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?

Reviewed by: Jeffrey Driban

Related Posts:

Risk Factors for Medial Tibial Stress Syndrome and Tibial Stress Fractures in Runners

Hamstra-Wright, K., Huxel Bliven, K., & Bay, C. (2014). Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis British Journal of Sports Medicine DOI: 10.1136/bjsports-2014-093462