Medial Tibial Stress Syndrome
Original Editors - Karsten De Koster
Top Contributors - Karsten De Koster, Claudia Karina, Nick Van Doorsselaer, Alex Palmer, Lucinda hampton, Admin, Kenza Mostaqim, Arno Van Hemelryck, Kim Jackson, Luna Antonis, Bieke Bardyn, Sally Ngo, WikiSysop, Wanda van Niekerk, Naomi O'Reilly, Fitz Van Roy, 127.0.0.1, Claire Knott, Venus Pagare, Chelsea Mclene, Daniele Barilla and Kai A. Sigel
Search Strategy [edit | edit source]
Search on Pubmed and Pedro with keywords: “Shin-splints”, “Medial tibial stress-syndrome” , “shin pain”and “tibial periostitis”. Search in libraries books about sport injuries, sports medicine, sport anatomy.
Definition/Description[edit | edit source]
The American Medical Association defines shin-splint syndrome as “pain and discomfort in the leg from repetitive activity on hard surfaces, or due to forceable, excessive use of the foot flexors[1]. The diagnosis should be limited to musculoskeletal inflammation, excluding stress fractures or ischemic disorders” ([1] Citation).
Shin-splints is a general term for overuse injuries of the lower leg, except stress fractures and compartmental syndrome.[2] Hutchins C.P. says that shin-splints is a controversial term, because authors disagree about the in- and exclusion criteria’s.[3]
A synonym for shin-splints is: medial tibial stress syndrome. But Bruckner and Kahn say: “A more descriptive term that accounts for the inflammatory, traction event on the tibial aspect of the leg common in runners is medial tibial traction periostitis or just medial tibial periostitis “.
There are five possibilities which can describe the experienced shin pain: bone stress, inflammation, vascular insufficiency, nerve entrapment and a raised intracompartmental pressure.[4]
Clinically Relevant Anatomy[edit | edit source]
The most important clinical region is the lower leg. A dysfunction of tibialis anterior and posterior, of soleus muscles are commonly implicated, also the area of attachment of these muscles can be the location of pain. [5]
Figure1:
Chasan N., shin-splints, http://srcpt.blogspot.com/2009/02/shin-splints.html, 2 February 2009
anatomy lower leg
Epidemiology /Etiology
[edit | edit source]
Shin-splints is most common with athletes who made training errors, especially when they overload or when they run too fast for his potential. As we can see this injury can also be related to changes in the training program like an increase in distance, intensity and duration.[6] (A1) Running on a hard or uneven surface and bad running shoes (like a poor shock absorbing capacity) could also be one of the factors related to the casualty. Biomechanical abnormalities as foot arch abnormalities, hyperpronation of the foot, unequal leg length,..[7] (D) are the most frequently mentioned intrinsic factors.
Women have an increased risk to incur stress fractures, especially this syndrome. This is due to nutrional, hormonal and biomechanical abnormalities. Individuals who suffer of overweight are more susceptible for this syndrome. Therefore it’s important that people with overweight combine their exercises with a diet or try to lose weight before starting a therapy or a training program. These people, along with poor conditioned people, should always slowly increase their training level. Cold weather contributes to this symptom, therefore it’s important (even more than usual) to warm up properly. [1] (A1)
“Internally a chronic inflammation of the muscular attachment along the posterior medial tibia and bony changes are considered to be the most likely cause of the medial tibial stress syndrome. “[8]
Characteristics/Clinical Presentation[edit | edit source]
The most common complication of shin-splints is a stress fracture which shows itself by tenderness of the anterior tibia.[6] Sensor and motor loss in association with exertional lower leg pain are another possible clinical symptom. Also pheripheral vascular disease could be a cause of the pain.[6] (A1)So the main symptom is pain on the medial side, in the second third of the leg. The pain is caused by repeated landing and take-off from the surface [8] . This pain worsens at each moment of contact.[7] The symptoms are often bilateral[1].
At first the patient only felt pain when starting the training but further on the pain could remain even when in rest. In some cases we can also see a certain degree of swelling. [8]
Differential Diagnosis[edit | edit source]
add text here
Diagnostic Procedures[edit | edit source]
Medial Tibial Stress syndrome gives a pain in the second third of the lower leg, when the lower leg is under load. In all of these cases the lower leg is very sensitive.[1]
Imaging studies are not necessary to diagnose shin-splints, but when a conservative treatment fails, it could be useful to take an echo. When the injury evolves to a stress fracture, an x-ray scan can show black lines. A triple-phase bone scan can make the difference between a stress fracture and a medial tibial stress syndrome.[8] The MRI can also exclude tumors/edemas.[7] But for the diagnostic procedure a good anamnesis and physical examination are designated. Shin-splints can also be a symptom of a chronic posterior.Compartment_Syndrome_of_the_Lower_Leg. Sometimes an elevated intracompartmental pressure in the deep compartment has been noticed says Puranen.[3] (A1)
Some other risk factors for shin-splits are an increased pronation, an increased varus tendency, increased muscular strength of the plantar flexors, increased double heel strikes during dance and an increased angular displacement during running.[3]
Outcome Measures[edit | edit source]
add links to outcome measures here (also see Outcome Measures Database)
Examination[edit | edit source]
During examination the anamnesis and physical examination of the lower leg will be sufficient. For the physical examination a good palpation of the lower leg will be necessary.
Medical Management
[edit | edit source]
In most cases conservative treatment will suffice, but for recalcitrant cases surgical treatment can be designated. They are often not a complete resolution but may improve symptoms of pain and function. A posterior fasciotomy is the common procedure performed. Surgical treatment can improve pain and functions. [6]
Physical Therapy Management
[edit | edit source]
Shin-splints can be threatened conservatively or surgically. Essentially the treatment may focus on: (a) reducing stress; (b) relieving pain; (c) providing alternative programs to maintain fitness; (d) correcting specific etiologic factors and (e) reintegration of the athlete into activity.[1] We will start with a conservative treatment:
The conservative treatment of this injury starts with rest. A therapist will recommend you 2-6 weeks of rest. This rest should be strictly applied. Otherwise the symptoms can be worsened. Prolonged rest is not ideal for an athlete, thus other therapies are necessary for a quick and safe return after a period of rest. This rest can be assisted by medication. The second thing a therapist will say is to use ice and eventually analgesic gels. The cryotherapy can be used after an exercise for a period of 20 minutes. There are a number of physical therapy modalities to use in the acute phase but there is no proof that these therapies (such as ultrasound, soft mobilization tissue,..[9] (A2))would be effective.[6] (A1)A corticoid injection is contraindicated because this can give a worse sense of healthy. Because the healthy tissue is also treated. A corticoid injection is given to reduce the pain, but only in connection with rest.[7] (D)
For the treatment of shin-splints it’s important to screen the risk factors, this makes it easier to make a diagnosis and to prevent this disease. In the next table you can find them[3](A1):
Intrinsic factors | Extrinsic factors |
Age Sex Height Weight Body fat Femoral neck anteversion Genu valgus Pes clavus Hyperpronation Joint laxity Aerobic endurance/conditioning Fatigue Strength of and balance between flexors and extensors Flexibility of muscles/joints Sporting skill/coordination Physiological factors |
Sports-related factors Type of sport Exposure (e.g., running on one side of the road) Nature of event (e.g., running on hills) Equipment Shoe/surface interface Venue/supervision Playing surface Safety measures Weather conditions Temperature |
In the subacute phase, in this phase the treatment would exist of modifying training conditions and to address eventual biomechanical abnormalities, change of training conditions could be decreased running distance, intensively and frequency. It is advised to avoid hills and uneven surfaces. During the rehabilitation period the patient can do low impact and cross-training exercises (like running on a hydro-gym machine). After a while the athlete should gradually return to his activities. In the next period they can increase some factors as intensity slowly[6](A1). Also a (eccentric) stretching and strengthening program can be introduced to overcome detectable muscle imbalance or contractures[1]. Also a proprioceptive training is designated, like this the effectiveness of joint, the stability and reaction on strange uneven surface can be stimulated. Also a heat retrainer can be of value[8].
Another thing that can help prevent a new or re-injury is to choose good shoes with good shock absorption. Therefore it’s important to change your shoes when the shock-absorbing mechanism of your shoes wears of (after 250-500 miles). Some patients strap their leg or the longitudinal arch. This can be inconvenient for some people, but success indicates that an orthosis can be helpful[10]. Another thing that can help to prevent shin-splints is to wear orthotics, in case of a biomechanical abnormality. An over-the-counter orthosis can help with excessive footpronation and pes planus. A cast or a pneumatic brace can be necessary in severe cases.[6]
Manual therapy can be used to control several biomechanical abnormalities of the spine, sacro-illiacal joint and various muscle imbalances. They are often used to prevent relapsing to the old injury. But manual therapy is not the only therapy that can be used; we have also acupuncture, ultrasound therapy injections and extracorporeal shock-wave therapy but heir efficiency is not yet proved.[6] (A1)
In most cases conservative treatment will suffice, but for recalcitrant cases surgical treatment can be designated. They are often not a complete resolution but may improve symptoms of pain and function.[6](A1)
Key Research[edit | edit source]
This text is mostly based on text of Galbraith R.M. and Lavallee M. E..
Resources
[edit | edit source]
Primary resources
GALBRAITH R.M. and LAVALEE M.E., ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med.; September 2009, 2(3):127-133. (E)
Craig D.I., ‘Medial Tibial Stress Syndrome: Evidence-based Prevention’, J Athl Training, June 2008; 43(3): 316-318. (A)
THACKER S.B.,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine & science in sports & exercises, the first of November 2002; 34(1):32-40. (A)
PURANEN J. and ORAVA S., (1979) ‘ Athletes’ leg pain’, British Journal of Sports Medcine, Spetmber 1979; 13(3):p.92-97. (C)
Secondary resources: Broos P., Sportletsels, Leuven/Apeldoorn: Garant, 1991. (p.22, 179-181).
Kjær M. et al, Sports Medicine; Basic science and clinical aspects of sports injury and physical activity, Oxford: Blackwell Publishing,2003. (p.530-535).
Peterson L. and Renström Per, Sports injuries: their prevention and treatment, 3th edition, London: Dunitz, 2001. (p.11,339-342).
Reid D.C. et al., Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo: Churchill Livingstone,1992. (p.269-280).
BECK B., (1998) ‘Tibial stress injuries: an aetiological review for the purposes of guiding management’, Sports Medicine, 1998, 26(4) 265-279.
BRUCKNER P. and KHAN K., ‘Clinical sports medicine’, 3th edition,North Ryde: McGraw-Hill, 2007(p.555-575).
Chasan N., shin-splints, (http://srcpt.blogspot.com/2009/02/shin-splints.html), 2 February 2009.
Sportsinjuryclininc, shin splints, (http://www.youtube.com/watch?v=jg79mQqiacM), online video, last accessed, 13 October 2007.
Widmark E., How to indentify, treat and prevent medial tibial stress syndrome, (http://www.fysionutrition.se/wp-content/uploads/How-to-treat-and-prevent-medial-tibial-stress-syndrome.pdf), 2009.
Clinical Bottom Line[edit | edit source]
A good knowledge of the anatomy is always important, but it’s also important you know the other disorders of the lower leg, which makes it easier to understand what’s going wrong. Also a detailed screening of known’s risk factors to recognize factor that could add to the cause of the condition and address these….
Recent Related Research (from Pubmed)[edit | edit source]
<span id="fck_dom_range_temp_1293393507582_461" />GALBRAITH R.M. and LAVALEE M.E., (2009) ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med., September 2009, (p.127-133)
References[edit | edit source]
see adding references tutorial.
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Reid D.C. et al.,(1992) Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo, Churchill Livingstone, (p.269-280). Cite error: Invalid
<ref>
tag; name "Reid et al." defined multiple times with different content Cite error: Invalid<ref>
tag; name "Reid et al." defined multiple times with different content - ↑ Kjær M. et al,(2003) Sports Medicine; Basic science and clinical aspects of sports injury and physical activity, Oxford, Blackwell Publishing, (p.530-535).
- ↑ 3.0 3.1 3.2 3.3 THACKER S.B.,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine &amp;amp; science in sports &amp;amp; exercises, the first of November 2002, (p.32-40).
- ↑ BRUCKNER P. and KHAN K., ‘Clinical sports medicine’, 3th edition,North Ryde: McGraw-Hill, 2007(p.555-575).
- ↑ THACKER S.B. (referred D’AMBROSIA) ,(2002) ‘The prevention of shin splints in sports: a systematic review of literature’ , Medicine &amp;amp; science in sports &amp;amp; exercises, the first of November 2002, (p.32-40).
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6. GALBRAITH R.M. and LAVALEE M.E., ‘Medial Tibial Stress syndrome: conservative treatment options’, Curr Rev Musculoskelet Med.; September 2009, 2(3):127-133. Cite error: Invalid
<ref>
tag; name "Galbraith and Lavalee" defined multiple times with different content - ↑ 7.0 7.1 7.2 7.3 Broos P., Sportletsels, Leuven/Apeldoorn: Garant, 1991. (p.22, 179-181). Cite error: Invalid
<ref>
tag; name "Broos" defined multiple times with different content - ↑ 8.0 8.1 8.2 8.3 8.4 Peterson L. and Renström Per, (2001) Sports injuries: their prevention and treatment, 3th edition London, Dunitz, (p.11,339-342).
- ↑ BECK B., (1998) ‘Tibial stress injuries: an aetiological review for the purposes of guiding management’, Sports Medicine, 1998, 26(4) 265-279.
- ↑ Reid D.C. et al. (referred Rasmussen),(1992) Sports injury assessment and rehabilitation, New York/ London/ Melbourne/ Tokyo, Churchill Livingstone, (p.269-280).