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MTSS Part3
2011 / 05 / 20 ( Fri )



The body of research evidence that is pertinent to the treatment of MTSS does not quite provide clear clinical practice guidelines for the treatment of MTSS. One of the major obstacles when reviewing the literature on any aspect of MTSS is the confusing terminology and the lack of agreement surrounding the definition, which makes comparison of studies very challenging. Only four studies were found in search for RCTs that investigated the effectiveness of the commonly practiced therapeutic interventions for MTSS, published over three decades. Those RCTs were rated using the PEDro scale scores. In addition, two recent, non-randomized controlled studies that investigated the effect of shockwave therapy (EWST) compared to home exercise program were also reviewed. Table 2 shows the PEDro scale scores of the four RCTs available in the current literature.

Cryotherapy, in the form of icing, appeared to be effective in alleviating symptoms related to MTSS in a large military study in 1974 combined with relative rest (Andrish et al., 1974). The actually method of icing used in the study was not described in the study (i.e., how much ice, type of ice, or type of cover used between the skin and ice). It was unclear from the study whether or not the use of cryotherapy was any more effective than rest alone. Two of the four RCTs, laser therapy study by Nissen et al.(1994) and orthotics study by Jonhston, yield insignificant results. The acupuncture study by Callison (2002) successfully demonstrated the effectiveness of acupuncture treatment combined with massage technique (not defined) compare to the conservative treatment, although the study was limited by its small sample size. Both of the two non-randomized controlled studies on shock wave therapy (EWST) demonstrated that EWST is a new, highly effective treatment for patients with MTSS whose improvement may be maintained for a long period of time. Even though both of these studies had some limiting inconsistencies (i.e., baseline similarity between the control group and treatment group), their positive findings can provide future base for practice and therefore need to be followed by upcoming investigations to confirm.

Other conservative treatment options―therapeutic ultrasound, use of insoles or orthotics, muscle stretching and strengthening―have some common features. These treatment regimens have been widely practiced in clinical settings for many years, but no published study was found that investigates their effectiveness. It seems that such practice originates from etiology theories and the hypotheses populated from those theories have become the standard care without being confirmed by RCTs. For example, multiple etiology studies suggest that the plantar flexor tightness is attributed to the development of MTSS. So, it would make sense to stretch those muscles for the purpose of relieving pain. No study has been done to test this hypothesis, but it appears that once stretching started to be practiced, it became the gold standard. Other etiology studies suggest the amount of foot pronation is linked to an increased risk for MTSS, so it is easy to assume that controlling pronation force with orthotics would help treat MTSS. Yet, nobody has ever investigated whether or not this assumption is true. Though there is always some gap between scientific understanding and practical application, it appears to be particularly pronounced in the case of MTSS.

Evidence-based practice should always be the common goal in practice of medicine, even though every clinician has his or her own clinical opinion and experience that are highly valuable and respected. Despite the high incidence, MTSS and its treatment have not been the most popular topics in the field of sports medicine and physical therapy. You can find hundreds of articles concerning the treatment and rehabilitation for anterior cruciate ligament (ACL) injuries, whose incidence is nowhere near that of MTSS. But yet, finding valuable information for evidence-based practice for the treatment of MTSS is far more challenging. Clinicians need to keep seeking solid evidence for their clinical practice, rather than sticking to what we have always done in order to provide better care today than yesterday.


The purpose of this paper is to review the clinically relevant research that addresses the evidence of effectiveness of commonly used therapeutic interventions for the treatment of MTSS, in the hope of finding valuable information for evidence-based practice in clinical settings. Little research has been done on the treatment of MTSS and only four randomized controlled trials were found in current literature. Those four studies and two non-randomized controlled studies were reviewed. The results of these studies suggest that cryotherapy, in the form of icing, combined with relative rest, extracorporeal shockwave therapy, and acupuncture appear to be effective to varying degrees in alleviating symptoms associated with MTSS. The effect of commonly used therapeutic interventions including muscle stretching and strengthening, ultrasound, and the use of anti-pronatory orthotics has not been investigated in any of the published literature that was available for review, although etiology studies and prevention studies suggest these measures should be included as part of the comprehensive management program for MTSS.

Table 1: Summary of Main Etiology Theories

Clement (1974): “Tibial Stress Syndrome” is caused by a periostitis that could progress to tibial stress fracture. Pain is caused by inflammation of the periosteum.
James et al(1978):The tibialis posterior muscle is involved in the etiology of MTSS. Tibialis posterior tendonitis is the first stage in a progression of MTSS, followed by periostitis and stress fracture. There is no one specific presentation of MTSS, but rather “diverse abnormalities” are associated with shin pain.
Johnell (1982): Tissue biopsy demonstrated stress microrfacture is a common cause of MTSS, supporting the existence of diverse abnormalities and a continuum of pathology.
Michael & Holde(1985): The analysis of biopsy samples demonstrated evidence of soleus fascia inflammation, vascular ingrowth, osteoblasts, and osteioids, all of which are associated with a bone remodeling response to repetitive stress.
Messier & Pittala(1988):Maximum pronation was significantly greater in the subjects with MTSS, and the difference between maximum velocity of pronation was even more significant.
Sommer & Vallentyne(1995):A standing foot angle of < 140 degrees and a varus alignment of the hindfoot and/or forefoot were associated with a history of MTSS.
Anderson et al(1997): Patients with acute shin splints have a spectrum of MR findings, which suggests this clinical entity is part of a continuum of stress response in bone.
Beck(1998): Tight plantar flexors could cause the tibia to bend like a bow, which creates a compressive load on the posterior-medial surface ofthe tibia. Persistent and increasing strain on the porous bone during remodeling incites a positive feedback loop that re-stimulates remodeling. This results in a protracted hypermetabolic state within the bone. This chronic remodeling in the cortical bone, mediated via the periosteum (with or without periosteal injury), probably represents the pathologic lesion of MTSS.
Couture & Karlson(2002): Stress placed on the tibia leads to a chronic bone remodeling cycle, which results in microfissures that cause pain. The “increased stress” is likely attributable to tight and/or fatigued soleus and/or gastrocnemius muscles.
Magnusson et al (2003): Low bone mineral density may develop in conjunction with the symptoms, rather than being a causative factor for MTSS.
Reinking & Hayes(2006): Athletes with exercise-related leg pain had significantly greater navicular drop values than those without.
Madeley (2006): Athletes with MTSS had significantly less endurance in plantar flexor musculature than those without. It was unclear whether the lack of endurance was the cause or an effect of MTSS.
Bouche & Johnson(2007): Fascial traction may play a role in the etiology of MTSS, as demonstrated by measures of fascia strain at the distal medial tibial crest insertion during loading of three fresh cadaver specimens.

Table 2: PEDro scale scores.


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