Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis
Hamstra-Wright KI, Huxel Bliven KC, Bay C. British Journal of Sports Medicine. 2014;0:1-9. Doi:10.1136/bjsports-2014-093462
Take Home Message: Risk of medial tibial stress syndrome (MTSS) is associated with increased body mass index, navicular drop, ankle plantarflexion range of motion (ROM) and hip external rotation ROM.
Medial tibial stress syndrome, often referred to as “shin splints”, is a very common problem in active individuals. The exact cause of MTSS is unknown, but it is thought to be related to overuse of the extensor muscles in the front of the shin, which pulls on the tibia and ultimately causes pain. If we could identify the key risk factors for MTSS then we may be able to develop prevention programs. The authors of this systematic review evaluated which key factors put physically active individuals at risk for MTSS. The authors used online search engines to identify relevant research studies on MTSS. They then scored the studies for quality by comparing several factors including: study objective, study population, outcome measurements, assessment of the outcome and analysis and data presentation. Of the 165 papers identified, 21 were included in the systematic review. These research papers included 3 cross-sectional, 9 case-control, and 9 prospective cohort studies of either military personnel or physically active individuals, which included high school and college athletes. When means and standard deviations of risk factors were reported 3 or more times, the authors included them in a meta-analysis. Nine risk factors met this criteria including body mass index, navicular drop, ankle plantarflexion ROM, hip external rotation ROM, ankle dorsiflexion ROM, quadriceps-angle (Q-angle), hip internal ROM, ankle inversion ROM, and ankle eversion ROM. The authors found that individuals with MTSS had greater body mass index, navicular drop, plantarflexion of the ankle, and hip external ROM compared with controls. Ankle dorsiflexion, inversion and eversion ROM, Q-angle, and hip internal rotation ROM were not related to increased risk for MTSS.
Medial tibial stress syndrome can be a very frustrating diagnosis, especially for those starting a new exercise program. Although MTSS implies a very specific etiology, there are several other causes for shin pain in active individuals that may confuse the diagnosis. Symptoms of MTSS can be similar to those of stress fractures, chronic exertional compartment syndrome, or nerve entrapment syndromes. Likewise, treating MTSS can be challenging. By using a meta-analysis, the authors of this paper were able to combine data from several studies to identify important associations between risk factors and MTSS. Knowing which risk factors may be more strongly related to the likelihood of developing MTSS can aide in diagnosing, treating, and hopefully preventing the symptoms. MTSS is sometimes diagnosed by clinical exam alone, bone scans and/or magnetic resonance imaging. Treatment usually involves a period of rest and may involve rehabilitation and changes in shoe wear. Based on these new findings we may be able to identify new, more effective therapy for MTSS. This study simply highlights risk factors. Additional studies will be necessary to demonstrate if altering these risk factors can influence the symptoms of MTSS or even if addressing some of these biomechanical risk factors during pre-season screening can help prevent MTSS. In the meantime, we should be aware of these risk factors, look for them in our patients with or at risk for MTSS, and consider targeting these risk factors in our prevention or rehabilitation programs.
Questions for Discussion: Would knowing which risk factors are associated with MTSS change how you diagnose it? Should we target our therapies for MTSS to try and reduce some of the risk factors identified? Is this even possible? Certainly BMI can change, but can we change increased hip ROM, navicular drop or ankle plantarflexion?
Written by: Hallie Labrador MD, MS
Reviewed by: Jeffrey Driban
Related Posts:Risk Factors for Medial Tibial Stress Syndrome and Tibial Stress Fractures in Runners