Sports Medicine Research: In the Lab & In the Field: Two Clinical Tests for Predicting Onset of Medial Tibial Stress Syndrome (Sports Med Res)
Thursday, June 21, 2012

Two Clinical Tests for Predicting Onset of Medial Tibial Stress Syndrome

Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test

Newman P, Adams R, Waddington G. Br J Sports Med. 2012 [Epub ahead of print].

Medial tibial stress syndrome (MTSS) is a painful and debilitating condition found in both athletes and recreationally active individuals who partake in running and walking activities. Typically, MTSS is categorized by pain along the posteriomedial border of the tibia and at times, pitting edema. Literature has shown that most interventions aimed at prevention of MTSS are ineffective therefore, Newman and colleagues attempted to identify the effectiveness of two clinical screening tests to identify individuals in a presymptomatic stage of MTSS. Three hundred and eight-four cadets at the Australian Defense Force Academy (96 female, 288 male, 17-19 years old) underwent a preparticipation musculoskeletal exam, which included two simple clinical tests for MTSS. Completion of the two tests took approximately 30 seconds and consisted of the shin palpation test (SPT) and shin oedema test (SOT). The SPT was performed by palpating the distal two thirds of the posteromedial lower leg and surrounding musculature. Pain with palpation was considered a positive test. Performing the SOT consisted of a sustained (5 second) hold of the distal two thirds of the medial surface of the tibia bilaterally. The test was considered positive if pitting edema was present. All tests were conducted by physiotherapists with a minimum of 2 years of experience. For 16 months after the assessments, the authors monitored the healthcare centers available to the cadets for any diagnoses of MTSS and noted any subsequent diagnostic imaging or treatment. Overall, 76 (20%) reported pain during the SPT and 12 (3%) had pitting edema, and 11 (3%) had both reported pain and pitting edema on one or both legs. Of those who tested positive during screening, 26 of 76 with positive SPT (34%), 11 of 12 with positive SOT (92%) and 11 of 11 with positive SPT and SOT (100%) were later diagnosed with MTSS by a doctor or physiotherapist. In contrast, among those with tested negative during screening, 276 of 307 with negative SPT (90%), 325 of 372 with negative SOT (87%), and 326 or 373 with positive SPT and SOT (87%) were not diagnosed with MTSS. These results suggest that both SPT (positive likelihood ratio = 3.38; ratio = probability of a positive test in someone with MTSS divided by the probability of positive test in someone who doesn’t get MTSS) and SOT (positive likelihood ratio = 7.26) are strongly predictive of future development of MTSS.

While clinicians see multiple patients in often a short period of time, the efficacy of clinical test is becoming increasingly important. This study suggests that the SPT and SOT are effective predictors of the future development of MTSS however, it results should be interrupted cautiously as little detail concerning the criteria used in make a diagnosis of MTSS. Without this, it makes it difficult to understand how a diagnosis of MTSS was reached and what methods were used to make that decision. Still, this study makes a strong case for inclusion of these quick tests into clinician’s preseason musculoskeletal screenings. The test took minimal time to perform, and the finding, combined with the athlete’s sport, and gender could aid a clinician in determining which athletes are at an increased risk for developing MTSS. With this knowledge, clinicians can be aware of early signs of the condition. By identifying this condition early on, treatment can be used to keep the condition from worsening. With this tool, future research should also begin to examine the most effective treatment options for MTSS at various stages. If certain treatments can be identified as being more efficient during early stages of the condition, this would give the clinician his or her next step. Tell us what you have found. Do you currently use these tests in your preseason musculoskeletal screening? If so, how have you used their results to impact your aware and treatment of MTSS?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

Related Posts:
Phil Newman, Roger Adams, Gordon Waddington (2012). Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test British Journal of Sports Medicine DOI: 10.1136/bjsports-2012-090409

11 comments:

Alyson said...

When I read the title of this article, I was very quick to read the post. I worked with D3 Men's and Women's Track and Field teams (both indoor and out), and had a constant struggle with athletes suffering from MTSS. MTSS would present itself at different stages of the season for some athletes, at different severity levels, and also with different complaints, and never in the same population of track athlete (jumper, sprinter, distance). I would say it was across the board we were seeing this. Although, I can say, an increase was noticed during the indoor season. We speculated it was because of the smaller track, tighter turns, and the ground surface wasn't too forgiving. While it being such a prevalent injury, treatment, and care is still relatively unknown, and a gold standard has not been set yet. I believe this article has opened a window to new treatment considerations, and has honed in on clinical findings that may have previously been overlooked. To screen someone with the SPT and SOT tests before season is brilliant, that way as an AT you can prevent MTSS from occuring, or at least slow it progress down. Now, to say that you should use this as an end-all, be-all for treatment and care for MTSS is not something I am ready to do yet. But, I am going to consider using it as another tool in my toolbox for dx and tx of MTSS, and prevention of this injury. Up until now, I haven't used these tests in the clinic, but can see where they can be play an integral role in the care of MTSS. We have used US, estim, ice, stretching, and kinesiotape, and have had some success with all or a combination of these treatment types. But, nothing has worked superbly. This article has given the chance for clinicians to take this information and place it in the plan of care as seen fit, or to allow for more research to be done.

Were the athletes in a pretty good physical shape when they came into camp, and got screened? What types of exercise were they doing? And, how did they come to the dx of MTSS?

I like the idea of future research being done on the correct tx options at certain points during the injury timeline. Allowing for a quicker, and safer recovery. This is an area that I see getting researched a lot in the near future. Thanks for this article.

Kyle Harris said...

Alyson,

Thanks for the comment its great to hear that someone who has a lot of experience with MTSS diagnosis and treatment sees these tests as important in the screening process. I do believe that what you said is absolutely true. This is not an end-all, be-all for screening but its simplicity allows for easy integration into pre-season screening. While the data presented in this study indicated that not all positive tests results in MTSS, being aware of potential cases of MTSS is a huge help in early intervention in these athletes. Have you found that patients in earlier stages of MTSS responded more quickly to treatment? If so, this would further support the implementation of these tests.

Bethany said...

I agree with Alyson that these test are not end-all, be-all tests. Similarly, I have never used them in practice before, but this article was great in showing clinicians a way to potentially assist in diagnosis of MTSS. I love the idea of being able to catch the development of MTSS at an early stage and/or even prevent a serious case of MTSS from occurring. Using these two tests as a prescreening method does not seem like a bad idea, especially since there does not appear to be much harm that could come to the athletes by simply performing the tests. More research in this area will absolutely help to make these tests (and/or others) move from a potential test to consider to a basic prescreening measure implemented into daily clinical practice.

samwalton said...

I'm glad to see so much discussion on this topic, and to see that people are really aiming to come up with efficient screening processes. I have a theory surrounding the findings of this study: That for these subjects to present with symptoms upon screening, it would lead me to believe that there is most certainly an underlying cause that would inevitably lead to further degradation due to continued or increased use, in the case of military or sport-related training.
That is to say that I feel as though this study's screening process "predicted" what was already there. They could very well have simply diagnosed those with pain and/or edema as already falling under the MTSS umbrella since symptoms were present at that moment. What they did find, however, are trends about relative rates of who's symptoms are doomed to get worse.

I have also had my fair share of experience dealing with MTSS in 4 years of Division 1 track and field and numerous cases in football, basketball and even hockey dry-land training (not to mention it's the reason my own competitive career was terminated).

What this study shows me is that a 30 second screening process for mild MTSS symptoms that may not have come up in the health history piece of a screening process should lead to further examination. If I were to implement this clinically it would manifest itself as a red flag to observe and discuss many things with my patient, such as;

Footwear/support - what helps, what doesn't, old vs. new footwear, proper level of stability.
>Cleats and basketball shoes generally do not provide sufficient support.
>Virtually everyone who wears track spikes can expect to have some biomechanical changes transitioning from other footwear. It's a must that these are worn only as much as necessary and that increasing volume in them is gradual.
>Is the athlete wearing flat sandals, flip flops, heels, UGG boots, etc. while not training? Footwear outside of training is just as important if not moreso. They spend more time out of training than in training.

Training intensity/duration and training surface - has it changed recently or will it change soon. A gradual adjustment is best generally best for the prognosis of overuse injury.

Observing gait - are there potential issues that need addressing with inserts or custom orthotics.


I have found success in treating early muscular-related MTSS with Ultrasound -thermal and non-thermal-, manual therapy such as strain-counterstrain and active release therapy, soft tissue treatments like Graston and SASTM, massage and stretching.
Much research has related many cases of MTSS as a secondary finding to tight plantarfexor musculature. Pulling out all stops to treat and improve strength and endurance in these muscles has helped even somewhat advanced cases in my experience.

I apologize for the voluminous post... I'll leave it at that for now. I'm interested to hear what you all have done for treatments and care as well.

Kyle said...

Samwalton, I think you bring up an excellent point. Not only do these simple tests allow a clinician to be aware and looking for signs of MTSS as the season begins, but a positive test opens a door for the clinician to gather much more detail about the athletes footwear choice and gait patterns. All crucial information. I think that this additional consultation could in essence help the athlete make changes which could further deter the progression of MTSS before it becomes a problem. I am curious though, how much of this consultation do you currently do with an athlete regardless of their test results? For example, do you observe gait patterns in all your track athletes pre season? I'm interested to see how much additional information would be gathered by this test yielding a positive result. Thanks of the great comments!

samwalton said...

Kyle, in my preseason screenings I would not typically watch them walk but rather obtain written and verbal history and also view them in a standing position. If they had a history or current signs or symptoms, I would discuss considerations for training, footwear, etc. and let them know that they could talk to me if anything was feeling sore or painful. If somebody would come to me with symptoms later on I would screen and address each individual.

I did not screen with great detail mostly because of the volume of athletes that we are responsible for. We had no set PPE day established so it was centered around each athlete's schedule. That didn't always bode well for us performing PPE's at their whim. In a more structured setting, I would most certainly dive deeper into anything that came up during the PPR process.

Kate said...

Like Alyson, I was quick to read this article as well due to my previous involvement with track and field athletes and agree with what she said...there is a wide array of symptoms and different patients rarely fit the same mold. So a possible diagnosing criteria that may fit a majority of the MTSS population is very intriguing to me. If there is a way that we can help find these patients before the develop MTSS, track and field season would definitely run more smoothly for me. However, after reading the overview of this study I wonder if the physicians and physiotherapists who made the final diagnosis of MTSS in this population were blinded to the results found in the pre-examination. If the physiotherapists both did the pre-exam and the final diagnosis a bias may have been created within the study. Also the tests used cannot solely be attributed to MTSS. If I had a patient come to me with point tenderness over the distal tibia and pitting edema I would have to also rule out other conditions such as stress fractures. However, I will use these tests in future encounters with my athletes as an additional diagnostic tool.

As far as treatment plans that have worked for me in the past...posterior tibialis tape jobs and arch supports have worked well. Most of my athletes that had presented with MTSS often presented with excessive pronation so once that problem was addressed the athlete normally functioned with much less pain.

Jeffrey Driban said...

Hi Kate: The article states "Treating health practitioners were not aware of specific preparticipation musculoskeletal screening results from the earlier screening." Therefore, the person who recorded the diagnosis in the injury surveillance system was unaware of the pre-participation screening. The hesitancy with these tests as prognostic indicators is well founded since the sensitivity and specificity are not 100% (when are they ever :). When these tests are positive we can feel comfortable that these tests may be telling us something about the risk of future MTSS but we also need to keep an open mind that they could be a sign of something else going on. Have a great one,
Jeff

Kirsten Miner said...

Interesting article this is the first I've heard of these two tests so I have not used them clinically. I thought it was interesting that some subjects who tested positive did not develop MTSS within the follow-up time frame. Although that is not to say that they wouldn't develop it later but it would be interesting to look at their footwear and gait patterns to see if they possessed some of the other signs that tend to go with this injury such as low arch and poor shoes or training surface.
As far as treatments go I have noticed that the effectiveness of treatment in "curing" the athlete quickly is very dependent on the athlete being proactive and not waiting until they have had shin pain for the past two weeks or more. Having said that I like to use ice massage and stretching prior to activity with ice after. I also have the discussion about footwear with my athletes and if their shoes are old suggest they go get new ones. I have also had good success with arch taping, if this helps I also suggest they check out the different off the shelf arch supports and see how they tolerate those before going the route of custom orthotics from a podiatrist. With this course of action usually improvements are seen after a couple of days. The other nice thing about this treatment is that with the exception of custom orthotics and possibly the new shoes it is inexpensive both for the athlete and the athletic trainer.

Kyle Harris said...

Kristen,

You raise some excellent points. I too think that evaluating the patient's footwear, gait patterns, and the presence of pes plantus/pes cavus, would be very valuable. I have actually seen an increased number of cases of MTSS in my current position. After ruling out footwear, and biomechanical factors I have come to believe that it is actually the condition and placement of our fields which is the contributing factor to the development of MTSS. While this may not be a modifiable factor, I stress athletes being proactive as you suggested. Apart from arch taping have you attempted any other taping techniques? A few athletes have asked for tape to be applied around the shin, they reported that having pressure helped relieve the symptoms but I have not found any evidence this is effective. Thanks for the comment!

Marisa Rizzo said...

I think it is very cool that these two tests can help predict MTSS. Even though the tests are not 100 percent correct even having some incite to the people that may acquire it can help by letting prevention things happen.

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