Treatment of Medial Tibial Stress
Syndrome: A Systematic Review
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]
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).
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authors searched for published and unpublished studies (randomized and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.
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.
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?
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
Related
Posts:
Posts:
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 junior in an athletic training program, I havn't had too much experience yet with medial tibial stress syndrome, but I've seen it a few times. In the instances that I witnessed, the treatment usually involved ice before and after activity and compression wrap. I was always curious if there were other more effective treatments for MTSS. I hope that more research is done to reveal what is best. I also believe that the diagnosis of MTSS is difficult and could be confusing to the athlete and even myself as a student. It seems like everyone just associates any tibal pain with MTSS and athletes are always throwing around the name "shin splints." You could always make a definite diagnosis with an MRI, but what clinical tests are best for diagnosing MTSS? From what I've seen manual resistive tests and palpation are usually done, but is there a gold standard in diagnosing MTSS?
Focusing on MTSS as being a definitive inclusive/exclusive diagnosis can be misleading. Viewing medial tibial pain (shin splints) on a spectrum offers a more salient understanding of the clinical presentation. From a pathophysiologic perspective, when physical stress is transmitted through bone, remodeling occurs. Overwhelming this process (overuse) results in somatic complaints which may or may not be confirmed with radiographic findings, e.g. X-ray, MRI, SPECT. As you eluded to, clinical findings are void of a true "gold standard" diagnostic study. Single-leg hopping, vibration via tuning fork and fulcrum testing have been utilized in conjunction with the above mentioned imaging modalities.
Continued research will help to narrow evaluation options, hopefully yielding a true "gold standard." At present, rest with graduated return to activity is the most favored treatment approach.
I have seen and treated athletes with medial tibial stress syndrome. From what I have worked with we have not sent an athlete out for an MRI, we usually diagnose based on pain symptoms. Some treatments we have done are having the athlete ice after practice as well as doing ultrasound before practices. We have also treated them by doing rehab, such as strengthening and stretching. We also usually tap the athlete using arch taping. I have only treated this within the high school level, so it was hard trying to get the athlete to come in daily. It was unsure whether what we were doing helped or not. I do believe that since MTSS is a common injury and since it can become serious MRI can be used to make a positive diagnosis.
I found this to be a very interesting systematic review to read. MTSS unfortunately is one condition that we do not know much about it compared to what we know about ACL tears or inversion ankle sprains. The one thing that makes me hesitant when going through the systematic review is the potential level of bias with each of the articles. Ideally you would like for there to be no bias in your study. This would prevent any of the outcome measures becoming skewed because of false representation of the data. I believe that apart from there not being a diagnosing gold standard we need to perform more randomized controlled trials with low potential bias. Those studies would yield the most accurate results as to what treatment would work the best for MTSS.
I have found that massaging with ice cups has been most effective in treating MTSS in my own personal cases. It is a painful treatment, but the outcomes were always positive. I have seen several tape jobs in the clinical setting, but never really saw a positive correlation between a decrease in pain and the tape job. As a volleyball player, my teammates and I have had our fair share of MTSS. I have never gotten an MRI to diagnose MTSS. It has been solely diagnosed by symptoms and palpation. I think that an MRI would be useful if the pain from MTSS does not subside within a few days of treatment to rule out any other pathologies. I feel as though MTSS is misdiagnosed a lot in athletes that are just "sore".