Medial tibial stress syndrome

Definition

MTSS is defined as exercise induced pain along the posteromedial border of the tibia.  Pain is provoked over a diffuse area (>5cm) along the posteromedial tibial border.

Pathophysiology

There is no defined understanding on the pathophysiology of MTSS, however there are theories:

Theory 1: Subcutaneous periostitis or oedema of the anteriomedial surface of the mid to distal third of the tibia due to microcracks.

Theory 2: Tension produced from the tibial attachment of the deep posterior calf fascia to the posteromedial tibial border.

Both can occur simultaneously.

Differential Diagnosis

Tibial stress fracture

These can be hard to differentiate from MTSS, and could be part of the same etiology. Point tenderness should be considered as a stress fracture until ruled out.

Chronic Exertional compartment Syndrome (CECS)

Muscular origin disorder with exercise induced leg pain, often bilateral, relieved by rest, and additional symptoms such as parasthesia, pallor, cold skin, loss of pulses.  Assessment is by intramuscular compartment pressure testing.

Vascular pathologies

Popliteal entrapment syndrome (PAES), peripheral artery disease, Raynauds, acute limb ischaemia, Deep Vein Thrombosis (DVT).  Present as exercise induced claudication.

Other Bone/Muscle/Tendon pathologies

Metabolic bone disease, Muscle Strains, Tendinopathy, Muscle/fascial hernias, Accessory muscles, Infection and Osteomyelitis, muscle or bone neoplasm, Osteosarcoma.

Nerve pathologies

Peripheral neuropathies, Lumbar Radiculopathy, Nerve entrapment syndromes.

Assessment

Subjective

Exercise induced leg pain along the distal 2/3rds of the medial tibial border produced by physical activity and relieved by relative rest

Objective

Pain on palpation of the posteromedial tibial border >5cm

Investigations

• If less than 5cm of tenderness bone stress injury should be suspected.
• USS is not recommended due to prevalence of periosteal and tendon findings in asymptomatic individuals.
• Bone mass density is reported to be site specific in chronic MTSS but returns to normal after injury.
• Vitamin D testing only recommended if it is considered a separate risk factor.

Risk factors

Modifiable

Intrinsic

• High BMI
• Increased ankle plantarflexion
• Pronated foot posture (increased navicular drop)
• Increased hip external rotation
• Low aerobic fitness

Extrinsic

• Change in training
• Orthotic use
• Changes in running volume and intensity
• Increased activity on hard surfaces
• External weight carrying while undertaking exercise

Non-modifiable

Intrinsic

• Female (2 x risk v males)
• Previous history of MTSS (1.5x risk)
• Previous running injury
• Lower years of running experience

Running related risks

• High shoe cushioning --> amplify leg stiffness and impact loading
• High shoe mass --> increased metabolic cost of running
• Compliant surfaces --> increase leg stiffness and oxygen consumption

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice 
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Give leaflet to reinforce verbal advice - NHSGGC Footwear Advice
  • Alternative Shoe Lacing Options

Check Timelines for recovery (Winters, 2017) 

• Women can take longer to recover from MTSS than men (mean days to recovery 89 v 64) 
• 90-120 days for recovery with multiple episodes is common.  
• Recovery defined as 18-minute run with less than 4/10 pain.

• Biomechanical assessment and potential prescription of Foot Orthoses 
  • Address biomechanical deficit if indicated by assessment. 
  • Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit 
  • The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records 
• Education and Advice 
  • Manage impact loading 
  • Offload if walking remains painful 
  • Pain education e.g. pacing, managing activities 
  • Discuss expectations of recovery timescales 
• Exercise Management 
  • Address lower limb through strength, flexibility and movement pattern training 
  • Use non-impact training to maintain/improve fitness 
  • Return to impact as able with progressive loading

Revisit the basic management from first- and second-line interventions and check for compliance and understanding. 

Consider referral for Extracorporeal Shockwave Therapy (ESWT) 

Ensure relevant risk factors have been considered and addressed along with factors that may indicate the presence of chronic pain. 

Surgical opinion

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include, hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further investigation

The other reason for referral to Orthopaedics is for “Further Investigations”. 

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to orthopaedics

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic clinician if you are unsure whether to refer. 

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Baltich, J., Maurer, C., & Nigg, B. M. (2015). Increased vertical impact forces and altered running mechanics with softer midsole shoes. PloS One, 10(4), e0125196-e0125196. https://doi.org/10.1371/journal.pone.0125196

Bartosik, K. E., Sitler, M., Hillstrom, H. J., Palamarchuk, H., Huxel, K. and Kim, E., 2010. Anatomical and biomechanical assessments of medial tibial stress syndrome. Journal of American podiatry medical association. 100(2). pp. 121-132.

Binkley, J. M., Stratford, P. W., Lott, S. A., and Riddle, D. L., 1999. The lower extremity functional scale (LEFS): Scale development, measurement, properties, and clinical application. Physical therapy [Online]. 79(4). pp. 371-383. Available from: lefs_validation.pdf (stoverpt.com)

Brewer, R. B. and Gregory, A. J. M., 2012. Chronic lower leg pain in athletes: A guide for the differential diagnosis, evaluation, and treatment. Sports Health. 4(2). pp. 121-127.

Farley, C. T., Houdijk, H. H. ., Van Strien, C., & Louie, M. (1998). Mechanism of leg stiffness adjustment for hopping on surfaces of different stiffnesses. Journal of Applied Physiology (1985), 85(3), 1044-1055. https://doi.org/10.1152/jappl.1998.85.3.1044

Ferris, D. P., Louie, M., & Farley, C. T. (1998). Running in the real world: Adjusting leg stiffness for different surfaces. Proceedings of the Royal Society. B, Biological Sciences, 265(1400), 989-994. https://doi.org/10.1098/rspb.1998.0388

Fuller, J. T., Fuller, J. T., Bellenger, C. R., Bellenger, C. R., Thewlis, D., Thewlis, D., Tsiros, M. D., Tsiros, M. D., Buckley, J. D., & Buckley, J. D. 2015. The effect of footwear on running performance and running economy in distance runners. Sports Medicine (Auckland), 45(3), 411-422. https://doi.org/10.1007/s40279-014-0283-6

Franklyn, M., and Oakes, B., 2015. Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. World Journal of Orthopaedics. 6(8). pp 577-89. https://doi.org/10.5312/wjo.v6.i8.577

Franz, J. R., Wierzbinski, C. M., & Kram, R. 2012. Metabolic cost of running barefoot versus shod: Is lighter better? Medicine and Science in Sports and Exercise, 44(8), 1519-1525. https://doi.org/10.1249/MSS.0b013e3182514a88

Hamstra-Wright, K., Huxel Bliven, K. C. and Bay, C. 2015. 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, 49 (6). pp 362 – 9.

Hamstra-Wright, K. L., and Bliven, K. C. H., 2020. What are the strongest risk factors for MTSS in active individuals? Athletic training and sports health care. 12(1). pp 11-. https://doi.org/10.3928/19425864-20181115-01

Hardin, E. C., Van Den Bogert, A. J. & HAMILL, J. (2004). Kinematic adaptations during running: Effects of footwear, surface, and duration. Medicine and Science in Sports and Exercise, 36(5), 838-844. https://doi.org/10.1249/01.MSS.0000126605.65966.40

Kerdok, A. E., Biewener, A. A., McMahon, T. A., Weyand, P. G., & Herr, H. M. (2002). Energetics and mechanics of human running on surfaces of different stiffnesses. Journal of Applied Physiology, 92(2), 469-478.

Kulmala, J., Kosonen, J., Nurminen, J., & Avela, J. (2018). Running in highly cushioned shoes increases leg stiffness and amplifies impact loading. Scientific Reports, 8(1), 17496-7. https://doi.org/10.1038/s41598-018-35980-6

Magnusson, H. I., Westlin, N. E., Nyqvist, F., Gärdsell, P., Seeman, E., Karlsson, M. K., 2001. Abnormally decreased regional bone density in athletes with medial tibial stress syndrome. The American journal of sports medicine. 29(6). pp 712-5. https://doi.org/10.1177/03635465010290060701

Magnusson, H. I., Ahlborg, H. G., Karlsson, C., Nyquist, F., and Karlsson M. K., 2003. Low regional tibial bone density in athletes with medial tibial stress syndrome normalizes after recovery from symptoms. The American journal of sports medicine. 31(4). pp 596-600. https://doi.org/10.1177%2F03635465030310042001

Moore, I.S., Jones, A. and Dixon, S., 2014. The pursuit of improved running performance: can changes in cushioning and somatosensory feedback influence running economy and injury risk?. Footwear Science, 6(1), pp.1-11.

Newman, P., Witchalls, J., Waddington, G., and Adams, R., 2013. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access Jornal of Sports Medicine. 2013. pp 229-241. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis – DOAJ

Raissi, G. R. D., Cherati, A. D. S., Mansoori, K. D. , and Razi, M. D., 2009. The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes. BMC Sports Sci Med Rehabil. 1(11). https://doi.org/10.1186/1758-2555-1-11

Winters, M., Moen, M.H., Zimmermann, W.O., Lindeboom, R., Weir A., Backx, F.J.G. and Bakker, E.W.P., 2020. Correction: The medial tibial stress syndrome score: A new patient-reported outcome measure. British journal of sports medicine. 54:e2.

Winters, M., Bon, P., Bijvoet, P., Bakker, E. W. P. and Moen, M. H., 2017. Are ultrasonographic findings like periosteal and tendinous edema associated with medial tibial stress syndrome? A case-control study. Journal of science and medicine in sport. 20(2). pp. 128-133.

Winters, M., Bakker, E. W. P., Moen, M.H., Barten, C. C., Teeuwen, R. and A Weir, 2018. Medial tibial stress syndrome can be diagnosed reliably using history and physical examination, British journal of sports medicine. 52(19). pp. 1267-1272.

Winters, M., Eskes, M., Weir, A., Moen, M. H., Backx, F. J., and Bakker, E. W., 2013. Treatment of medial tibial stress syndrome: a systematic review. Sports Med. 43(12). pp 1315-33. https://doi.org/10.1007/s40279-013-0087-0

Yates, B. and White, S., 2004. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. The American journal of sports medicine. 32(3). pp. 772-780.