Download Medial-Tibial-Stress-Syndrome-Teaching-Pack-1

Medial Tibial Stress Syndrome (MTSS)
(Shin Splints)
Normal Anatomy
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Bone remodels under wolff’s law
Remodelling takes place via mechanotransduction
Remodelling is based on the force and load placed through the bone
If loading on a bone increases the bone will remodel itself to become stronger and resist the
loading
If loading on a bone decreases the bone will become less dense and weaker due to the lack
of stimulus
Remodelling occurs quickly in cancellous bone
Remodelling occurs slowly in cortical bone
The tibia has a slight bow
Soleus, Tibialis posterior and flexor hallucis longus all attached onto the tibia
Pathology
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Overuse injury resulting in stress reaction of the tibia and surrounding musculature
Periostitis of the tibia most commonly in acute phases
Develops into bone remodelling
MTSS can be considered on the bone stress continuum with stress fractures
Mechanism of Injury
Insidious
 Change in training, change in environment of activity or changes in footwear all alter the
stress through the tibia
 Typically runners
Soft Tissue Traction
 Soleus, flexor halluces longus and potentially tibialis posterior tension increases, causing
strain on tibial fascia and periosteum
Tibial Bowing
 Calf muscles cause repeated bending or bowing of the tibia at its narrowest point
 Causes a stress reaction and periosteal reaction
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Classification
Grade 1
 Periosteal edema
Grades 2 -3
 Progressive periosteal and bone marrow edema
Grade 4
 Cortical stress fracture
Examination
Subjective
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Vague diffuse pain along the posteromedial border of the middle distal tibia with exertion
Pain worse at the beginning of exercise and then subsides
As injury progresses pain can be present throughout activity or even rest
Reports a change in
o Training methods (load, intensity, pace, mileage, routine)
o Training environment (terrain)
o Training equipment (shoes)
Objective
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Pain on hopping
Tenderness on palpation of the medial ridge of the tibia (tibialis posterior and soleus
muscle origins)
Nil neurological signs
Increased pronation of the subtalar joint
Kinetic chain abnormalities (tibial torsion, femoral anteversion, leg-length discrepancy, knee
varus/valgUS)
Tightness triceps surae
Weakness lower limb and proximal control
Abnormal gait – forefoot running
Uneven wearing on shoes
Further Investigations
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X –ray
Bone Scans
MRI
Management
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Multimodal
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Focus on controlling the load and stress that goes through the tibia
o Decrease running distance/time
o Increase recovery time
o Change running style
o Change running footwear
o Change biomechanics (orthotics, increasing ROM, increasing Strength)
Conservative
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Reduce pain and inflammation
o Massage
o Ice
o NSAID’s
o Orthotics
o Appropriate loading
o Reduce stride length
Restore Normal Range of Movement
o Ankle, Knee and Foot
 Soft tissue massage
 Foam rolling
 Stretching
 Dry needling
 Joint mobilisations
 Joint manipulations
Restore Normal Muscle Activation
o Tibialis Anterior
o Flexor Hallucis Longus
o Plantarflexors
o Invertors
o Hip External Rotators and abductors
Restore Dynamic Stability
o Proprioceptive work
Return to sport/activity specific exercise
o Gait re-education
o Gradually increasing running time/distance
Plan B
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Extracorporeal shockwave therapy
Surgery rarely indicated
References
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(Galbraith and Lavallee 2009, Reshef and Guelich 2012, Winters, Eskes et al. 2013, Hamstra-Wright,
Huxel Bliven et al. 2014, Franklyn and Oakes 2015)
Franklyn, M. and B. Oakes (2015). "Aetiology and mechanisms of injury in medial tibial stress
syndrome: Current and future developments." World J Orthop 6(8): 577-589.
Galbraith, R. M. and M. E. Lavallee (2009). "Medial Tibial Stress Syndrome: Conservative Treatment
Options." Curr Rev Musculoskelet Med 2.
Hamstra-Wright, K. L., K. C. Huxel Bliven and C. Bay (2014). "Risk factors for medial tibial stress
syndrome in physically active individuals such as runners and military personnel: a systematic review
and meta-analysis." British Journal of Sports Medicine.
Reshef, N. and D. R. Guelich (2012). "Medial tibial stress syndrome." Clin Sports Med 31(2): 273-290.
Winters, M., M. Eskes, A. Weir, M. H. Moen, F. J. Backx and E. W. Bakker (2013). "Treatment of
medial tibial stress syndrome: a systematic review." Sports Med 43(12): 1315-1333.
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