para>MTSS may account for up to 31% of all overuse injuries in high school athletes (2). � �
ETIOLOGY AND PATHOPHYSIOLOGY
- 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
- Anatomic structures affected include the following:
- Flexor hallucis longus
- Tibialis anterior
- Tibialis posterior
- Soleus
- Crural 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 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 " �particularly 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 " �common in recruit/boot camp
- Gymnasts, soccer, and basketball players
- Ballet dancers
GENERAL PREVENTION
- Proper technique for guided calf stretching and lower extremity strength training
- Rehabilitation for prior injuries
- Other suggested recommendations
- Gait analysis and retraining, particularly for overpronation
- Orthotic 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
- Bone
- Tibial stress fractures
- Typically, pain persists at rest or with weight-bearing activities.
- Focal tenderness over the anterior tibia
- Muscle/soft tissue injury
- Strain, tear, tendinopathy
- Muscle hernia
- Fascial
- Chronic exertional compartment syndrome (3)[C]
- Pain without direct tenderness on exam
- Pain increases with exertion and resolves at rest.
- Pain is described as cramping or squeezing.
- Pain with possible weakness or paresthesias on exam
- Interosseous membrane tear
- 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.
- Infection
- Malignancy
DIAGNOSTIC TESTS & INTERPRETATION
- 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.
- 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 both
- Severe limitation of physical activity and
- Failure of 6 months of conservative treatment
- Patient 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. � �
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 � �BW. Overuse lower extremity injuries in sports. Clin Podiatr Med Surg. 2014;32(2):239 " �251.22 Cuff � �S, Loud � �K, O 'Riordan � �MA. Overuse injuries in high school athletes. Clin Pediatr (Phila). 2010;49(8):731 " �736.33 Hutchinson � �M. Chronic exertional compartment syndrome. Br J Sports Med. 2011;45(12):952 " �953.44 Politano � �AD, Bhamidipati � �CM, Tracci � �MC, et al. Anatomic popliteal entrapment syndrome is often a difficult diagnosis. Vasc Endovascular Surg. 2012;46(7):542 " �545.55 Chang � �GH, Paz � �DA, Dwek � �JR, et al. Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment. Clin Imaging. 2013;37(5):836 " �846.66 Fields � �KB, Sykes � �JC, Walker � �KM, et al. Prevention of running injuries. Curr Sports Med Rep. 2010;9(3):176 " �182.77 Moen � �MH, Holtslag � �L, Bakker � �E, 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 � �MH, Rayer � �S, Schipper � �M, et al. Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. Br J Sports Med. 2012;46(4):253 " �257.99 Hirschm � �ller � �A, Baur � �H, M � �ller � �S, 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 " �965.1010 Schulze � �C, Finze � �S, Bader � �R, 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 � �B. The Tibialis Anterior Stretch " �Kinetic Health. https://www.youtube.com/watch?v=6Z6XM63x2TM. June 19, 2014.
- Cosca � �DD, Navazio � �F. Common problems in endurance athletes. Am Fam Physician. 2007;76(2):237 " �244.
- Hamstra-Wright � �KL, Bliven � �KC, Bay � �C. 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 " �369.
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 � �
SNOMED
- 202888004 anterior shin splints (disorder)
- 202889007 Posterior shin splints
CLINICAL PEARLS
- MTSS is the preferred term for "shin splints. " �
- 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.