Two simple clinical tests for predicting onset of medial
tibial stress syndrome: shin palpation test and shin oedema test

Newman P, Adams R,
Waddington G. Br J Sports Med. 2012 [Epub ahead of print].

Medial tibial stress
syndrome (MTSS) is a painful and debilitating condition found in both athletes
and recreationally active individuals who partake in running and walking
activities. Typically, MTSS is categorized by pain along the posteriomedial
border of the tibia and at times, pitting edema. Literature has shown that most
interventions aimed at prevention of MTSS are ineffective therefore, Newman and
colleagues attempted to identify the effectiveness of two clinical screening
tests to identify individuals in a presymptomatic stage of MTSS. Three hundred
and eight-four cadets at the Australian Defense Force Academy (96 female, 288
male, 17-19 years old) underwent a preparticipation musculoskeletal exam, which
included two simple clinical tests for MTSS. Completion of the two tests took
approximately 30 seconds and consisted of the shin palpation test (SPT) and
shin oedema test (SOT). The SPT was performed by palpating the distal two
thirds of the posteromedial lower leg and surrounding musculature. Pain with
palpation was considered a positive test. Performing the SOT consisted of a
sustained (5 second) hold of the distal two thirds of the medial surface of the
tibia bilaterally. The test was considered positive if pitting edema was
present. All tests were conducted by physiotherapists with a minimum of 2 years
of experience. For 16 months after the assessments, the authors monitored the
healthcare centers available to the cadets for any diagnoses of MTSS and noted
any subsequent diagnostic imaging or treatment. Overall, 76 (20%) reported pain
during the SPT and 12 (3%) had pitting edema, and 11 (3%) had both reported
pain and pitting edema on one or both legs. Of those who tested positive during
screening, 26 of 76 with positive SPT (34%), 11 of 12 with positive SOT (92%) and
11 of 11 with positive SPT and SOT (100%) were later diagnosed with MTSS by a
doctor or physiotherapist. In contrast, among those with tested negative during
screening, 276 of 307 with negative SPT (90%), 325 of 372 with negative SOT
(87%), and 326 or 373 with positive SPT and SOT (87%) were not diagnosed with
MTSS. These results suggest that both SPT (positive likelihood

= 3.38; ratio = probability of a positive test in someone with MTSS divided by
the probability of positive test in someone who doesn’t get MTSS) and SOT (positive
likelihood ratio = 7.26) are strongly predictive of future development of MTSS.

While clinicians see
multiple patients in often a short period of time, the efficacy of clinical
test is becoming increasingly important. This study suggests that the SPT and
SOT are effective predictors of the future development of MTSS however, it
results should be interrupted cautiously as little detail concerning the
criteria used in make a diagnosis of MTSS. Without this, it makes it difficult
to understand how a diagnosis of MTSS was reached and what methods were used to
make that decision. Still, this study makes a strong case for inclusion of
these quick tests into clinician’s preseason musculoskeletal screenings. The
test took minimal time to perform, and the finding, combined with the athlete’s
sport, and gender could aid a clinician in determining which athletes are at an
increased risk for developing MTSS. With this knowledge, clinicians can be
aware of early signs of the condition. By identifying this condition early on,
treatment can be used to keep the condition from worsening. With this tool,
future research should also begin to examine the most effective treatment
options for MTSS at various stages. If certain treatments can be identified as
being more efficient during early stages of the condition, this would give the clinician
his or her next step. Tell us what you have found. Do you currently use these tests in your preseason musculoskeletal screening? If so, how have you used their results to impact your aware and treatment of

Written by: Kyle
Reviewed by: Jeffrey

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Phil Newman, Roger Adams, Gordon Waddington (2012). Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test British Journal of Sports Medicine DOI: 10.1136/bjsports-2012-090409