Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities. It presents with load bearing exercises that causes pain over the front of the lower leg bone (tibia) and is an early stress injury that can lead to stress fractures in the tibia if not identified early.
The incidence of MTSS ranges between 13.6% to 20% in runners and up to 35% of the new runners will develop it.
Large increases in load and exercise volume involving high impact activities can put people at high risk of risk developing MTSS. Risk factors include being a female, past ankle sprains, muscles imbalances and altered running mechanics due to past injuries.
Pathophysiology
The pathophysiologic process resulting in MTSS can be related to unrepaired microdamage accumulation in the cortical bone of the tibia. The pain is secondary to inflammation of the periosteum (outer lining of bone),
Bone stress injuries of the leg/shin can be a common presentation for runners. We need to appreciate the importance of bone load and
capacity in the development of bone stress injury. Its a balance between the load of the activity and the capacity for your tissues to tolerate that load. Its important to identify factors that influence bone load.
Clinical Presentation
- Increasing pain during exercise related to the medial tibial border in the middle and lower third
- Pain can persists for hours or days after activity
Management
Management of MTSS should focus on rest and activity modification with less repetitive, load-bearing exercise and gradually building up load. Assessment should initially aim to identify, bio mechanical overload factors.
Prevention of MTSS has been investigated in some studies and orthotic insoles has shown to help offload the bone and symptoms.
Over-stress avoidance is the main preventive measure of MTSS or shin-splints.
In the first 4 weeks intermittent rest with low load exercise combined with cryotherapy can help reduce symptoms. Prolonged rest is not advocated.
Treatment should aim to modify training conditions and to address eventual bio mechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency and intensity by 50%. It is advised to avoid hills and trail runs.
- During the rehab process the patient can do low impact such as x-training exercises. After a few weeks athletes may slowly increase training intensity and duration and add sport-specific activities. Developing strong hip function, can improve running mechanics and prevent lower-extremity overuse injuries. [14]
- Proprioceptive balance exercises can be done with a one-legged stand or balance board which improves efficiency of joint and postural-stabilizing muscles and help the body react to running surface incongruities
- Choosing good shoes with good shock absorption can help to prevent a new or re-injury. Therefore it is important to change the athlete’s shoes every 250-500 miles, a distance at which most shoes lose up to 40% of their shock-absorbing capabilities.
In case of problems of the foot, individuals may benefit from orthotics. - Acupuncture and extracorporeal shock-wave can be beneficial for pain management.
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