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Medial Tibial Stress Syndrome (MTSS)/Shin Splints

- Multifactorial anatomic and biomechanical factors - Overuse injuries causing or limited by - Microtrauma from repetitive motion leading to periosteal inflammation - Overpronation of the subtalar joint and tight gastrocnemius/soleus complex with increased eccentric loading of musculature inserting along the medial shin - Interosseous membrane pain - Periostitis - Tears of collagen fibers - Enthesopathy

- Intrinsic or personal risk factors: - Greater internal and external ranges (>65 degrees) of hip motion - Significant overpronation at the ankle - Imbalance of inverters and everter musculature of the ankle and foot - Female gender - Leaner calf girth - Femoral neck anteversion - Navicular drop - Genu varum

- External or environmental factors - Lack of physical fitness - Inexperienced runners " пїЅparticularly those with rapid increases in mileage and inadequate prior conditioning - Excessive overuse or distance running, particularly on hard or inclined (crowned) surfaces - Prior injury - Equipment (shoe) failure

- Other risk factors - Elevated BMI - Lower bone mineral density - Tobacco use

- Those typically affected include the following: - Runners - Military personnel " пїЅcommon in recruit/boot camp - Gymnasts, soccer, and basketball players - Ballet dancers

- Muscle/soft tissue injury - Strain, tear, tendinopathy - Muscle hernia

- Nerve - Spinal stenosis - Lumbar radiculopathy - Common peroneal nerve entrapment

- Vascular - DVT - Popliteal arterial entrapment (4)[B] - Rare but limb-threatening disease - History of intermittent unilateral claudication - MRI reveals compression of the artery by the medial head of the gastrocnemius muscle.

- Plain radiographs help rule out stress fractures if >2 weeks of symptoms (5). - Bone scintigraphy - Diffuse linear vertical uptake in the posterior tibial cortex on the lateral view. - Stress fractures demonstrate a focal ovoid uptake.

para>MTSS may account for up to 31% of all overuse injuries in high school athletes (2). пїЅ пїЅ

ETIOLOGY AND PATHOPHYSIOLOGY

  • Multifactorial anatomic and biomechanical factorsOveruse injuries causing or limited byMicrotrauma from repetitive motion leading to periosteal inflammationOverpronation of the subtalar joint and tight gastrocnemius/soleus complex with increased eccentric loading of musculature inserting along the medial shinInterosseous membrane painPeriostitisTears of collagen fibersEnthesopathyAnatomic structures affected include the following:Flexor hallucis longusTibialis anteriorTibialis posteriorSoleusCrural fascia
  • Pathogenesis: theorized to be due to persistent repetitive loading, which leads to inadequate bone remodeling and possible microfissures causing pain without evidence of fracture or ischemia

RISK FACTORS

  • Intrinsic or personal risk factors:Greater internal and external ranges (>65 degrees) of hip motionSignificant overpronation at the ankleImbalance of inverters and everter musculature of the ankle and footFemale genderLeaner calf girthFemoral neck anteversionNavicular dropGenu varum
  • External or environmental factorsLack of physical fitnessInexperienced runners " пїЅparticularly those with rapid increases in mileage and inadequate prior conditioningExcessive overuse or distance running, particularly on hard or inclined (crowned) surfacesPrior injuryEquipment (shoe) failure
  • Other risk factorsElevated BMILower bone mineral densityTobacco use
  • Those typically affected include the following:RunnersMilitary personnel " пїЅcommon in recruit/boot campGymnasts, soccer, and basketball playersBallet dancers

GENERAL PREVENTION

  • Proper technique for guided calf stretching and lower extremity strength training
  • Rehabilitation for prior injuries
  • Other suggested recommendationsGait analysis and retraining, particularly for overpronationOrthotic footwear inserts

COMMONLY ASSOCIATED CONDITIONS

  • Rule out stress fracture and compartment syndrome.
  • Pes planus (flat feet)

DIAGNOSIS

HISTORY

  • Patients typically describe dull, sharp, or deep pain along the lower leg that is resolved with rest.
  • Patients are often able to run through the pain in early stages.
  • Pain is commonly associated with exercise (also true with compartment syndrome), but in severe cases, pain may persist with rest.

PHYSICAL EXAM

  • Tenderness to palpation is typically elicited along the posteromedial border of the middle-to-distal third of the tibia.
  • Pain with plantar flexion
  • Ensure neurovascular integrity of the lower extremity, examining distal pulses, sensation, reflexes, and muscular strength.

DIFFERENTIAL DIAGNOSIS

  • BoneTibial stress fracturesTypically, pain persists at rest or with weight-bearing activities.Focal tenderness over the anterior tibia
  • Muscle/soft tissue injuryStrain, tear, tendinopathyMuscle hernia
  • FascialChronic exertional compartment syndrome (3)[C]Pain without direct tenderness on examPain increases with exertion and resolves at rest.Pain is described as cramping or squeezing.Pain with possible weakness or paresthesias on examInterosseous membrane tear
  • NerveSpinal stenosisLumbar radiculopathyCommon peroneal nerve entrapment
  • VascularDVTPopliteal arterial entrapment (4)[B]Rare but limb-threatening diseaseHistory of intermittent unilateral claudicationMRI reveals compression of the artery by the medial head of the gastrocnemius muscle.
  • Infection
  • Malignancy

DIAGNOSTIC TESTS & INTERPRETATION

  • Plain radiographs help rule out stress fractures if >2 weeks of symptoms (5).
  • Bone scintigraphyDiffuse linear vertical uptake in the posterior tibial cortex on the lateral view.Stress fractures demonstrate a focal ovoid uptake.
  • High-resolution MRI reveals abnormal periosteal and bone marrow signals, which are useful for early discrimination of tibial stress fractures.
  • Increased pain and localized tenderness warrants further imaging with MRI due to concern for tibial stress fracture.
  • Exclude compartment syndrome using intracompartmental pressure testing.

TREATMENT

GENERAL MEASURES

  • Activity modification with a gradual return to training based on improvement of symptoms
  • Patients should maintain fitness with low-impact activities such as swimming and cycling.
  • Continue activity modification until patients are pain-free on ambulation.
  • Good supportive footwear is recommended.

MEDICATION

  • Analgesia with acetaminophen or other oral nonsteroidal anti-inflammatory agent
  • Cryotherapy (ice massage) is also advised to relieve acute-phase symptoms (6)[C].

ADDITIONAL THERAPIES

  • Stretching of the gastrocnemius, soleus, and peroneal muscles are treatment mainstays (6)[C].
  • Calf stretch, peroneal stretch, TheraBand exercises, and eccentric calf raises may improve endurance and strength.
  • Compression stockings have been used to treat MTSS with mixed results.
  • Structured running programs with warm up exercises have not been demonstrated to reduce pain in young athletes (7)[B].

SURGERY/OTHER PROCEDURES

  • Surgical intervention includes a posterior medial fascial release in individuals with bothSevere limitation of physical activity andFailure of 6 months of conservative treatmentPatient should be counseled that complete return of activity to sport may not be always achieved postoperatively. Surgical risks include infection and hematoma formation.
  • Extracorporeal shock wave therapy (ESWT) may decrease recovery time when added to a running program (8)[B].

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Individualized polyurethane orthoses may help chronic running injuries (9)[A].
  • Special insoles, shock-absorbing running shoes, and knee braces have not been shown to decrease the incidence of MTSS (6)[C].
  • Ultrasound, acupuncture, aquatic therapy, electrical stimulation, whirlpool baths, cast immobilization, taping, and steroid injection may help improve pain.
  • Physical therapy approaches including Kinesio tape and fasical distortion massage may yield quicker return to activity (10)[B].

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Patients should avoid prematurely resuming preinjury running pace.
  • Stretching and strengthening exercises should be added.
  • Preinjury training errors should be identified and corrected with a gradual return to activity dictated by symptoms (pain).

PROGNOSIS

The condition is usually self-limiting, and most patients respond well with rest and nonsurgical intervention. пїЅ пїЅ

COMPLICATIONS

  • Stress fractures and compartment syndrome
  • Undiagnosed MTSS or chronic exertional compartment syndrome can lead to a complete fracture or tissue necrosis, respectively.

REFERENCES

11 Fullem пїЅ пїЅBW. Overuse lower extremity injuries in sports. Clin Podiatr Med Surg. 2014;32(2):239 " пїЅ251.22 Cuff пїЅ пїЅS, Loud пїЅ пїЅK, O 'Riordan пїЅ пїЅMA. Overuse injuries in high school athletes. Clin Pediatr (Phila). 2010;49(8):731 " пїЅ736.33 Hutchinson пїЅ пїЅM. Chronic exertional compartment syndrome. Br J Sports Med. 2011;45(12):952 " пїЅ953.44 Politano пїЅ пїЅAD, Bhamidipati пїЅ пїЅCM, Tracci пїЅ пїЅMC, et al. Anatomic popliteal entrapment syndrome is often a difficult diagnosis. Vasc Endovascular Surg. 2012;46(7):542 " пїЅ545.55 Chang пїЅ пїЅGH, Paz пїЅ пїЅDA, Dwek пїЅ пїЅJR, et al. Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment. Clin Imaging. 2013;37(5):836 " пїЅ846.66 Fields пїЅ пїЅKB, Sykes пїЅ пїЅJC, Walker пїЅ пїЅKM, et al. Prevention of running injuries. Curr Sports Med Rep. 2010;9(3):176 " пїЅ182.77 Moen пїЅ пїЅMH, Holtslag пїЅ пїЅL, Bakker пїЅ пїЅE, et al. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:12.88 Moen пїЅ пїЅMH, Rayer пїЅ пїЅS, Schipper пїЅ пїЅM, et al. Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. Br J Sports Med. 2012;46(4):253 " пїЅ257.99 Hirschm пїЅ пїЅller пїЅ пїЅA, Baur пїЅ пїЅH, M пїЅ пїЅller пїЅ пїЅS, et al. Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. Br J Sports Med. 2011;45(12):959 " пїЅ965.1010 Schulze пїЅ пїЅC, Finze пїЅ пїЅS, Bader пїЅ пїЅR, et al. Treatment of medial tibial stress syndrome according to the fascial distortion model: a prospective case control study. ScientificWorld Journal. 2014;2014:790626.

ADDITIONAL READING

  • Abelson пїЅ пїЅB. The Tibialis Anterior Stretch " пїЅKinetic Health. https://www.youtube.com/watch?v=6Z6XM63x2TM. June 19, 2014.
  • Cosca пїЅ пїЅDD, Navazio пїЅ пїЅF. Common problems in endurance athletes. Am Fam Physician. 2007;76(2):237 " пїЅ244.
  • Hamstra-Wright пїЅ пїЅKL, Bliven пїЅ пїЅKC, Bay пїЅ пїЅC. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analyasis. Br J Sports Med. 2015;49(6):362 " пїЅ369.

CODES

ICD10

  • S86.899A Other injury of other muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter
  • S86.891A Other injury of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
  • S86.892A Other injury of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter

ICD9

844.8 Sprains and strains of other specified sites of knee and leg пїЅ пїЅ

SNOMED

  • 202888004 anterior shin splints (disorder)
  • 202889007 Posterior shin splints

CLINICAL PEARLS

  • MTSS is the preferred term for "shin splints. " пїЅ
  • Diagnosis is based on the history of repetitive overuse accompanied by characteristic shin pain.
  • Pain that is worsened with activity and relieved with rest is commonly described along the middle and distal third of the posteromedial tibial surface.
  • Treatment includes ice, activity modification, analgesics, eccentric stretching, gait retraining, and a gradual return to activity.