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Medial Tibial Stress Syndrome • Easily Explained | 2024

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Medial Tibial Stress Syndrome

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Medial tibial stress syndrome (MTSS), a periostitis at the posterior medial border of the tibia, results from repetitive overuse, such as running. It’s account for 60% of all injuries causing leg pain in athletes.

A number of generic terms of Medial Tibial Stress Syndrome have evolved over the years to describe exercise-related leg pain:

  1. medial tibial syndrome,
  2. tibial stress syndrome,
  3. shin splints,
  4. posterior tibial syndrome,
  5. soleus syndrome,
  6. periostitis.
See Also: Femoral Stress Fracture
Medial Tibial Stress Syndrome site of pain
Medial Tibial Stress Syndrome site of pain
Medial Tibial Stress Syndrome site of pain 2
Medial Tibial Stress Syndrome site of pain

Medial Tibial Stress Syndrome Causes

MTSS appears to involve periosteal irritation indicated by a diffuse linear uptake on a bone scan along the length of the tibia. The anatomic site of the abnormality has been fairly well localized to the fascial insertion of the medial soleus.

The onset of Medial Tibial Stress Syndrome is attributed to the following causes:

  1. training errors (training on a hard surface, increasing load too quickly),
  2. incorrect footwear,
  3. Overuse or weakness of the tibialis anterior, EDL, or EDB,
  4. biomechanical abnormalities.

Prolonged pronation, indirectly measured via static observation, an excessive navicular drop or directly using more sophisticated gait measures, is a key feature associated with the development of this condition.

A bone stress reaction, MTSS may be a precursor to stress fractures, and bone scans in individuals with MTSS reveal uptake of the radionucleotide in the involved region

Medial Tibial Stress Syndrome imaging

Clinical Evaluation

Patients with MTSS describe a gradual onset of symptoms, consistent with many overuse injuries.

Early in the progression, patients describe a dull aching pain along the middle or distal posteromedial tibia
at the beginning of an exercise session that subsides as activity continues but returns when the activity is over. At this stage, the pain typically subsides quickly with rest. With continued training the pain usually becomes more severe, and persistent, and with increasing chronicity, the pain may be present with ambulation or at rest.

The diffuse pain at the posteromedial tibial border covers a broad span (greater than 5 cm), not the localized tenderness associated with stress fractures.

Palpation at the medial and distal posteromedial border is painful.

Repetitive muscle testing of the long toe flexors, posterior tibialis, or soleus may replicate symptoms that emerge with fatigue of these muscles.

Imaging

Radiographs and bone scans is required to differentiate from stress fractures.

tibial stress fracture
Tibial stress fracture

Differential Diagnosis

Differential Diagnosis of Medial Stress Syndrome include:

  1. Tibial stress fracture,
  2. deep posterior exertional compartment syndrome,
  3. deep vein thrombosis,
  4. popliteal artery entrapment syndrome
FindingStress FractureMedial Tibial Stress SyndromeAcute Compartment SyndromeChronic Exertional Compartment Syndrome
Symptom CharacteristicsLocalized over the involved area of the boneMore diffuse along the posteromedial border of the middle or distal one-third of the tibiaSevere pain in the involved compartment of the leg Numbness on the dorsum of the foot, especially the web space between the 1st and 2nd toes (anterior)
Dorsalis pedis pulse may be diminished (anterior)
Pain in the involved compartment of the leg Numbness on the dorsum of the foot, especially the web space between the 1st and 2nd toes
Dorsalis pedis pulse diminished
OnsetFollowing changes in footwear or playing surfaces or increases in intensity, duration, or frequency of activityFollowing changes in footwear or playing surfaces or increases in intensity, duration, or frequency of activityAcute following trauma to the anterior leg
Acute during exercise but symptoms not decreasing with rest
Symptoms increasing in proportion to exercise, resulting in inability to continue
Pain possibly limiting activity after symptoms begin
Pain PatternsIncreased with activity and decreased with rest
Possibly progressing to constant pain
Initially, pain at the start of activity, possibly diminishing with continued participation; pain possibly increasing again at the end of activity
Pain decreasing with rest
Unremitting pain most likely prohibiting activityPain increasing with activity
Pain decreasing with rest
Positive FindingsLocalized pain with palpationPain with palpation over the posteromedial tibia
Pain during toe raises
Pain during resisted plantarflexion, inversion, dorsiflexion, or toe flexion.
Pain with active or resisted motion of the compartment’s muscles
Pain with passive stretching of the compartment’s muscles
Pain after or during exercise
Negative Test ResultsAROM
MMT
PROM
AROM
PROM
Most test results negative if the individual has not been exercising recently
Definitive DiagnosisBone scan
Radiograph
MRI
Bone scan may show periosteal irritationIntracompartmental pressure minus diastolic BP ≥30 mm Hg
Pain that does not subside with rest
Increased intracompartmental pressure after activity
Pain that subsides with rest
AROM = active range of motion; MRI = magnetic resonance imaging; PROM = passive range of motion; MMT = manual muscle test

Medial Tibial Stress Syndrome Treatment

Medial Tibial Stress Syndrome is treated non-operatively, consisting of:

  1. Rest from the offending activities is typically effective.
  2. Activity modification, followed by a gradual return to sports
  3. Controlling excessive pronation through adequate footwear or orthotics also provides relief.
  4. An examination of lower extremity biomechanics and posture accompanied by appropriate strengthening and ROM exercises may be necessary.

References

  1. Andrish JT: Leg pain. In: DeLee JC, Drez D, eds. Orthopedic Sports Medicine. Philadelphia, PA: WB Saunders, 1994:1603–1607.
  2. Bennett JE, Reinking MF, Pluemer B, Pentel A, Seaton M, Killian C. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther. 2001 Sep;31(9):504-10. doi: 10.2519/jospt.2001.31.9.504. PMID: 11570734.
  3. Yates, B, and White, S: The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Amer J Sports Med, 32:772, 2004.
  4. Willems, TM, et al: Gait-related risk factors for exercise-related lowerleg pain during shod running. Med Sci Sports Exer, 39:330, 2007.
  5. Edwards, PH, Wright, ML, and Hartman, JF: A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med, 33:1241, 2005.
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