ratio differed significantly as a result of the pad support, compared to no pad support in the MTSS group. The pad support only resulted in significant differences in arch height, compared to no support in the control group. Furthermore, thumb side angle, calcaneal angle, and arch height ratio were significantly different between the MTSS and control groups.

CONCLUSIONS:
Our study results suggest that changes in foot morphologies because of the use of a pad can be measured objectively in patients with MTSS.
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NewsBot · Feb 11, 2021

Validation of a Machine Learning Algorithm to enhance decision making in the management of Medial Tibial Stress Syndrome
Angus Shaw, Jeremy Witchalls, Phil Newman
HRI - Research Institute for Sport & Exercise

Background: Medial Tibial Stress Syndrome (MTSS) has been identified as the most costly musculoskeletal injury (MSKI) to the British army (Sharma, Greeves et al. 2015), affecting 35-80% of military trainees. There is no reliable treatment for MTSS and reoccurrence rates are high. Prevention of MTSS is critical to reducing operational burden. Typically injury prediction is complex, multivariate, and has not been capable of discerning individual level risks.

Aim: This study investigated the accuracy of a machine learning approach that combines best known risk factors into an individual risk profiling tool for a common MSKI.

Method: Using a prospective design, this study collected a suite of key variables, determined in a previous study of navy recruits (Garnock, Witchalls et al. 2018), in a new population from the Australian Defence Force Academy. Data was obtained from 107 recruits (35 females and 75 males). Follow-up was conducted at 3 months to determine those in the group that had developed MTSS, when a total of 99 recruits (69 males, 30 females) remained for inclusion in statistical analysis. Six ensemble learning algorithms- Decision Tree, Support Vector Machine, Logistic Regression, K-Nearest Neighbour, Random Forest and Naïve Bayes were deployed and trained 5 times on random stratified samples of 75% of the dataset. The resultant algorithms were tested on the remaining 25% of the dataset and the models were compared for classification accuracy, precision and recall, and Predictive Lift. The most accurate new algorithm was additionally deployed on the previous dataset of navy recruits in order to further validate the accuracy of the model.

Results: Random Forest modelling was the most accurate with a classification accuracy of 92%, Area Under the Curve 98%, precision 91% and recall 92%. When this model was applied to an unrelated dataset it performed with similarly high classification accuracy of 93%, Area Under the Curve 93%, precision 93% and recall 93%. Lift curve analysis showed that treating the top 30% of at risk individuals would result in an 80% reduction in MTSS injuries.

Conclusions: This model is highly accurate in predicting those who will develop the debilitating condition of MTSS. The model provides important preventive capacity which should be trialled as an intervention.
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NewsBot · Oct 5, 2021

Evidence-Based Management of Medial Tibial Stress Syndrome in Runners
Anne Kuwabara, Paige Dyrek, Emily Miller Olson & Emily Kraus
Current Physical Medicine and Rehabilitation Reports (2021)

Purpose of Review
To present a synthesis of recent literature regarding the risk factors and management for MTSS.

Recent Findings
Risk factors include female sex, prior history of MTSS, less running experience, female athlete triad/RED-S, higher BMI, smoking, and biomechanical abnormalities. Management includes activity modification, gait retraining, orthotics, medications, and, very rarely, surgery.

Summary
MTSS is an overuse injury commonly seen in runners. The pathophysiology remains disputed, and diagnosis is often determined from clinical presentation alone. For unclear reasons, women are at increased risk for development of MTSS. Other risk factors include increased BMI, prior history of MTSS, less running experience, smoking, presence of at least one component of the female athlete triad/RED-S, and biomechanical abnormalities. Treatment often includes cessation of high-impact activity, gait retraining, neuromuscular training, and orthotics. In rare circumstances, surgery may be considered. Identifying risk factors is important for prevention and individualized management.
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NewsBot · Oct 11, 2021

Evaluation of Motor and Sensory Function in Female
Endurance Runners with and without Medial Tibial Stress
Syndrome
M. Mohammadi1, M. Karimizadeh Ardakani2
Sport Medicine Studies Volume 12, No 28, 2021, Page 127-148

The aim of the present study was to compare sensory and motor performance in female
runners with and without medial tibial stress syndrome (MTSS). According to the
objectives and content, the present study was descriptive and comparative. Fifty female
endurance runners with the age of 20 to 30 years were divided into two groups of 25 people
with MTSS (mean age 23.04 years, weight 60.40 kg and height 164.56 cm) and without
injuries (Mean age 23.36 years, weight 61 kg and height 162.52 cm). Yates criterion was
used to diagnose the injured group and to assess sensory function and motor function,
measurement of sense of knee and ankle joint position, and the functional movement
screening (FMS) test was applied, respectively. The results of the analysis of variance
showed that there was a significant difference between the two groups in the subscales.
Moreover, the overall score of the FMS test in the sense of joint position (P <0.05) and
individuals in the group with MTSS had more deviation in the reconstruction of the target
angle. Therefore, it is recommended that endurance runners with MTSS should pay
attention to their weaknesses in their exercise program.
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NewsBot · Mar 4, 2022

Foot Orthoses Enhance the Effectiveness of Exercise, Shockwave, and Ice Therapy in the Management of Medial Tibial Stress Syndrome
Aynollah Naderi et al
Clin J Sport Med. 2021 Mar 24

Objective: Our aim was to assess the effects of adding arch-support foot-orthoses (ASFO) to a multimodal therapeutic intervention on the perception of pain and improvement of recovery from medial tibial stress syndrome (MTSS) in recreational runners.

Design: A prospective randomized controlled trial.

Setting: Sport training and medical centers.

Participants: Fifty female recreational runners with MTSS were randomized into 2 groups.

Interventions: Runners either received ASFO or sham flat noncontoured orthoses. Both groups received a multimodal therapeutic intervention, including ice massage, ankle muscle exercises, and extracorporeal shockwave therapy.

Main outcome measures: Pain during bone pressure using a numerical Likert scale (0-10), MTSS severity using an MTSS scale, perceived treatment effect using the global rating of change scale, and quality of life using the short Form-36 questionnaire were determined at week 6, 12, and 18.

Results: Pain intensity and MTSS severity were lower, and the perceived treatment effect and physical function were better in the ASFO than in the sham flat noncontoured orthoses group at week 6 and week 12. Cohen's dz effect size for between-group differences showed a medium difference. However, arch-support foot-orthoses did not add to the benefits of multimodal therapeutic intervention on pain, MTSS severity and perceived treatment effect at week 18.

Conclusions: Adding ASFO to a therapeutic intervention leads to an earlier diminishment of pain and MTSS severity, and improved PF and perceived therapeutic effects.
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NewsBot · Apr 26, 2022

Effect of Compression Therapy in the Treatment of Tibial Stress Syndrome in Military Service Members
Matthew N. Peterson et al
Journal of Sport Rehabilitation: 20 Apr 2022

Context: Tibial stress syndrome (TSS) is an overuse injury of the lower extremities. There is a high incidence rate of TSS among military recruits. Compression therapy is used to treat a wide array of musculoskeletal injuries. The purpose of this study was to investigate the use of compression therapy as a treatment for TSS in military service members. Design: A parallel randomized study design was utilized. Methods: Military members diagnosed with TSS were assigned to either a relative rest group or compression garment group. Both groups started the study with 2 weeks of lower extremity rest followed by a graduated running program during the next 6 weeks. The compression garment group additionally wore a shin splints compression wrap during the waking hours of the first 2 weeks and during activity only for the next 6 weeks. Feelings of pain, TSS symptoms, and the ability to run 2 miles pain free were assessed at baseline, 4 weeks, and 8 weeks into the study. Results: Feelings of pain and TSS symptoms decreased during the 8-week study in both groups (P < .05), but these changes were not significantly different between groups (P > .05). The proportion of participants who were able to run 2 miles pain free was significantly different (P < .05) between the 2 groups at the 8-week time point with the compression garment group having a significantly increased ability to complete the run without pain. Conclusions: Although perceptions of pain at rest were not different between groups, the functional ability of running 2 miles pain free was significantly improved in the compression garment group. These findings suggest that there is a moderate benefit to using compression therapy as an adjunct treatment for TSS, promoting a return to training for military service members.
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