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authors searched for published and unpublished studies (randomized and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

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


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