Medial Tibial Stress Syndrome

Autumn means that youth overuse injuries increase as school sports resume, and lower extremity stress is particularly amplified when athletes move indoors onto hard floors. Medial tibial stress syndrome (MTSS), aka Medial Tibial Traction Periostitis, is a common result of this increased load. The diagnosis of MTSS describes exercise-induced pain along the posteromedial border of the tibia.  The condition is commonly referred to as “shin splints” and is a familiar malady in athletes and soldiers where it affects up to 1/3 of those populations.  (1-4) MTSS is responsible for approximately 15% of all running injuries.  (1)

Medial tibial stress syndrome 

The condition affects the vulnerable insertion points of the tibial fascia and deep ankle flexors along the medial tibial crest. MTSS is believed to result from repetitive eccentric contraction of the deep flexors during running, jumping, or impact loading.  (5) Repetitive traction on the medial tibial crest results in myofascial strain, periosteal inflammation, and bony stress reaction.  (6-13) Early etiological theories focused on myofascial strain, but current evidence suggests that a bony stress reaction is the most likely cause of MTSS.  (14-20) 

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Newer research suggests that traction periostitis may be an inflammatory precursor to a tibial stress fracture.  (21) The stress of exercise can weaken bone.  Healthy bone responds to this stress by remodeling itself more densely. Stress reactions occur when the normal adaptive remodeling response is unable to keep pace with the loads of excessive training, i.e., high demands with inadequate recovery times. (22,23) Prolonged insult may lead to a tibial stress fracture, and many authors now believe that MTSS and stress fracture represent two different points along a continuum of bony stress reaction.  (24,25)  

Mechanism of Injury

The leading mechanism of injury is repetitive eccentric contraction from running or jumping on hard surfaces.  (26-28) Excessive or improper training is the leading factor in the development of medial tibial stress syndrome.  (2,3,29-33) Common training errors include the “terrible too’s” (too much, too fast, too long.)  (31-34) Athletes who run more than 20 miles per week are at increased risk of developing MTSS.  (35) Inexperienced runners or those with poor technique are at greater risk.  (4) Running with a narrow or “crossover” gait increases tibial stress. (87)

Foot hyperpronation is a significant risk factor for the development of MTSS, as a collapsing foot puts additional stress on the suspect tissues.  (4,10,12,14,28,36) Interestingly, the use of orthotics is associated with the development of MTSS, although orthotic use should not be viewed as an independent risk factor since those using orthotics are likely to hyperpronate. (4) Females are affected more frequently and have a 1.5-3.5 increased likelihood of progressing to a stress fracture.  (4,37) Additional risk factors include a prior history of MTSS and increased BMI.  (4)

Clinical Presentation

The clinical presentation of MTSS includes vague, diffuse pain over the middle to distal posteromedial tibia.  Athletes often present following an increase in activity intensity or duration.  Symptoms are often worse with exertion, particularly at the beginning of a work-out.  (38)  Initially, symptoms may subside during training, but as the condition progresses, symptoms may linger throughout activity or even at rest.  (38) Pain that persists more than five minutes post-activity carries a higher suspicion of a stress fracture.  (49) Clinicians should be alert for symptoms of numbness or paresthesia, which could suggest exercise-induced compartment syndrome.

Clinical evaluation demonstrates diffuse tenderness over the posteromedial tibial border. Prolonged stress may generate a periosteal reaction detectable as a “rough” or “bumpy” feel upon palpation.  (39) Tenderness from MTSS should involve at least 5 cm of the tibial border.  (39) More focal tenderness, the presence of anterior tibial tenderness, or any significant swelling, suggests a stress fracture. Applying a vibrating tuning fork over the tibia may help detect stress fracture (75% sensitivity). (40) Single leg hopping is painful in about half of MTSS cases (and 70-100% of stress fractures) (41-43) The Talar Bump Test may help differentiate tibial stress fracture from MTSS.

Assessment

Tenderness over the flexor digitorum longus and tibialis posterior is a clinical hallmark of the condition, although whether this is a primary cause or secondary effect remains uncertain.  (44,45) Clinicians should assess for the presence of hypertonicity in the gastroc or soleus, as this finding is commonly associated with MTSS.  (46,47)

The presence of foot hyperpronation may be assessed through the navicular drop test (performed by marking the navicular and measuring the amount of drop from non-weight bearing to weight bearing.)  (48) Clinicians should assess for other potential risk factors, including inflexibility or imbalance of the hamstring and quadriceps, genu varus or valgus, tibial torsion, femoral anteversion, and leg length discrepancies.  (14) Hip abductor weakness is a common culprit of many lower chain overuse injuries and may be assessed through the “hip abductor weakness cluster.”  (86) Excessive external rotation of the hip is another known contributor.  (4,50)

Assessment of gait or running patterns can identify biomechanical errors.  (51,52) Clinicians should assess joint mobility throughout the lower extremity. Neurovascular assessment is typically unremarkable.  (38) The presence of sensory or motor loss suggests an alternate diagnosis, including exertional compartment syndrome, peripheral neuropathy, or radiculopathy.  

Imaging

Imaging of early and uncomplicated MTSS is often unnecessary.  (53) Imaging is appropriate in the presence of “red flags”: focal tenderness, pain at rest, or when the patient fails to improve with a reasonable trial of conservative care.  (53) Radiographs taken within the first 2-3weeks are not likely to show any change; however, patients with longstanding MTSS may demonstrate periosteal reaction, indicating callus formation and stress fracture. (55)  

Clinicians should be vigilant for the possibility of a stress fracture.  Plain films frequently do not demonstrate the signs of tibial stress fracture (periosteal elevation/callus formation or cortical lucency). (42,56,57) Unresponsive patients or those with a higher likelihood of stress fracture (runners) may benefit from advanced imaging, including MRI or bone scan.  (58) MRI is highly sensitive (74-100%) and is best able to grade the progression of stress reaction from periosteal edema (Grade 1), to progressive bone marrow edema (Grade 2-3), to cortical stress fracture (Grade 4).  (59-61)  

In addition to a stress fracture, the differential diagnosis of MTSS includes exertional compartment syndrome, peripheral vascular disease, muscle strain, occult fracture, infection, neoplasm, DVT, peripheral neuropathy, popliteal artery entrapment syndrome, lumbosacral radiculopathy, and vascular claudication.  (62-64)

Treatment

The successful management of MTSS requires the removal of risk factors, and rest. Clinicians must identify the combination of training errors and biomechanical risk factors that led to the development of the patient’s condition.  (65) No intervention has proven more successful than rest for the management of MTSS.  (4) Unfortunately, patients often are affected by MTSS during a time when they are training for a sport or upcoming event.  Continuance of the offending activity will often lead to undue chronicity, frustration for patient and clinician, and decreased performance capabilities. Athletes may need to decrease frequency, intensity, and duration of impact activities, including running and jumping. Athletes may need to consider non-weight bearing cross-training, such as stationary cycling or pool running. Initially, anti-inflammatory modalities, including ultrasound or e-stim, may provide relief.  (67)  Ice or home ice massage may provide an anti-inflammatory or palliative benefit.  

Resolution of MTSS requires the correction of any associated kinetic chain dysfunction.  (68-70) Stretching exercises and myofascial release are appropriate for the gastroc, soleus, hip external rotators, tibialis posterior, and tibialis anterior muscles.  (71) Strengthening exercises may be appropriate for the tibialis posterior and hip abductors. Manipulation may be employed to resolve joint restrictions in the spine, sacroiliac joint, pelvis, and lower extremity.  (69,70,74) 

Orthotics

Arch supports or custom orthotics may be appropriate for patients with fallen arches (75), although at least one contradictory systematic review suggests that orthotics may be causative and are not useful for prevention.  (76) The use of compressive taping, bracing, or stockings are thought to enhance bone remodeling and are used by some providers, although supporting evidence is inconclusive.  (77-79) Additional possibilities for the management of MTSS include dry needling, autologous blood injection, platelet-rich plasma (PRP) injections, prolotherapy, and acupuncture.  (74,80) Extracorporeal shock wave therapy (ECST) may speed recovery times.  (81)

Conclusion

Return to activity should start slowly with a graded running program, beginning with a 1/4 mile run and progressing by 1/4 mile each time the athlete has no pain for two consecutive workouts.  (82) Athletes should initially avoid running on hard or uneven surfaces and begin at a lower intensity and distance, increasing by no more than 10-15% per week. Runners should first increase distance, then pace, and avoid hard or unlevel surfaces, including hills. Runners with a narrow gait may benefit from incorporating a wider step width. (87) Clinicians should assess shoes for excessive wear and match the patient to the most appropriate shoe (i.e., stability, neutral, cushioning). Running shoes lose half of their shock absorption capacity after 300-500 miles and should be replaced within that range.  (83-85)

Surgical intervention, including posterior fasciotomy, is rarely indicated for MTSS. (74)

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