Medial Tibial Stress Syndrome

By admin Last updated Oct 16, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Benjamin A. Hasan

Basics

Description

Typically an overuse injury, with pain over the posteromedial border of the middle to distal thirds of the tibia, but there may be pain in other locations circumferentially around the lower leg.
Historically attributed to degenerative tendinopathy or periostitis
Newer evidence points to repetitive bony overload of the posteromedial tibial border (1)
May be on a continuum with stress fracture
Synonym(s):
- “Shin splints,” a misnomer widely accepted in the running and sports medicine communities (2)
- Medial tibial stress syndrome, the most medically appropriate term (3)
- Tibialis posterior myofasciitis
- Soleus syndrome
- Posterior tibial tendinitis

Epidemiology

Shin splints is the diagnosis in 13% of injuries to runners (2).
Incidence has been reported between 4 and 35% in military studies, 4% in currently training U.S. Navy recruits (3).

Risk Factors

Risks for development of lower extremity overuse syndromes have been commonly observed by runners, coaches, trainers, therapists, and physicians (1,3,4,5,6):

Repetitive stress, especially running and jumping
<5 yrs of experience in running (1)[B]
Overpronation or other lower extremity alignment abnormalities (7,8)[B]
Increase in training intensity
Change in running/playing surface
Training on surfaces
Inability to decrease intensity or duration of training
Female sex
Elevated body mass index (BMI)
History of prior medial tibial stress syndrome

General Prevention

Prevention methods often encouraged [C]:
- Achilles tendon stretches
- Foam or rubber heel pads
- Shock-absorbing insoles: Most promising in studies (9)
- Footwear specific to foot type
- Gradually increasing running programs
Systematic review shows now statistical benefit from any reported prevention (9).

Diagnosis

History

Often insidious and progressive
Temporally related to sudden increase in intensity/duration of activity, or change in playing/running surface from a softer surface to a harder surface such as concrete
Early in course: Pain with onset of exertion, usually relieved by rest:
- Sometimes relieved as activity continues
- Often worse with toe-off
Late in course: Pain through full duration of activity:
- Pain may continue after cessation of inciting activity.

Physical Exam

Tenderness to palpation along the middle to distal thirds of the tibia, along the posteromedial border
Lower extremity kinetic chain examination may reveal excessive pronation or other alignment abnormalities
Chronic cases: Induration, soft tissue swelling, or nodularity
Shoe examination reveals wear pattern, age of shoes

Diagnostic Tests & Interpretation

Imaging

Plain films of anteroposterior and lateral tibia are often normal; may show cortical hypertrophy or demineralization (2)
Bone scan: Diffuse uptake along the posteromedial border of the tibia, often seen better on delayed images, involves radiation, shows whole body (if concern for bilateral or other associated areas of bony tenderness as in multiple stress fractures)
MRI: Bone marrow edema and periosteal signal may be seen, similar sensitivity and specificity to bone scan, no radiation, single body part at a time (10)

Differential Diagnosis

Stress fracture
Compartment syndrome
Muscular strain
Nerve entrapment
Fascial defects
Popliteal artery entrapment syndrome
Effort-induced venous thrombosis

Treatment

Acute treatment (2,6)[C]:

NSAIDs most beneficial in acute stages
No benefit to immobilization
Ice most beneficial in acute stage
Complete rest if possible
Otherwise, 20–50% reduction in mileage/inciting activity, with slow return to previous level of activity as symptoms resolve (9)[C]
Cross-training with nonimpact activities: Swimming, water running, bicycling

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Additional Treatment

Additional Therapies

Special considerations [C]:
- Special taping techniques by athletic trainers may improve symptoms.
- For very flat feet (pes planus), consider more supportive shoes or supportive inserts.
- For very high-arched feet (pes cavus), consider increased cushioning in shoes or shock-absorbing inserts.
Rehabilitation (9)[C]:
- Target-specific stretching and strengthening exercises
- Towel calf stretches
- Tracing alphabet with toes
- Alternate heel/toe walking

Surgery/Other Procedures

Generally limited success, but in some studies, success rates of 29–93% have been reported (11)[B].
Surgical procedures for recalcitrant cases:
- Surgical release of the investing fascia around the soleus insertion on the posteromedial aspect of the tibia. Medial tibial stress syndrome is not a compartment syndrome, but releasing this fascia has helped.
- Surgical division of the insertion of the soleus on the periosteum can relieve associated periostitis.
- Cauterization of the periosteum over the posteromedial tibia allows scarring and reattachment of the periosteum.

Ongoing Care

Changes in training techniques:
- Increase rest days.
- Add in cross-training days with nonweight-bearing activity such as swimming and biking.
- Slow increase in training intensity/duration, with no more than a 10% increase per week
Correct shoe type for foot type:
- Some people benefit from custom orthotics.
- Most people just need the right shoe for pes planus or pes cavus foot type.

Patient Education

Much education required
Advance training intensity gradually to prevent overuse (9)[C].
Rest sufficiently to overcome symptoms.
Return slowly to avoid recurrence.
New shoes every 3–6 mos, 200–300 miles of wear (9)[C]

References

1. Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors to medial tibial stress syndrome: a prospective investigation. Med Sci Sports Exerc. 2009.

2. Andrish JT. In DeLee JC, Drez D, Miller MD, eds. Orthopedic sports medicine. 2nd ed. Philadelphia: Saunders, 2003:2155–2161.

3. Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome: a critical review. Sports Med. 2009;39:523–546.

4. Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports Med. 1998;26:265–279.

5. Bennett JE, Reinking MF, Pluemer B, et al. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther. 2001;31:504–510.

6. Cosca DD, Navazio F. Common problems in endurance athletes. Am Fam Physician. 2007;76:237–244.

7. Tweed JL, Avil SJ, Campbell JA, et al. Etiologic factors in the development of medial tibial stress syndrome: a review of the literature. J Am Podiatr Med Assoc. 2008;98:107–111.

8. Tweed JL, Campbell JA, Avil SJ. Biomechanical risk factors in the development of medial tibial stress syndrome in distance runners. J Am Podiatr Med Assoc. 2008;98:436–444.

9. Thacker SB, Gilchrist J, Stroup DF, et al. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34:32–40.

10. Haims A, Jokl P. In Johnson TR, Steinbach LS. Essentials of musculoskeletal imaging. Rosemont, IL: AAOS; 2004:516–519.

11. Abramowitz AJ, Schepsis A, McArthur C. The medial tibial syndrome. The role of surgery. Orthop Rev. 1994;23:875–881.

Additional Reading

Locke S. Exercise-related chronic lower leg pain. Aust Fam Physician. 1999;28:569–573.

Touliopolous S, Hershman EB. Lower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Med. 1999;27:193–204.

Codes

ICD9

844.9 Sprain of unspecified site of knee and leg

Clinical Pearls

Activity should be avoided until pain and tenderness resolve, followed by a slow, structured return to prior level of activity.
There is no good evidence that special taping or an ACE bandage will shorten recovery, but it may help to improve symptoms.
If time cannot be taken off from training, relative rest, with a 20–50% decrease in training intensity/duration. Work in cross-training days, with nonweight-bearing activity.
Rehabilitation exercises should aim at stretching and strengthening involved musculotendinous units.
- Use a towel to pull your foot toward you and stretch your calf. Trace the alphabet with your feet. Alternate walking on toes and heels. “Toe raises” to strengthen lower leg while standing on stairs or steps [C].