Medial tibial stress syndrome: causes, prevention, and treatment

Medial Tibial Stress Syndrome: Causes, Prevention, and Treatment

What is Medial Tibial Stress Syndrome?

Medial Tibial Stress Syndrome ( MTSS), also known as tibial periostitis or shin splints , is a common overuse injury that significantly affects athletes , especially runners , and is also seen in military personnel .

How does Medial Tibial Stress Syndrome manifest?

It is characterized by pain located along the tibia , specifically on the posteromedial side of its distal two-thirds .

What causes Medial Tibial Stress Syndrome?

The precise cause of SETM is not yet fully understood, but several mechanisms have been postulated, including repetitive microdamage generated by mechanical stress , inflammation resulting from muscle pull on the tibia, and excessive flexion of the tibia during physical activity.

How common is Medial Tibial Stress Syndrome?

In terms of prevalence , SETM represents a considerable problem in active populations. A general review notes that up to 35% of athletes may be affected, and in runners , it contributes between 10% and 20% of all injuries. A specific study in Saudi Arabia revealed a prevalence of previous diagnosis of SETM of 1.8% in the general population; however, this figure contrasts with that observed in competitive runners, where the literature reports a prevalence range between 20% and 60% , underscoring this population's susceptibility to injury.

What factors increase the risk of developing Medial Tibial Stress Syndrome?

Risk factors associated with the development of SETM are diverse and include both intrinsic and extrinsic elements .

What intrinsic factors are associated with Medial Tibial Stress Syndrome?

Intrinsic factors include female sex (although the association is not consistent across studies and may vary by population), greater magnitude of tarsal scaphoid drop (an indicator of foot mechanics), higher body mass index (although its predictive role is still debated), certain biomechanical abnormalities of the foot such as pes planus and excessive pronation , lower extremity limb discrepancy , and in women, decreased range of hip internal rotation .

What extrinsic factors are associated with Medial Tibial Stress Syndrome?

Extrinsic risk factors include errors in training planning and execution , such as sudden increases in volume or intensity, running on hard or uneven surfaces that increase impact, and wearing inappropriate athletic footwear that does not provide sufficient cushioning or support.

How does Medial Tibial Stress Syndrome present clinically?

The clinical presentation of SETM is bilateral pain or tenderness along the medial aspect of the tibia, with the distal region being the most affected. Patients often describe pain that worsens with physical activity and is relieved with rest . Pain is typically more pronounced the day after exercise. In more severe and chronic cases, pain may persist even at rest. During physical examination , tenderness may be palpated along the posteromedial border of the tibia, and in some cases, swelling is noted in the affected area.

How is Medial Tibial Stress Syndrome diagnosed?

The diagnosis of SETM is based primarily on a detailed patient history and physical examination findings . Imaging techniques , such as radiography , computed tomography (CT) , and magnetic resonance imaging (MRI) , play a key role in excluding other pathologies that may mimic the symptoms of SETM, such as stress fractures or chronic exertional compartment syndrome. MRI is considered the most sensitive imaging modality for identifying soft tissue abnormalities associated with SETM.

Prevention of Medial Tibial Stress Syndrome:

Prevention of medial tibial stress syndrome focuses on identifying and modifying risk factors, both intrinsic and extrinsic. Key strategies include:

1.-Training Load Management:

• Avoid overtraining: It is crucial not to exceed the body's ability to adapt to the stress of exercise.
• Gradual progression: Any increase in training intensity, duration, or frequency should be gradual, allowing tissues to adapt without overloading. Training increases are a significant risk factor.
• Activity modification: For athletes at risk or with early symptoms, it may be necessary to adjust the type of activity to reduce impact on the tibia, considering low-impact alternatives such as swimming or cycling during periods of intense training.
• Rest and Recovery Planning: Ensuring adequate rest periods between training sessions is critical to allowing for the repair of micro- tissue damage.

2.-Biomechanics Optimization:

• Correcting Excessive Pronation: For individuals with excessive foot pronation, wearing orthotics with arch support can help control movement and reduce stress on the tibia.
• Evaluation and treatment of navicular drop: In runners with a significant navicular drop, orthoses may be considered to improve foot alignment and decrease tibial stress.
• Addressing leg length discrepancy: If there is a significant difference, shoe lifts can be used to balance the load on both limbs.
• Improving strength and flexibility : Exercise programs aimed at strengthening the calf muscles (soleus and gastrocnemius) as well as the hip muscles (abductors and rotators) can improve leg stability and running mechanics. Maintaining adequate flexibility is also important, although evidence regarding stretching as a direct preventative measure is limited.

3.-Footwear Selection and Maintenance:

• Appropriate footwear: Wearing running shoes that provide adequate cushioning and support for the type of activity and the runner's biomechanics is essential.
• Regular Replacement: Shoes should be replaced periodically (usually every 500-800 kilometers) as cushioning capacity deteriorates with use.
• Consider insoles: Cushioned insoles can help reduce impact.

4.-Additional factors:

• Proper warm-up: Perform a thorough warm-up before physical activity to prepare your muscles and tendons for the stress of exercise.
• Avoid hard or uneven surfaces: Whenever possible, choosing softer surfaces for running or training can lessen the impact on your shin.
• Dietary Considerations: Ensuring adequate intake of vitamin D and calcium may be important for bone health, although their specific role in preventing medial tibial stress syndrome requires further research.

 

 

Treatment of Medial Tibial Stress Syndrome:

Treatment for medial tibial stress syndrome focuses on relieving pain and inflammation, promoting healing of the affected tissues, and addressing the underlying factors contributing to the injury. Strategies include:

1.-Pain and Inflammation Management (Acute Phase):

• Relative rest: Reducing or ceasing activities that cause pain is essential to allow healing. This doesn't mean complete inactivity, but rather avoiding high-impact exercise.
• Cryotherapy: Applying ice to the affected area for 15-20 minutes, several times a day, can help reduce pain and inflammation.
• Analgesics: Analgesics such as paracetamol or NSAIDs (ibuprofen, naproxen) can be used to control pain, always under the supervision of a health professional.

2.-Physical Therapy (Subacute Phase and Rehabilitation):

• Stretching exercises: Gentle stretching of the calf muscles (gastrocnemius and soleus) may help improve flexibility, although their effectiveness as a sole treatment is limited.
• Strengthening exercises: A progressive strengthening program for the calf muscles (emphasizing eccentric exercises), as well as the hip and core muscles, is crucial to improving stability and biomechanics.
• Proprioceptive exercises: Training balance and proprioception (awareness of the body's position in space) can help improve neuromuscular control and prevent recurrence. Exercises such as standing on one leg or using a balance board are helpful.
• Manual Therapy: In some cases, manual therapy techniques aimed at addressing biomechanical imbalances in the spine, pelvis, or lower extremities may be beneficial.

3.-Orthosis:

Orthotics: Wearing custom orthotics with arch support can help correct foot biomechanics, especially in cases of excessive pronation or navicular drop, thereby reducing stress on the tibia.

4.-Activity Modification and Return to Sport:

Low-impact activities: During the rehabilitation phase, low-impact activities such as swimming or cycling can be performed to maintain fitness without overloading the tibia.
Gradual return: Return to sports activities should be gradual, slowly increasing the intensity, duration, and frequency of training, as long as the pain does not recur.

5.-Other therapies:

• Extracorporeal shock wave therapy: Some studies suggest that this therapy may be helpful in relieving pain in cases of chronic medial tibial stress syndrome, although more research is needed to confirm its effectiveness.
• Corticosteroid injections: Although they may provide short-term pain relief, they are generally not recommended as first-line treatment due to potential side effects and a lack of evidence of long-term benefits.

It is important to emphasize that treatment should be individualized and guided by a healthcare professional experienced in sports injuries. Identifying and addressing each patient's specific risk factors is key to successful recovery and preventing the recurrence of medial tibial stress syndrome.

Current research on medial tibial stress syndrome continues to strive to clarify the underlying risk factors and identify the most effective prevention and treatment strategies. Variability in the definitions used for medial tibial stress syndrome and in research methodologies has led to inconsistencies in the results of some studies, particularly in the identification of specific risk factors in competitive runners.