Sports Med 2009; 39 (7): 523-546 REVIEW ARTICLE 0112-1642/09/0007-0523/$49.95/0 ª 2009 Adis Data Information BV. All rights reserved. Medial Tibial Stress Syndrome A Critical Review Maarten H. Moen,1 Johannes L. Tol,2 Adam Weir,2 Miriam Steunebrink2 and Theodorus C. De Winter2 1 Department of Sports Medicine of the University Medical Centre Utrecht and Rijnland Hospital, Leiderdorp, the Netherlands 2 Department of Sports Medicine of the Medical Centre Haaglanden, the Hague, the Netherlands Contents Abstract. 523 1. Methods. 525 1.1 Literature Search . 525 2. Aetiology . 525 2.1 Functional Anatomy. 525 2.2 Biomechanics . 532 3. Histology . 532 4. Patient Examination . 533 4.1 History. 533 4.2 Physical Examination . 533 4.3 Imaging . 534 4.3.1 Radiograph . 534 4.3.2 Bone Scan . 534 4.3.3 Magnetic Resonance Imaging . 535 4.3.4 High-Resolution Computed Tomography Scan . 536 4.3.5 Imaging Summary . 537 5. Risk Factors . 537 5.1 Risk Factor Studies. 537 5.2 Risk Factor Summary . 538 6. Therapy . 538 6.1 Conservative . 538 6.2 Surgery . 539 7. Prevention . 540 7.1 Prevention Studies . 540 7.2 Prevention Summary . 541 8. Discussion. 541 9. Conclusions . 543 Abstract Medial tibial stress syndrome (MTSS) is one of the most common leg injuries in athletes and soldiers. The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. The name given to this condition refers to pain on the posteromedial tibial border during exercise, with pain on palpation of the tibia over a length of at least 5 cm. Histological studies fail to provide evidence that MTSS is caused by perios- titis as a result of traction. It is caused by bony resorption that outpaces bone 524 Moen et al. formation of the tibial cortex. Evidence for this overloaded adaptation of the cortex is found in several studies describing MTSS findings on bone scan, magnetic resonance imaging (MRI), high-resolution computed tomography (CT) scan and dual energy x-ray absorptiometry. The diagnosis is made based on physical examination, although only one study has been conducted on this subject. Additional imaging such as bone, CT and MRI scans has been well studied but is of limited value. The pre- valence of abnormal findings in asymptomatic subjects means that results should be interpreted with caution. Excessive pronation of the foot while standing and female sex were found to be intrinsic risk factors in multiple prospective studies. Other intrinsic risk factors found in single prospective studies are higher body mass index, greater internal and external ranges of hip motion, and calf girth. Previous history of MTSS was shown to be an extrinsic risk factor. The treatment of MTSS has been examined in three randomized con- trolled studies. In these studies rest is equal to any intervention. The use of neoprene or semi-rigid orthotics may help prevent MTSS, as evidenced by two large prospective studies. Medial tibial stress syndrome (MTSS) is one describe signs on physical examination. Frequently of the most common causes of exercise-induced when in the (older) literature the term ‘shin splints’ leg pain.[1] Incidences varying from 4% to 35% is used, ‘medial tibial stress syndrome’ is meant. are reported, with both extremes being derived More recently, an updated and better definition from military studies.[2-4] This condition is most was proposed by Yates and White.[4] They described frequent among military personnel, runners and MTSS as ‘‘pain along the posteromedial border athletes involved in jumping, such as basketball of the tibia that occurs during exercise, excluding players and rhythmic gymnasts.[5,6] pain from ischaemic origin or signs of stress There is much controversy about the defini- fracture.’’ Additionally, they stated that on palpa- tion and terminology of this condition. Different tion with physical examination, a diffuse painful authors have used different names, such as ‘shin area over a length of at least 5 cm should be pre- soreness’,[7] ‘tibial stress syndrome’,[8] ‘medial sent. However, since no official definition exists, tibial syndrome’,[9] ‘medial tibial stress syn- many authors use their own definition of MTSS. drome’,[10] ‘shin splints syndrome’[11] and ‘shin This makes comparison between studies difficult. splints’.[12] In this review we chose to use ‘medial Before diagnosing MTSS, the diagnosis of ti- tibial stress syndrome’ because, in our opinion, bial stress fracture and exertional compartment this best reflects the aetiology of the syndrome. syndrome should be excluded (see section 4). MTSS is characterized by exercise-related pain Detmer[14] in 1986 developed a classification on the posteromedial side of the mid- to distal tibia. system to subdivide MTSS into three types: In 1966 the American Medical Association defined (i) type I – tibial microfracture, bone stress reaction the condition (then termed shin splints) as: ‘‘pain or cortical fracture; (ii) type II – periostalgia from or discomfort in the leg from repetitive running chronic avulsion of the periosteum at the perios- on hard surfaces or forcible excessive use of the teal-fascial junction; and (iii) type III – chronic foot flexors; diagnosis should be limited to mus- compartment syndrome. In the recent literature, culotendinous inflammations, excluding fracture stress fracture and compartment syndrome are or ischaemic disorder.’’[13] This definition is the qualified as separate entities. only available official definition given in the lit- The objective of this review is to provide a erature, but in our opinion is outdated and was critical analysis of the existing literature on never well accepted among clinicians. It does not MTSS. Aetiology, biomechanics, histology, patient ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (7) Medial Tibial Stress Syndrome 525 evaluation, diagnostic imaging, risk factors, Table I. Assessment of methodological quality and level of evi- therapy and prevention are discussed. dence (reproduced from Institute for Quality and Healthcare, the Netherlands,[15] with permission) 1. Methods Assessment of methodological quality of studies concerning intervention (treatment/prevention) 1.1 Literature Search A1: Systematic review of at least two independently conducted studies of A2 level – The electronic databases MEDLINE (1966 2009), A2: Randomized double-blind clinical comparing study of good EMBASE (1980–2009), CINAHL (1982–2009), quality and size SPORTDiscus (1975–2009) and Cochrane Library B: Randomized clinical study, with moderate quality and size, or were searched for articles. The search terms ‘shin other comparing research (case-control study, cohort study) splints’, ‘medial tibial syndrome’, ‘medial tibial C: Case series stress syndrome’ and ‘tibial stress syndrome’ were D: Expert opinion used with no restrictions for language. The re- Assessment of methodological quality of studies concerning ferences from the articles were screened and in imaging and aetiology this way additional articles were obtained. A1: Systematic review of at least two independently conducted studies of A2 level Using the search terms, 382 possible titles were Imaging screened. Of these, 334 were not relevant as they A2: Research comparing against a gold standard/reference test, with discussed sports injuries in general, stress frac- an adequate number of participants tures, compartment syndromes or other topics. B: Research comparing against a gold standard/reference test, with The 48 relevant titles were screened for related an inadequate number of participants titles in the references. In total, 110 references were Aetiology found, of which 104 articles could be obtained. A2: Prospective research with adequate and non-selective follow-up, Articles were judged using the Institute for with control for confounding Quality of Healthcare (CBO [Centraal Begeleid- B: Prospective research with not all criteria mentioned under A2, or retrospective research ings Orgaan]) classification system[15] (table I) and Imaging and aetiology methodological quality and level of evidence were C: Case series assessed. Methodological quality status (A1, A2, D: Expert opinion B, C, D) and level of evidence status (1, 2, 3, 4) Level of evidence were assessed (see tables II and III). The assess- 1: One systematic review (A1) or at least two independently ment was done independently by two researchers conducted studies of A2 level (strong evidence) (MM and MS). If methodological quality and level 2: One study of A2 level, or at least two independently conducted of evidence were scored differently, a third author studies of B level (moderate evidence) (AW) made the final decision (on two occasions). 3: One study of B or C level (limited evidence) Randomized controlled studies on the preven- 4: Expert opinion (no evidence) tion and treatment of MTSS were also assessed using the Delphi scoring list[39] (table IV and V). This is a list of criteria for quality assessment of between the location of the pain and the anato- randomized clinical trials when conducting sys- mical structures. In these studies the distal at- tematic reviews. This list contains nine points and tachments of different leg muscles were compared each was scored as being present or not. The with the site of symptoms in MTSS. maximal score for the Delphi list is nine points. Michael and Holder[49] dissected 14 specimens and found fibres of the soleus muscle but not the 2. Aetiology posterior tibialis muscle on the posteromedial ti- [50] 2.1 Functional Anatomy bial border. Saxena et al. dissected ten cada- vers and found that the distal attachment of the There is much controversy about the anato- tibialis posterior muscle was 7.5 cm proximal to mical basis for MTSS. Post-mortem studies the medial malleolus. He concluded from this have been performed to examine the relationship that the tibialis posterior muscle caused MTSS. ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (7) ª 526 2009 Adis Data Information BV.