Treatment of Medial Tibial Stress Syndrome: A Systematic Review
Winters, M, Eskes, M, Weir, A, Moen, MH, Backx, FJ, Bakker, EW. . Sports Med, August 27, 2013. [Epub ahead of print]
Take Home Message: There is limited evidence that iontophoresis, ice massage, ultrasound, phonophoresis, or extracorporeal shockwave therapy may benefit patients with medial tibial stress syndrome (MTSS). However, there is no evidence to support other commonly used treatment options for MTSS (e.g., low-energy laser treatment, stretching/strengthening exercises, sports compression stockings).
Various treatment modalities exist for medial tibial stress syndrome (MTSS) although the effectiveness of each individual therapeutic intervention remains uncertain. Winters et al conducted a systematic review to determine which treatment options were most efficacious. The authors searched for published and unpublished studies (randomized and non-randomized trials) that evaluated changes in pain, recovery time, or global perceived effect. Eleven trials met the inclusion criteria. All random control trials revealed a high risk of bias. Per Smith et al (1986), all examined treatments (iontophoresis, ice massage, ultrasound and phonophoresis) offered significant pain relief when compared with the control group (no treatment modality). Of the available treatment approaches, extracorporeal shockwave therapy (ESWT) as studied by Rompe et al (2011) demonstrated the most potential as assessed by degree of recovery and pain severity. The authors concluded that no intervention was the most efficacious in treating MTSS and that low-energy laser treatment, stretching/strengthening exercises, sports compression stockings, leg braces or pulsed electromagnetic fields had no treatment effect in any of the reviewed studies.
Frequently encountered, MTSS is widely accepted as an overuse injury afflicting the periosteum of the tibia. Initial treatment involves modified rest (no impact cardiovascular training; e.g., aquatherapy or cycling) and evaluation of foot mechanics for overpronation or pes planus. Additional treatment modalities, as reviewed by the authors, include iontophoresis, phonophoresis, ice massage, ultrasound therapy, and ESWT. Two major points can be drawn from this study. First, current available research on the treatment of MTSS is limited and confounded by numerous variables including flawed methodologies, multiple biases, duration of follow-up and the lack of a universal outcome measure. Secondly, though this review did not yield a “gold standard” for the treatment of MTSS, it did shed light on the efficacy as well as the ineffectiveness of available treatment options. This has a strong clinical implication; low-energy laser treatment, stretching and strengthening exercises, sports compression stockings, lower leg braces and pulsed electromagnetic fields have not been proven to be effective in treating MTSS. In contrast, the above mentioned modalities (iontophoresis, phonophoresis, ESWT, etc.) may offer some benefit. Concerted research incorporating a clinical measure such as the “number needed to treat” using one or more of these treatment modalities would help in furthering our approach to patients with MTSS.
Questions for Discussion: What treatment modality do you find most beneficial in managing MTSS? Do you manage based on symptoms alone or rely on MRI findings to confirm the diagnosis?
Written by: Andrew W. Albano, Jr. DO
Reviewed by: Jeffrey Driban