UNDERSTANDING MEDIAL TIBIAL STRESS SYNDROME, ITS AETIOLOGY, REHABILITATION AND PREVENTION METHODS
UNDERSTANDING MEDIAL TIBIAL STRESS SYNDROME, ITS AETIOLOGY, REHABILITATION AND PREVENTION METHODS
An archetypal sports injury amongst athletes is Medial Tibial Stress Syndrome (MTSS) also commonly known a Shin Splints. MTSS is a common injury that occurs among running athletes in both team and individual sports. With the injury site in the lower extremity region and is induced by extended, repetitive, and overuse application of force or load (Galbraith & Lavallee, 2009; Gallucci Jr, 2014; Carr & Sevetson, 2008; DeLacerda, 1980). MTSS looks like a “hairline crack in the bone” (Gallucci Jr, 2014, p. 24). Although it is not a severe health problem, it can lead to severe complications if not treated timely (Galbraith & Lavallee, 2009). Under fatigue, muscles cannot absorb the constant force, and the load is transferred to the bones and gradually the bones become weaker.
Additionally, osteoporosis increases weakening of the bone. Thus, as a result, stress fractures occur from MTSS (Gallucci Jr, 2014, p. 25). The MTSS is the result of muscles being pulled away from the site of its attachment to the tibia. Therefore, when the bone lacks the muscle strength, the bone becomes a primary force absorber, and repetitive force weakens the bone causing MTSS (Gallucci Jr, 2014, p. 25-26). The progression of shin splints then gradually leads to stress fractures (Gallucci Jr, 2014, p.25). Similarly, muscle plays a crucial role in stabilizing the joint or bone by absorbing the shock when the load is there on the bones, and ultimately muscles protect the skeletal system. “However, too many stresses can cause muscle fatigue which reduces the ability to absorb the shock.” (DeLacerda, 1980).
Wilder & Sethi (2004) have argued that the majority of sports injuries are the result of overuse. From the statistics of running injury clinics, approximately 20% of injuries were related to the lower leg, 15% related to the ankle, and 15% of injuries were related to the foot. Nevertheless, other data suggests that MTSS occupies around 12% to 18% in total running injuries and approximately 4% of military suffer from shin splints in the U.S.A. (Wilder & Sethi, 2004, p. 74). A study around the 1980s also suggested that shin splints occurred among approximately 10 to 15% of running injuries (Bates, 1985, p. 133). On the other hand, a study conducted among dancers suggested that there was a high prevalence of injuries in lower extremities among the dancers as around 47% of the dancers in the study population were found with chronic injuries (Bowling, 1989). Likewise, a study conducted on high school students also found that 12% of the students had symptoms of MTSS (Bennett et al., 2001). Even Thacker et al. (2002) have highlighted that MTSS can disable young athletes.
A large portion of the population is affected by MTSS, predominantly athletes or active people who are involved in running, trekking, dancing, as well as military personal. Thus, causing health complications short term and other psychological traumas. In this context, this study aims to understand MTSS (Shin Splints), assess its aetiology, and explore potential rehabilitation and prevention methods.
The muscles and bone have a natural capacity to recover and rebuild on their own when provided adequate time and favourable environments such as no forceful stress or load. When the bone cannot recover or heal due to inadequate recovery time, an imbalance between breaking down and rebuilding of muscles occurs. Therefore, when the breakdown of muscles and bone is not offset by regeneration or recovery, stress fractures in bones can result (Galbraith & Lavallee, 2009; Gallucci Jr, 2014). Wilder and Sethi (2004) have argued that MTSS is “felt by most to represent a periostalgia or tendinopathy along with the tibial attachment of the tibialis posterior or soleus muscles” (p. 74). Moreover, the symptoms of posterior compartment syndrome and fascial inflammation also indicate MTSS.
The MTSS among women is higher as the prevalence of stress fractures is 1.5 to 3.5 times higher in women than men. Low bone density and osteoporosis in women could be attributed to such a higher risk (Galbraith & Lavallee, 2009, p. 128; Gallucci Jr, 2014; Wilder & Sethi, 2004; DeLacerda, 1980). The diet pattern, menstrual pain (dysmenorrhea), or amenorrhea (absence of menstruation) could have also contributed to a higher risk amongst women (Gallucci Jr, 2014, p. 26). Furthermore, a study by Bennett et al. (2001) suggested a correlation between the navicular and MTSS injury suggesting that pronation of navicular drop could lead to an increase in the injuries (p. 508).
Causes of Tibial Stress Reactions
MTSS is the result of multi-factors that undergo a wide range of biomechanical abnormalities as argued by Galbraith and Lavallee (2009) and Wilder and Sethi (2004). According to Galbraith and Lavallee (2009), it was assumed that MTSS is caused by underlying periostitis of the tibia resulted from tibial strain because of the load over it. However, recent studies have shown the evidence that tibial stress injuries include “tendinopathy, periostitis, periosteal remodelling and stress reaction of the tibia” (Galbraith & Lavallee, 2009, p. 127). Further, Galbraith and Lavallee (2009) have argued that the different forms of tibial stress injuries are caused by overuse and repetitive loads for an extended period that develops abnormal strain and bending of the tibia. Likewise, Gallucci Jr (2014) has stated that “poor mechanics, flat feet or fallen arches, inflexible or weak muscles, improper shoes or training and playing in hard surfaces” result in stress fracture (p. 26). There are various risk factors for the injury and categorized into intrinsic or personal and extrinsic or environmental and various components in these categories are illustrated in Figure 1.
The diagnosis of the MTSS should be carefully performed by the clinicians focused and observing lower extremity in the tibial region of the body (Galbraith & Lavallee, 2009). Galbraith and Lavallee (2009) further have added that the athletes might feel weakness in their triceps, muscle fatigue, and altering their running biomechanics. Consequently, a careful examination of the flexibility within the hamstring and quadriceps muscles is key to diagnoses of MTSS (p. 129). Therefore, an in-depth physical examination, along with a thorough history is usually enough to diagnose for the MTSS (Galbraith & Lavallee, 2009, p. 129; Tolbert & Binkley, 2009).
Tibial stress is in the lower part of the shin, at first on the inner medial part of the leg and an early pain is felt usually during activity and pain elevates gradually after the activity (Gallucci Jr, 2014, p. 26, Bates, 1985). A “tender spot” (Bates, 1985; Gallucci Jr, 2014; Tolbert & Binkley, 2009) is developed along the shin, that can be felt by the athletes when palpated at the site of the bone. Therefore, to identify MTSS or stress fractures, it is required to undergoing either x-ray, bone scan, or Magnetic Resonance Imaging (MRI) (Gallucci Jr, 2014, p. 26). A larger dense size of fracture in the x-ray suggests that the athlete has had pain for a considerably longer period (Gallucci Jr, 2014, p. 26). Therefore, the most common type of complain in MTSS is a shared pain in the lower extremity, along the middle distal tibia and the pain is worse at the beginning which subsides gradually (Galbraith & Lavallee, 2009, p. 128; Tolbert & Binkley, 2009). In the case of MTSS, slight edema can be observed in the subcutaneous region of the tibia (Bates, 1985).
However, a study by Beck and Osternig (1994) had argued that the symptoms of MTSS take place around soleus and flexor digitorum longus muscles and deep crural fascia but not at the site of tibialis posterior which was argued by other studies (p. 1059-1060).
Rehabilitation and Prevention of the Medial Tibial Stress Syndrome (Shin Splints)
Bennett et al. (2001) and Galbraith and Lavallee (2009) have argued that several advancements have taken place in the last few decades for treating MTSS and treatment success is highly based on the experiences of clinicians and experts. At the same time, Gallucci Jr (2014) has argued that stress fractures can also be prevented through proper dietary intake, i.e. balanced diet and inclusion of vitamin D regularly in their diets, as well as and training of athletes using appropriate equipment and surfaces types. Undoubtedly, rehabilitation of MTSS is highly recommended to identify, the stress reaction as early as possible and temporarily suspend the activity (running, training, or even standing and walking) in order to identify MTSS or stress fracture and consult a health care professional (Gallucci Jr, 2014; Carr & Sevetson, 2008; Wilder & Sethi, 2004). Gallucci Jr (2014) has suggested that it may be required to utilise a walking boot, air cast, or full lower leg air cast for up to a maximum of 20 weeks, in the prevention of a full fracture. Furthermore, it is also essential to be pain-free before beginning any aerobic activity or training, and the ankle joint should be flexible with a full rotation of movement (Gallucci Jr, 2014). This should be then followed up by four-way ankle exercises and lastly prescribe resistance training. Regarding military personal, Bennett et al. (2001) have argued that injuries can be prevented by adapting to conducive environments like daytime for exercise, use of boots and running shoes (p. 34)
Moreover, as per Galbraith and Lavallee (2009), a stepwise treatment of MTSS is recommended. The snapshot of the steps is given in Table 1. Aligned to recommendations of Galbraith and Lavallee (2009), Carr and Sevetson, (2008) also had found that orthotics, rest and ice helped athletes to recover from the MTSS as nearly 88% of the athletes found to recovered from the MTSS symptoms and returned to running (p. 407). Moreover, the rest and ice treatment had aided in quicker recovery time from the injury and in turn a reduction in the number of rest days before resuming training (Carr & Sevetson, 2008, p. 407).
Steps of treatment of MTSS
Summary of Action
Rest and continue to ice
Therapy: Application of ultrasound, whirlpool baths, phonophoresis, mobilization of augmented soft tissue, electrical stimulation.
Modification of the training routine addressing the biomechanical abnormalities.
Avoid running on hills and inclines.
Light impact and where possible off feet training such as swimming and fixed bike.
Gradually increase the intensity and duration of the exercise.
Source: Adapted from Galbraith and Lavallee (2009)
Moreover, Tolbert and Binkley (2009) have put forward a guideline for treatment and prevention of MTSS for especially those involved as strength and conditioning coach to recover from MTSS or shin splints. Key phases recommended by them consists of arm-Up, Hamstring Stretching, Gastrocnemius Stretching, Soleus Stretching and Ice Message (p. 70-72).
Area of the body it concerns
The MTSS or shin splints, cover a wide range of muscles, bones, and nerves that are affected by MTSS causing pain and other health complications among the injured athletes. MTSS is associated to various biomechanical abnormalities of the lower limbs of the human body and MTSS are connected to body parts such as knee, tibia, femora, feet, leg, shin, and foot muscles including soleus (Galbraith & Lavallee, 2009; Gallucci Jr, 2014) More specifically, the tibialis posterior, flexor digitorum longus and gastrocnemius-soleus. Additionally, the dense connective tissue of the deep crural fascia (DCF), attaches to the medial border of the tibia. Although, this structure has deep insertions to the medial tibial border, finishing at the medial malleolus implicating involvement in creating traction-induced injury (Stickley et al., 2009). Anatomically the DCF could pull on the periosteum and the muscular contractions of plantar flexors, namely soleus, can also cause a tibial bending moment due to the attachment site of soleus, at the top of the tibia, and its insertion at the calcaeneus (Stickley et al., 2009).
Medial Tibial Stress Syndrome or Shin Splints is a widely spread injury of lower extremity experienced by athletes, ranging its effect from acute mild pain in the shin region in the early stage progressed to severe pain, in lack of treatment. Early diagnosis and treatment is the best strategy to heal MTSS, for which a large number of studies have recommended a stepwise treatment or prevention methods that consist of rest, ice, analgesics in the early phase, followed by modification in the training routine, stretching and strengthening lower extremities, use of appropriate shoes, and manual therapy are useful for healing and repair of MTSS. However, further testing on the correlation of DCF on MTSS may be required to rule out DCF as an injury site.
Bates, P. (1985). Shin splints–a literature review. British Journal of Sports Medicine, 19(3), 132–137. https://doi.org/10.1136/bjsm.19.3.132
Beck, B. R., & Osternig, L. R. (1994). Medial Tibial Stress Syndrome. The Journal of Bone and Joint Surgery, 76(7). http://dx.doi.org/10.1136/bjsm.19.3.132
Bennett, J. E., Reinking, M. F., Pluemer, B., Pentel, A., Seaton, M., & Killian, C. (2001). Factors Contributing to the Development of Medial Tibial Stress Syndrome in High School Runners. Journal of Orthopaedic & Sports Physical Therapy, 31(9), 504–510. https://doi.org/10.2519/jospt.2001.31.9.504
Bowling, A. (1989). Injuries to dancers: prevalence, treatment, and perceptions of causes. British Medical Journal, 298(6675), 731-734. https://doi.org/10.1136/bmj.298.6675.731
Carr, K., & Sevetson, E. (2008). How can you help athletes prevent and treat shin splints? The Journal of Family Practice, 57(6).
DeLacerda, F. G. (1980). A Study of Anatomical Factors Involved in Shinsplints. Journal of Orthopaedic & Sports Physical Therapy, 2(2), 55–59. https://doi.org/10.2519/jospt.1922.214.171.124
Galbraith, R. M., & Lavallee, M. E. (2009). Medial tibial stress syndrome: conservative treatment options. Current Reviews in Musculoskeletal Medicine, 2(3), 127–133. https://doi.org/10.1007/s12178-009-9055-6
Gallucci Jr, J. (2014). Soccer Injury Prevention and Treatment: A Guide to Optimal Performance for Players, Parents, and Coaches. Demos Medical Publishing.
Stickley, C., Hetzler, R., Kimura, I., & Lozanoff, S. (2009). Crural Fascia and Muscle Origins Related to Medial Tibial Stress Syndrome Symptom Location. Medicine & Science in Sports & Exercise, 41(11), 1991–1996. https://doi.org/10.1249/mss.0b013e3181a6519c
Thacker, S. B., Gilchrist, J., Stroup, D. F., & Dexter Kimsey, C. (2002). The prevention of shin splints in sports: a systematic review of literature. Medicine & Science in Sports & Exercise, 34(1), 32–40. https://doi.org/10.1097/00005768-200201000-00006
Tolbert, T. A., & Binkley, H. M. (2009). Treatment and Prevention of Shin Splints. Strength and Conditioning Journal, 31(5), 69–72. https://doi.org/10.1519/ssc.0b013e3181b94e3c
Wilder, R. P., & Sethi, S. (2004). Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clinics in Sports Medicine, 23(1), 55–81. https://doi.org/10.1016/s0278-5919(03)00085-1