Research Review By Dr. Jeff Muir©

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Date Posted:

October 2013

Review Title:

Medial Tibial Stress Syndrome: Diagnostic Tests, Risk Factors and Prognostic Factors

Papers Reviewed:

  1. Newman P, Adams R & Waddington G. Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test. Br J Sports Med 2012; 46: 861–864.
  2. Moen MH, Bongers T, Bakker EW et al. Risk factors and prognostic indicators for medial tibial stress syndrome. Scand J Med Sci Sports 2012: 22: 34–39.

Background Information:

Medial Tibial Stress Syndrome (MTSS) is a common and debilitating condition associated with running and walking activities. MTSS is generally associated with activity, with athletes, soldiers and recreational sports participants among the most commonly affected. Overall, the highest incidence of MTSS seems to be found in members of the military – a patient population often studied in relation to this condition (1). MTSS typically presents with pain along the posteromedial border of the tibia that occurs during or after exercise. Pain of ischemic origin (as in a compartment syndrome) or signs of stress fracture typically exclude a diagnosis of MTSS, although these conditions can certainly coexist. Diagnosis of MTSS is generally based on clinical presentation, where examination will reveal palpable tenderness within the posteromedial musculature and bone–muscle-fascia interface. Bone scans, x-ray, Doppler Ultrasound and compartment pressure tests are often used to differentiate MTSS from compartment syndrome, popliteal artery entrapment syndrome and overt stress fracture.

Several risk factors for MTSS have been identified, including increased pronation of the mid-foot while standing, high body mass index (BMI), female gender, lean calf girth, increased hip internal and external rotation and increased plantar flexion range of motion (1-3).

This review will discuss two recent studies (4,5) that attempted to identify:
  1. Simple and reliable clinical tests that may also be valuable in predicting the potential for development of MTSS; and
  2. the risk factors that indicate an increased likelihood of developing MTSS.
One group of authors evaluated the shin palpation test (SPT) and the shin oedema (or edema) test (SOT, to remain consistent with the authors) for their ability to predict development of MTSS. A separate group of authors evaluated the clinical value of several demographic and range of motion measurements to identify potential risk factors. Both studies used cohorts of military personnel (either cadets or trainees), as these populations are noted to have a high incidence of MTSS.

Pertinent Results:

Diagnosis (study #1):
  • In evaluating the 2 clinical tests (shin palpation test [SPT] and the shin oedema test [SOT]), the authors tested 384 Australian Defence Force Officer Cadets (96 female, 288 male) aged 17-19.
  • Seventy-six individuals reported shin pain on palpation of one or both legs. A total of 58 individuals (representing 64 cases of MTSS) were recorded.
  • A positive SPT was found to be a highly significant predictor for future onset of MTSS: those who tested positive on this test were 4.63 times more likely to develop MTSS symptoms at some point in the following 16 months.
  • The Shin Oedema Test (SOT) was also strongly predictive of future onset of MTSS symptoms at some point in the following 16 months. Those who tested positive on this test were 76.1 times more likely to develop MTSS.
Risk Factors for MTSS (Study #2):
  • In evaluating risk factors, 35 male recruits were tested (15 subjects, 20 control).
  • Univariate regression showed that BMI, decreased internal hip range of motion, positive navicular drop test and increased ankle plantar flexion were significantly associated with MTSS.
  • After multivariate regression analysis, increased ankle plantar flexion, decreased internal hip range of motion and a positive navicular drop test were significantly associated with MTSS.
  • BMI was significantly associated with time to full recovery (p < 0.005).
  • The duration of symptoms (p < 0.218), the baseline Sports Activity Rated Scale (SARS) score (p < 0.789), the distance run without pain (p < 0.270), decreased internal range of hip motion (p < 0.375), positive navicular drop test (p < 0.292) and increased ankle plantar flexion (p < 0.750) were not found to be significantly related to time to full recovery.

Clinical Application & Conclusions:

Diagnosis (Study #1):
The SPT and SOT tests are components of a normal clinical examination used to diagnose MTSS. A combination of history and location of pain plus positive results from these tests are indicative of MTSS. This paper, however, also illustrates the value of these tests in predicting MTSS. Both shin pain and shin oedema are highly predictive of subsequent development of MTSS. In terms of sensitivity, a negative shin oedema test could help us identify those having a lower chance of developing MTSS symptoms with activity. It is noteworthy that both tests are better predictors in males who develop MTSS than in females.

Risk Factors (Study #2):

The following are proposed as verified risk factors for MTSS:
  1. Increased ankle plantar flexion,
  2. decreased internal hip range of motion, and
  3. positive navicular drop test.
Only higher BMI was proposed as a risk factor for a longer recovery time in MTSS.

The following were revealed NOT to be indicators for time to full recovery from MTSS:
  1. Previous duration of symptoms,
  2. functional activity score,
  3. symptom-free running distance at baseline,
  4. increased ankle plantar flexion,
  5. decreased internal range of hip motion, and
  6. positive navicular drop test.
You should note that some of these factors increase one’s risk of developing MTSS, but cannot tell us much about how the condition may progress and/or resolve on an individual basis.

Clinicians can consider these factors and employ these two simple clinical tests in practice to assist in the initial differential diagnosis and assessment of MTSS (don’t forget to differentially diagnose compartment syndromes and stress fractures!).

Study Methods:

Diagnosis (Study #1):
Subjects were recruited from first-year Australian Defence Force Academy Officer Cadets. Officer Cadets with an existing injury or medical restriction were not included in the testing. The two clinical tests being investigated were performed as follows:

Shin Palpation Test (SPT): This test involved palpation of the distal two thirds of the posteromedial lower leg including the posteromedial border of the tibia and associated musculature bilaterally. Any reported pain was noted by the therapist.
Shin Palpation Test
Shin Oedema Test (SOT): Sustained palpation (5 second hold) of the distal two thirds of the medial surface of the tibiae bilaterally was conducted and any signs of pitting oedema were recorded.
Shin Oedema Test
Injury Surveillance:
Injury surveillance was conducted via data collection at three different health centres when Officer Cadets presented for medical assistance over the 16 months following the screening tests. Surveillance involved self-reporting of the injury and surrounding circumstances, plus the observations of the treating practitioner.

Risk Factors (Study #2):
Male subjects were recruited from two Royal Dutch Army bases.

Inclusion criteria:
  • Exercise-induced pain in the leg on the posteromedial tibial border
  • Pain on palpation of the posteromedial tibia for at least 5 cm
  • Presence of symptoms for at least 2 weeks
Exclusion criteria:
  • History of tibial fracture
Physical Examination:
Physical examination included measurement of the following:
  1. Hip internal and external ranges of motion,
  2. knee flexion and extension,
  3. ankle dorsi and plantar flexion ranges of motion,
  4. subtalar eversion and inversion,
  5. hallux extension and flexion,
  6. maximal calf girth,
  7. lean calf girth,
  8. standing foot angle, and
  9. navicular drop test.

Study Strengths / Weaknesses:

Limitations:
  • Each study was conducted in a population of army/military personnel which, while representing a cohort that is more likely to develop MTSS, may not allow for extrapolation of results to the general public.
  • The sample size in each study was relatively small.
  • Each study was a retrospective case-control design, which are open to information and selection bias.
Strengths:
  • The authors of each study were comprehensive in their methodology, despite the lower-level research designs.
  • Clinical applications were foremost in the study design for each study, allowing for easy knowledge translation.

Additional References:

  1. Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med 2004: 32(3): 772–780.
  2. Burne SG, Khan KM, Boudville PB et al. Risk factors associated with exertional tibial pain: a twelve months prospective clinical study. Br J Sports Med 2004: 38(4): 441–445.
  3. Raissi GR, Cherati AD, Mansoori KD, Razi MD. The relationship between lower extremity alignment and medial tibial stress syndrome among nonprofessional athletes. Sports Med Arthrosc Rehabil Ther Technol 2009: 1(1): 11–18.
  4. Newman P, Adams R, Waddington G. Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test. Br J Sports Med 2012; 46: 861–864.
  5. Moen MH, Bongers T, Bakker EW et al. Risk factors and prognostic indicators for medial tibial stress syndrome. Scand J Med Sci Sports 2012: 22: 34–39.