Treatment of Medial Tibial
Stress Syndrome: A Systematic Review
Stress Syndrome: A Systematic Review
Winters
M, Eskes M, Weir A, Moen MH, Backx FJG, Bakker EWP. Sports Med. 2013 August 27. [EPub ahead of print]
M, Eskes M, Weir A, Moen MH, Backx FJG, Bakker EWP. Sports Med. 2013 August 27. [EPub ahead of print]
Take Home Message: More
quality research needs to be conducted to support evidence-based practice in
the management of medial tibial stress syndrome.
quality research needs to be conducted to support evidence-based practice in
the management of medial tibial stress syndrome.
Medial
tibial stress syndrome (MTSS) is a common injury prevalent in runners, jumpers,
and military personnel. Repetitive overload on the tibia can cause bone
microdamage, leading to widespread tibial pain. Treatment methods can be
conservative or surgical; however, the most effective treatment for MTSS is
unknown. This study systematically reviewed the literature to determine the
effectiveness of conservative and surgical treatments for MTSS. Following an
extensive literature search, the authors selected eleven studies. Inclusion
criteria for this review were: randomized and non-randomized clinical trials
that included participants with exercise-induced pain consistent with MTSS and
measurable outcomes of recovery time and pain improvement. Of the included
studies, none evaluated surgical treatments. These studies included 11 conservative
treatments: 1) iontophoresis, 2) phonophoresis, 3) ice massage, 4) ultrasound, 5)
low-energy laser treatment, 6) periosteal pecking, 7) stretching and
strengthening exercises, 8) a sports compression stocking, 9) lower leg braces,
10) extracorporeal shockwave therapy (ESWT), and 11) pulsed electromagnetic
field. The two studies that assessed the effect of ESWT on MTSS were the only
studies that reported a significant reduction in pain or recovery time. The
trial by Rompe et al found a reduction of pain in
participants who received ESWT treatment in combination with a home exercise
program compared with control participants who only completed the home exercise
program. Another observational study by Moen et al found that participants in a graded running
program were able to complete it significantly faster when receiving ESWT
treatments compared with patients who did not receive ESWT. Analysis of all
included trials revealed a strong risk of bias and poor methodological quality.
The authors concluded there is no evidence of high quality to support the use
of any intervention on MTSS.
tibial stress syndrome (MTSS) is a common injury prevalent in runners, jumpers,
and military personnel. Repetitive overload on the tibia can cause bone
microdamage, leading to widespread tibial pain. Treatment methods can be
conservative or surgical; however, the most effective treatment for MTSS is
unknown. This study systematically reviewed the literature to determine the
effectiveness of conservative and surgical treatments for MTSS. Following an
extensive literature search, the authors selected eleven studies. Inclusion
criteria for this review were: randomized and non-randomized clinical trials
that included participants with exercise-induced pain consistent with MTSS and
measurable outcomes of recovery time and pain improvement. Of the included
studies, none evaluated surgical treatments. These studies included 11 conservative
treatments: 1) iontophoresis, 2) phonophoresis, 3) ice massage, 4) ultrasound, 5)
low-energy laser treatment, 6) periosteal pecking, 7) stretching and
strengthening exercises, 8) a sports compression stocking, 9) lower leg braces,
10) extracorporeal shockwave therapy (ESWT), and 11) pulsed electromagnetic
field. The two studies that assessed the effect of ESWT on MTSS were the only
studies that reported a significant reduction in pain or recovery time. The
trial by Rompe et al found a reduction of pain in
participants who received ESWT treatment in combination with a home exercise
program compared with control participants who only completed the home exercise
program. Another observational study by Moen et al found that participants in a graded running
program were able to complete it significantly faster when receiving ESWT
treatments compared with patients who did not receive ESWT. Analysis of all
included trials revealed a strong risk of bias and poor methodological quality.
The authors concluded there is no evidence of high quality to support the use
of any intervention on MTSS.
Currently
there is not enough quality evidence to positively recommend any specific
treatment for the management of MTSS. This systematic review revealed the need
for more research to be conducted with quality methodology to determine the
effectiveness of various treatments. Of all the interventions for MTSS reported
in the literature, ESWT appears to be potentially beneficial. Practitioners
often rely on evidence-based medicine to guide their clinical decisions but in
the case of MTSS, one specific management strategy cannot be justified over
another. This forces clinicians to rely heavily on their experience to make
clinical decisions and develop treatment plans while encouraging further
research in this area.
there is not enough quality evidence to positively recommend any specific
treatment for the management of MTSS. This systematic review revealed the need
for more research to be conducted with quality methodology to determine the
effectiveness of various treatments. Of all the interventions for MTSS reported
in the literature, ESWT appears to be potentially beneficial. Practitioners
often rely on evidence-based medicine to guide their clinical decisions but in
the case of MTSS, one specific management strategy cannot be justified over
another. This forces clinicians to rely heavily on their experience to make
clinical decisions and develop treatment plans while encouraging further
research in this area.
Questions for Discussion: What
method(s) of treatment have you found most useful for MTSS? Do you believe
conservative methods or surgical methods yield better results?
method(s) of treatment have you found most useful for MTSS? Do you believe
conservative methods or surgical methods yield better results?
Written
by: Laura Marley
by: Laura Marley
Reviewed
by: Lisa Chinn and Jeffrey Driban
by: Lisa Chinn and Jeffrey Driban
Related
Posts:
Posts:
Risk Factors for Medial Tibial Stress Syndrome and Tibial Stress Fractures in Runners
Winters M, Eskes M, Weir A, Moen MH, Backx FJ, & Bakker EW (2013). Treatment of Medial Tibial Stress Syndrome: A Systematic Review. Sports Medicine (Auckland, N.Z.) PMID: 23979968
As a newly certified athletic trainer, I cannot speak from tons of experience. However, I have seen my mentors use soft tissue/stretching for the muscles surrounding the tibia (ant. tib. mostly), as well as shin taping. Overall, the results of this SR are not surprising to me. Although I have seen several of these work on certain patients (sometimes more psychologically than anything, to be honest), I haven't seen anything conclusive used clinically. I am curious to see what other clinicians have to say about this topic.
Although treating the symptoms of MTSS really depends on the athlete and his presentation, I believe it's always best to get to the source of the problem, which typically is excessive pronation. By identifying the problem, a clinician can decrease those excessive forces placed on the medial tibia through the use of orthotics or arch taping, and potentially eliminate the problem all together. Because the treatment studies are so inconclusive, this is typically my go-to when dealing with this condition.
In this post, I like how the studies that were included did not explore surgical options to relieve the pain of Medial Tibial Stress Syndrome. Too often, surgery is the first option, adding to recovery time, and when dealing with athletes that may not be a viable option. This study does touch on interesting points to look further into. If I were to research this in the future, I would compare the ESWT treatment, and a surgical treatment to get a better idea as to if it actually is better to not go the surgical route. Overall, I think this is a very important study because a lot of those who lead active lifestyles, along with athletes at all levels at some point suffer with this syndrome, be it acute or chronic. Providing numerous options for treatment makes the recovery of the athlete less stressful.
I like the points that Erica made above, and agree that these results are not suprising. I also agree with the point that she made, that as clinicians, we need to look at the cause of the symptoms in addition to treating them. If we don't do this, and allow the patient to continue the activity that caused the MTSS to begin with, we could possibly be allowing the condition to develop into something more serious such as stress fractures. That being said, in my experience, I have found that conservative treatment is usually enough to correct and manage this condition. It could be as simple as fitting the patient for orthodics or teaching proper running/landing techniques. I don't think surgery should be utilized as an option until extensive conservative methods have been tried.
Erika and Kelsey: Great point! I would agree that finding the cause of the problem should be the starting point of creating a solution. This way, you are actually fixing the problem rather than treating the symptoms.
Jasmyn: In my experience I have not seen surgery as a first resort but it would be interesting to compare the results of surgical and ESWT treatments. I am also not too familiar with ESWT. I would like to know what factors doctors consider when deciding if surgery is necessary from the beginning.
I felt the above ladies all made excellent points, and like Jasmyn, was pleasantly encouraged to see that conservative methods are being utilized and explored further; I also agree with the sentiment that the cause of the individuals pathology needs to be determined. In my brief but continuing experience with distance runners, as well as track athletes, any of our-stress related injuries also receive a degree of nutritional evaluation and possible counseling/modifications (Iron, Vitamin D, etc.). Between nutritional evaluation and intervention, removal from and slow return to activity, intrinsic foot and shank strengthening ("toe yoga", e.g.), postural and biomechanical assessment and correction, and potentially e-stim or bone stim applied to the painful area/site, we have had a great deal of success thus far this season (Knock on wood!) I am definitely curious to see how research progresses, and what the outcomes are to determine what to incorporate and what to leave behind in practice.
None of the studies are sufficiently free from methodological bias to recommend any of the treatments investigated. Of those examined, ESWT appears to have the most promise.
A lot of good points we're made in the comments to this article, I wonder is research on preventative measures could be a help, or if there is any?
Jaason: Insoles may be preventative (https://www.ncbi.nlm.nih.gov/pubmed/21735382). I believe their is some ongoing research exploring other prevention strategies.
I found this article to be interesting, especially about theextracorporeal shockwave therapy.If athletes were able to complete a running program with extracorporeal shockwave therapy along with in an in home exercise program, could this be a new sort of modality used for other injures too?
Seeing MTSS as an overuse injury, I believe conservative treatment yields better results. Though rest would be key, the reoccurrence of MTSS is very high. Personally I find myofascial release of the structures surrounding the gastroc and soleus, followed by stretching of the hamstrings and adductors reduces pain. But as you all ready noted, there isn't a lot of research on the gold standard for MTSS treatment. But seeing MTSS as an overuse injury, I do not see the benefit of spending the money of surgical treatment.
Sylvia, ESWT could be a modality of interest but it won't be something we use in the sports medicine clinic.