Medial Tibial Stress Syndrome

MEDIAL TIBIAL STRESS SYNDROME “SHIN SPLINTS” Dr Vernon Morkel 1996482590 TABLE OF CONTENTS  Introduction  History  Clinical Evaluation  Special Investigations  Three stage assessment  Problem list formulation  Plan and Progression  Discussion INTRODUCTION  26 y.o male, rugby player – backline  Plays rugby for fun, not very fit  Bank clerk  Smoker & social drinker  No chronic medical conditions HISTORY  Came of rugby field during pre-season practice  Intense pain – over both lower legs  Started gradually during running exercise  Has to stop running for relieve  Flared up with increased exercise intensity  Previous h/o ‘shin-splints’ CLINICAL EVALUATION  Tenderness over post.med borders – both tibias  Middle 3rd of tibias – most tenderness  Pain – passive ankle dorsiflexion  Pain – plantar flexion against resistance  Pain – ‘toe raises’  Pain – 4-5 single leg hops  Hyperpronation – both feet SPECIAL INVESTIGATIONS  None indicated  None done THREE STAGE SUMMARY Clinical  Medial Tibial Stress Syndrome (Shin Splints)  Brought on – intense & repetitive running exercises Personal  Concerned – he frequently has to stop running or exercise – severe leg pain THREE STAGE SUMMARY Social Afraid – miss out on team selection Friends – ‘sissy’, for quitting exercise PROBLEM LIST FORMULATION Active  Painful lower legs – Medial Tibial Stress Syndrome (Shin Splints) Passive  Preventing him from completing training sessions & matches  General fitness deteriated PLAN AND PROGRESSION  Iced lower legs – initially  Analgesia  Recommended – 10 days rest from running  Refer – innersoles to improve hyperpronation  Physiotherapy Still in rest period & awaiting innersoles PATHOPHYSIOLOGY OF MTSS Unclear (many theories) Periostitis (inflammation of the periosteum) Tearing of the muscle bone interface Soleus m, tibialis post & flex digi longus – culprits Stress reaction of the bone (tibia) CLINICAL PICTURE History Patients often c/o pain Posteromedial border of tibia Distal 2/3 of tibia During running activities Increase in running intensity Change of running surface CLINICAL EXAMINATION  Tenderness over – cm area  Post.med border, middle & distal thirds of tibia Provocative tests for MTSS pain with:  Passive ankle dorsiflexion  Resisted plantar flexion  Toe raises  – single leg hops RISK FACTORS FOR MTSS  abrupt increase in training activities  inadequate shoes  hard or inclined running surfaces  previous MTSS  female gender  increased BMI RISK FACTORS FOR MTSS (2)  increased foot pronation  increased varus tendency of the forefoot and/or hind foot  hip internal or external rotation  increased muscular strength of plantar flexors DIFFERENTIAL DIAGNOSIS  Stress fractures of the tibia – caused by repetitive loading with resulting microfracture  Chronic exertional Compartment syndrome – is a condition of increased pressure in the fascial compartments of the leg DIFFERENTIAL DIAGNOSIS (2)  Peripheral Nerve entrapment – most often caused by trauma, the common peroneal, superficial peroneal and saphenous nerves are most commonly at risk for entrapment  Popliteal artery entrapment syndrome – is an uncommon overuse injury, frequently caused by compression of the popliteal artery by surrounding musculotendinous structures as it exits the popliteal fossa (Brewer and Gregory 2012) SPECIAL INVESTIGATIONS  X-rays – rarely positive early on X-rays performed to weeks after onset of pain may reveal periosteal reaction or a radiolucent line (stress fracture)  Radio isotopic bone scan – can confirm the presence of MTSS or a stress fracture  MRI scan – is the investigation of choice for lower leg pain  MRI arteriograph – can confirm popliteal artery syndrome TREATMENT OPTIONS  Rest for to 10 days from painful activities  Icing  Analgesia for pain relieve  Stretching of calf musculature  Strengthening of calf musculature  Activity modification  Orthotics or inner soles to correct foot hyperpronation TREATMENT MODALITIES (2)  Extracorporeal Shock Wave Therapy (ESWT) – is a new treatment modality for MTSS Rompe et al (2010) used low-energy ESWT to treat MTSS After 15 months 76% of the treatment group were able to return to their sport symptom free, compared to only 37% of the control group This study showed that low-energy ESWT is safe and effective to treat MTSS TREATMENT MODALITIES (3)  Bisphosphonates (currently used for treatment of osteoporosis) – Moen at el (2011) administered bisphosphonates to two athletes diagnosed with chronic MTSS Both athletes returned to their sport in a much shorter time These case reports raise the possibility that bisphosphonates could decrease the time to return to sport in MTSS patients  Surgery – only for very severe cases of shin splints that not respond to conservative treatment However the effectiveness of surgery remains unclear PREVENTION MEASURES  Shock-absorbent insoles  Pronation control insoles (specifically controlling navicular drop)  Graduated running programs  Correcting training errors: – like an abrupt increase in training activity -Changing to a harder training surface LEARNING EXPERIENCE Abruptly increasing training activities, changing running surfaces and inadequate shoes – ‘shin splints’, correcting these factors and rest are important to manage the condition REFERENCES Brewer, RB., et al, 2012 Chronic lower leg pain in athletes: A guide for the differential diagnosis, evaluation and treatment Sports Health, 4(2), 121-127 Brukner & Khan, 2012 Clinical Sports Medicine, 4th ed, NSW, Australia, McGraw- Hill Craig, DI., 2008 Medial Tibial Stress Syndrome: Evidence-Based Prevention Journal of Athletic Training, 43(3), 316-318 Loudon, JK., 2010 Use of foot Orthoses and Calf Stretching for individuals with Medial Tibial Stress Syndrome Foot & Ankle Specialist, 3(1), 15-20 Moen, MH., 2011 The treatment of medial tibial stress syndrome with bisphosphonates Sport & Geneeskunde, 1, 22-25 Newman, P., 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, 1-5 Rompe, JD., et al, 2010 Low-Energy Extracorporeal Shock Wave Therapy as a treatment for Medial Tibial Stress Syndrome The American Journal of Sports Medicine, 38(1), 125-132 Yates, B., 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), 772-780   THANK YOU Dr VERNON MORKEL vmorkel@iway.na ... treatment for Medial Tibial Stress Syndrome The American Journal of Sports Medicine, 38(1), 125-132 Yates, B., 2004 The Incidence and Risk Factors in the development of Medial Tibial Stress Syndrome... 2008 Medial Tibial Stress Syndrome: Evidence-Based Prevention Journal of Athletic Training, 43(3), 316-318 Loudon, JK., 2010 Use of foot Orthoses and Calf Stretching for individuals with Medial Tibial. .. Definition Medial Tibial Stress Syndrome (MTSS) is defined as pain along the posteromedial border of the tibia that occurs during exercise, excluding pain from ischaemic origin or signs of stress