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6
Brief resume of the intended work:
6.1
Need for the study
Medial Tibial Stress Syndrome Type II (MTSS), otherwise known as shin splints according to the
American Medical Association is defined as “pain and discomfort in the leg from repetitive activity
on hard surfaces, or due to forceful, excessive use of foot flexors. The diagnosis should be limited
to musculoskeletal inflammations excluding stress fractures and ischeamic disorders.1
Shin splints is a poorly understood condition, which commonly afflicts long distance runners,
joggers, jumpers and aerobic dancers. Otherwise called exercise induced leg soreness, this refers to
inflammation of muscles, tendons and periosteum of the lower leg.2
MTSS is characterised by exertional pain along the posteromedial border of the middle and distal
thirds of the tibia. Pain is typically felt over a much more diffuse area than in stress fractures, it
becomes more apparent during activity, and disappears after a variable period of rest. On clinical
examination, there is diffuse extreme tenderness along the posteromedial border of the tibia,
peripheral pulses are normal and no neurological changes are apparent.3
The exact incidence of exercise-induced shin pain in athletes is difficult to determine, but it
accounts for an estimated 10% to 20% of all injuries in runners and up to 60% of all overuse
injuries of the leg. 4,5
Experts do not agree upon the cause of MTSS with the cause unknown, prevention is difficult.6
Some factors contributing to MTSS are mechanical faults and muscle imbalance such as weakness
in the pelvic stabilizers (gluteus medius) which allows the hip to drop and the knee to drift inward
during stance. This position causes the foot/ankle to pronate. Mechanical faults are often far
removed from the site of injury and require evaluation of the entire kinetic chain.7
Traditionally, ice and heat in conjunction with biomechanical correction and supportive exercises
have been advocated in the treatment of shin splint.8
Therapeutic approaches have so far had little focus on resolving the periosteal component of this
condition, but have rather targeted the symptomatic pain aspect of the condition. Treatment
protocols vary from biomechanical interventions (orthotics), to non-steroidal anti-inflammatory
drugs and modalities such as ultrasound all with varying degrees of success.9
.
Low level laser therapy (LLLT) is used in wound management, soft tissue injuries, joint conditions;
arthritis, dermatological conditions and acupuncture.10
Phototherapy, in the form of low-level laser therapy(LLLT) or the use of infrared light, can
decrease inflammation, increase the speed of tissue healing, and decrease pain.11
Studies have also shown that low level laser therapy is an effective treatment modality in shin
splints.12
Studies have shown that phonophoresis is a effective treatment in for shin splints.
However no study was done to compare the effectiveness between phonophoresis and laser therapy.
So, the need for this study is to compare the effects of phonophoresis & low level laser therapy in
the treatment of medial tibial stress syndrome type II.
6.2
Hypothesis:
Null hypothesis
There will not be any significant effect between phonophoresis and low level laser therapy in the
treatment of shin splints
Experimental hypothesis
There will be a significant effect between phonophoresis and low level laser therapy on shin splints.
6.3
Review of Literature
Ashutosh Chauhan, P Sarin 2006 conducted a prospective randomized trial study to assess
efficacy of low level laser therapy (LLLT) in treatment of stress fractures in tibia.68 cases were
enrolled. 34 each in control and test group. Control cases were treated with placebo and test group
with laser-therapy. Complete resolution of pain and tenderness, and return to painless ambulation
was taken as end point of therapy in both groups. They concluded that low level laser therapy
(LLLT) appears beneficial in treatment of stress fracture.10
Hamilton, Robert Tyler 2006 conducted a study to evaluate Single-leg Triple Hop Test as a
predictor of lower limb strength, power, and balance. 40 subjects performed the single-leg triple
hop (SLTH), with quadriceps (Quad60, Quad180) and hamstrings (Ham60, Ham180) isokinetic
strength at 60º·s-1 and 180º·s-1, vertical jump height (VJ), and scores on the Balance Error Scoring
System test (BESS). SLTH predicted 69.5% of the variance in VJ, and 49-59% in strength
measures. They concluded that SLTH is a useful clinical test to predict an athlete’s lower limb
strength and power.13
García-Fernández,etal 2006 conducted a study to establish the reliability and validity of the
measurement of the pressure pain threshold using the Dolorímetro Electrónico Portátil (Portable
Electronic Dolorimeter) (DEP) in persons without pain (12 men and 18 women) and in patients
with chronic pain. The assessment of the pressure pain threshold using the DEP was done over three
sessions. Regarding reliability, high correlation coefficients were obtained. To test validity,
criterion instruments such as a pain sensitivity self report administered before and after assessment.
Participants
with pain showed significant correlations between the Pre condition self-report and the
medical report. The results showed as a whole the appropiate psychometric properties of the DEP.14
Amarjeet Singh, GB Sethy, JS Sandhu, AGK Sinha 2003 conducted a study to compare the
efficacy of iontophoresis and phonophoresis with diclofenac sodium (1%) in the treatment of shin
splints were examined in this study. Twenty five athletes with shin splints were randomly divided
into two groups: Ionto group (N= 13) and Phone group (N= 12). Diclofenac sodium (1%) was used
for Iontophoresis (5 mA, 15 min) and Phonophoresis (1W/c 2, 10 min). They concluded that
Iontophoresis and phonophoresis can be used clinically to decrease pain and inflammation and to
increase the healing of bone in the treatment of shin splints.15
Maj Yatendra Kumar Yadav 2000 conducted a study to find the role of ultrasound therapy in the
treatment of stress fractures.75 cases of stress fracture positive on radiograph were studied. Of these
32 cases comprised the control group and underwent conventional therapy while 45 cases were
treated with ultrasound therapy.Results of the study proved that ultrasound speeds up healing
of stress fractures and drastically reduces the time required to return to training.16
Mark D.Klaiman.etal 1998 conducted a study to determine whether pain response after
phonophoresis(PH) differs from the pain response after ultrasound(US).49 subjects with soft tissue
injuries including epicondylitis,tenosynovitis were randomly assigned to PH and US group. Both
group received 8minutes ultrasound at 1.5w.cm-2 three times per week for 3 weeks and for a PH
group a gel containing 0.05% fluoconide was used as a coupling agent. Results of the study shows
that US decreases pain and increased the pressure tolerance in the selected soft tissue injuries, the
addition of fluocinide does not augment the benefits of ultrasound used alone.17
James D. Heckman, John P. Ryaby, Joan Mccabbe, R.N.I, John J. Frey, Ray F. KILCOYNE
1994 conducted a study to evaluate the use of a new ultrasound stimulating device as an adjunct to
conventional treatment with a cast. Thirty-three fractures were treated with the active device and
thirty-four, with a placebo control device. At the end of the treatment, there was a statistically
significant decrease in the time to clinical healing (p = 0.01) and also a significant decrease in the
time to over-all (p = 0.0001). They concluded that low intensity ultrasound stimulation in the
accelerates the normal fracture-repair process.18
Nissen LR, Astvad K, Madsen L 1994 conducted a study to examine the effect of low-energy laser
therapy on shin splints. Constripts from the Jutland Dragoon regiment with shin splints were given
either active laser treatment (40 mW in 60 sec per cm tender tibia edge) or placebo laser. All
patients were exempted from normal duty concerning activities like running and march. Forty-nine
patients participated in the study, 23 in the laser group and 26 in the control group.They found no
significant differences between the groups regarding pain visual analog score and readiness to
return to active duty after 14 days.8
Wayne Smith, F. Winn, , R. Parette 1986 study to compare the effects of ice massage,
ultrasound, iontophoresis, and phonophoresis in young adults with a shinsplint syndrome. Fifty
patients from a military recruit population with shinsplint syndrome were randomly assigned into 5
groups of 10. The results indicated that none of these treatment modalities was superior to another;
however, all were clearly superior to a controlled treatment program.19
6.4 Objectives of the study:
1. To evaluate the effect of phonopheresis on medial tibial stress syndrome type II.
2. To evaluate the effect of low level laser therapy on medial tibial stress syndrome type II.
3. To compare the effect of phonopheresis and low level laser therapy on medial tibial stress
syndrome type II.
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Materials and Methods:
7.1 Source of data:
1. Sports Authority of India,Bangalore
2. Sports Authority of Karnataka,Bangalore
7.2Method of collection of data
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Population: subjects with type II medial tibial stress syndrome.
Sampling design : Simple random sampling.
Sample size : 45 Subjects.
Study design : Experimental design-pre to post test.
INCLUSION CRITERIA:
1. Subjects diagnosed with typeII medial tibial stress syndrome by a physician or a
physiotherapist
2. Subjects between ages of 18-35yrs.
3. Subjects presenting the following signs
(a) Pain and tenderness localized to the distal two thirds of the medial border of the
tibia at the junction of the periosteum and the fascia.
.
(b) Pain in this area, exacerbated by weight bearing or physical activity and relieved by
rest.
(c) The presence of „tender spots‟-rough, well localized, exquisitely tender corrugated
areas, arising due to the build up of a new periosteal layer, felt when applying firm
finger pressure.
EXCLUSION CRITERIA:
1 Subjects with stress fracture .
2 Subjects with other lower limb musculoskeletal pathology or fractures.
3 Subjects with ischemic disorder.
4 Subjects with muscle herniation,muscle spasm.
5 Subjects with compartmental syndrome.
6 Malignancies, precancerous lesions or tissue damaged by radiation therapy
7 Pes anserinus bursitis
Materials Used:
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Ultrasonic gel
Cotton
TOOLS USED:
Ultrasound machine.
Low Level Laser machine.
Pressure algometer
7.3 Methodology:
Interventions to be performed:
Informed consent will be taken from the subjects.
Subjects who meet the inclusion criteria will be assigned into three groups based on random
assignment.
A pre treatment pain sensitivity will be taken as perceived by the visual analogue scale & pain
sensitivity as obtained through the use of an algometer.
A pre treatment Single Leg Distance Hop Teat will be performed to check for the lower limb
functional status.
The skin surface to be treated should be inspected,any inflammatory skin conditions should be
avoided.(a)
The part to be treated should be well supported and cleaned with water so as to decrease skin
resistance.(b)
Group A
Phonophoresis will be given 5 days per week for the period of two weeks.
Phonophoresis will be applied with continuous ultrasound at a frequency of 1 MHz and at the
intensity of 1 w/cm2 for the time period of 10 minutes.
Diclofenac sodium (1%) gel will be used
The treatment head is moved continuously over the surface while even pressure is maintained in
order to iron out the irregularities in the sonic field. The emitting surface is kept parallel to the skin
surface to reduced reflection and pressed sufficiently firmly to exclude any air.the rate of treatment
must be slow enough to allow the tissue to deform and thus remain in complete contact with the
treatment head. The intensity is returned to zero before the transducer is removed from the tissue
surface.
Group B
The above steps (a) and (b) are repeated.
The subjects are instructed to wear goggles to avoid any risk of accidental application of the laser
beam into the eyes
Low level laser therapy will be given 5 days per week for the period of two weeks.
Energy density applied per sitting will be 8 j/cm2
.The laser applicator is applied to the surface before switching on. It is important to maintain the
laser applicator in contact with the tissues so that the beam is applied at right angles in order to
achieve maximal penetration. The device is switch off before removing the applicator from skin
contact.
The skin is checked for any hot spots or blisters.
Group C
This group will receive SHAM treatment and will serve as control group.
A post treatment pain sensitivity will be taken as perceived by the visual analogue scale & pain
sensitivity as obtained through the use of an algometer.
A post treatment Single Leg Distance Hop Teat will be performed to check for the lower limb
functional status.
Outcome measures:
1. Visual Analogue Scale(VAS)
2. Pressure Pain Threshold(PPT)
3. Single Leg Distance Hop Test(SLDHT)
Statistics:
Statistical analysis will be performed by using SPSS software for window (version 14.0) and P
value will be set as 0.05.
Descriptive statistics will be done.
Anova will be done to compare between group differences.
Krushkal-Wallis test will be done for within group differences
7.4 Ethical Clearance
As this study involving human subjects the Ethical Clearance has been obtained from the
Ethical committee of Padmashree Institute of Physiotherapy, Nagarbhavi, Bangalore as per
the ethical guidelines for Bio-medical research on human subjects, 2000 ICMR, New Delhi.
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List of References:
1.Thacker,S, Gilchrist,J, Stroup,D, Kimsey,D. The prevention of shin splints in sports: a systematic
review of literature. Medicine and Science in Sports and Exercise.2002; pp 32-40.
2. AMA subcommitte on the classification of sports injuries, standard nomenclature of athletic
injuries, Chicago.1966.
3.Bhatt, R, Lauder, I, Finlay, D, Allen, M, Belton. Correlation of bone scintigraphy and histological
findings in medial tibial syndrome. British Journal of Sports Medicine.2000 Vol 34: 49-53.
4.Batt ME: Shin splints: a review of terminology. Clin J Sport Med 1995;5(1):53-57.
5.Bates P: Shin splints: a literature review. Br J Sports Med 1985;19(3):132-137.
6.Thacker SB, Gilchrist J, Stroup DF, Kimsey CD. The prevention of shin splints in sports: a
systematic review of literature. Med Sci Sports Exerc. 2002;34(1):32–40.
7.Shin Pain Medial Tibial Stress Syndrome. www.sportsperformancecentres.com
8.Wayne Smith, F. Winn, R. Parette.Comparative Study using Four Modalities in Shinsplint
Treatments.The Orthopaedic and Sports Physical Therapy Sections of the American Physical
Therapy Association. 1986.
9.Noakes, TD. Lore of running. 4th edition. Oxford University Press.2001;1047-1056
10. Ashutosh Chauhan, P Sarin. Low Level Laser Therapy in Treatment of Stress Fractures Tibia: A
Prospective Randomized Trial.MJAFI 2006; 62 : 27-29.
11.Joshua Dubin,Rachel Appel Dubin, and Gregory Doerr. Training brings athletes back after shin
pain.biomechanic archieves.june 2008
12.Ghamsari SM, Yamada H, Acorda JA, Taguchi K, AbeN. Histopathological effects of low level
laser therapy on secondary healing of teat wounds in dairy cattle. Laser Ther 1995; 7: 81-8.
13.Hamilton, Robert Tyler,Single-leg Triple Hop Test as a Predictor of
Lower Limb Strength, Power, and Balance.Directed by Dr. Sandra J. Shultz.2006 ;p77 .
14.García-Fernández etal. Reliability and validity of the pain threshold measurement with the Dolorímetro
Electrónico Portátil (Portable Electronic Dolorimeter) in healthy individuals and patients with musculoskeletal pain.
The Pain Clinic,2006; Vol 18: 377-386.
15. Amarjeet Singh, GB Sethy, JS Sandhu, AGK Sinha. A comparative study of the efficacy of
Iontophoresis and Phonophoresis in the treatment of Shin Splint.2003
16.Maj Yatendra Kumar Yadav.The role of ultrasound therapy in the treatment of stress
fractures.MJAFI2000;56:95-98.
17.Mark D.Klaiman.etal. Phonophoresis versus Ultrasound in the treatment of common
musculoskeletal conditions.Med Sci Sports Exerc.1998;vol 30:1349-1355.
18.JD Heckman, JP Ryaby, J McCabe, JJ Frey and RF Kilcoyne. Acceleration of tibial fracturehealing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg Am. 1994;76:26-34.
19. Nissen LR, Astvad K, Madsen L.Low-energy laser therapy in medial tibial stress
syndrome.Ugeskr Laeger.1994;156(54):7329-31