MTSS or Medial Tibial Stress Syndrome is a common exercised-induced leg injury among athletes and military personnel. MTSS is referred by pain along the inner edge of the Tibia. MTSS can develop chronically when a person has drastically increased the stress they induce on the body. In more technical terms it’s the inflammation of the muscles, tendons, and bone tissue around the tibia. This can be very painful for the athlete and it may cause them to have to sit out if the pain becomes to severe enough. This is why in this literature review we will be discussing the conservative treatment options for MTSS. This condition is prevalent in the military and athletic population, this leads into my PICO question; In the military or athletic population is there a conservative treatment option more effective in controlling pain and inflammation when compared with other conservative treatment options. The conservative treatments that will be compared in this literature review are Bracing, Stretching and Running, Modalities and Shockwave therapy.
The articles that were reviewed had the same contentious with the etiology of this injury. The studies for the cause of MTSS were inconclusive but risk factors were assessed and they were grouped into 3 categories of including training intensity, anatomic and biological factors. But science had yet to be able to identify a sole mechanism of injury. A theme I found when evaluating the articles is the stress-frequency relationship. This relationship states that running a greater distance without increasing the speed increases the stress applied to the bone because the number of steps have increased. Some training variables mentioned were mentioned as risk factors that did not relate to distance of increased training was worn out shoes or the hard running surface and that increased the risk of injury. The biological factors mentioned were flat feet improper biomechanics. This observation was met with the fact that it is merely observational findings that need to be studied more to be found conclusive. Evaluating the articles, I found that training error accounted for more that 60% of running injuries. This included over training a body part and exceeding their current limit or threshold. In all the studies they listed some risk factor and causes but they all mentioned the complexity of MTSS and admitted that apart of extrinsic and intrinsic factors, every case is individually special so there is no conclusive research yet that shows a specific MOI that could be the direct cause of this injury.
The methods for these cases all used similar types of studies to do their research including published and non-published, random and non-randomized clinical trials were all eligible for inclusion. The participants that were allowed had exercise induced pain on the medial border of the tibia and in addition presence of pain by palpation on the medial and distal third of the tibia. A common theme of exclusion factors across all studies were the presence of a stress fracture, acute and chronic exertional compartment syndrome. Those could all cause lower leg pain so they were carefully evaluated and ruled out if participating subjects were found to have any of those other than MTSS. The studies focused on the effect of an intervention and the time it took for patients to recover and return to pain free activity. The databases searched were for the most part the same; Pub-med, Cinhal, Cohrane central register of controlled trials. Most articles had no language restrictions and had key words like “MTSS”, “medial tibial stress syndrome”, “Shin Splints” then they narrowed the search even further with terms like “Rehabilitation” and “Treatment”. The articles focused on papers that included conservative treatments and rehabilitation of MTSS. The Cochrane risk of bias tool was used when evaluating the literature for inclusion. Some of the methods weren’t very descriptive since they were mostly systematic reviews and some RCTs. For example, the treatment for Shockwave therapy never specified about the inclusion or exclusion criteria nor did they specify what the pain scale they were using was. The articles also didn’t dive much into the subject pools so there wasn’t much diversity or description. The only inclusion criteria I saw across the board was that they just needed to have shin splints and no other injuries or current injuries. The only subjects I found to be mentioned frequently are athletes and military personnel. Also the articles seemed to focus more on etiology and risk factors rather than the treatment.
The treatment options discussed throughout the articles focused on the goal of pain control mostly in the acute phase. The articles had a general agreement that there was no conclusive treatment of MTSS. This was measured by a pain threshold and by that it means how long a subject could run before feeling pain again. What was reviewed and searched for was conservative treatment options for MTSS. From searching the articles, I found a common theme in the conservative methods of treatment that was used. There was; bracing, ice massage, ultrasound, stretching and strengthening exercise, and shockwave therapy were all discussed in the articles. The Clinical bottom line was that there is no one treatment that is better or more effective at returning a patient back to pain free activity compared to the rest of the treatment options stated above. The articles found no significant differences in the pain analog scale and the return to pain free activity. The rehabilitations focus on 9 weeks of non-weight bearing rest were a Brace was used as the intervention. In 2 of the studies the lower leg brace vs a non-lower leg brace was tested in addition to a running program and those were all conducted on military personnel except for one which I thought was a flaw of the study because if this was to be tested on the athletic population as well then the results would’ve been more conclusive. By more conclusive it means that the results would have significantly more value since it could be used more in the athletic population where returning to pain free activity is often frustrating. Every article emphasized rest as the first step toward rehabilitation and running pain free. In the Acute phase cryotherapy was found to be effective in reducing pain symptoms along with NSAIDS although the effect of anti-inflammatories requires more research because it’s just a palliative treatment that reduces the symptoms of pain rather than address the cause so it could be getting worse and the patient wouldn’t be able to feel it. But this also depends on the time of injury, this wasn’t discussed in the article and I feel they should’ve gone more in depth on the pharmalogical aspects of rehab. Although there is not one sure fire way of treating MTSS it’s important to look at the positives and realize that there are still many treatment options and participating in active treatment is better than not doing anything at all. In the studies there was always a control group that did nothing in terms of the different types of treatment, for example in the study using modalities as a treatment option 4 groups had actual treatment done while the last group was the control group which received no modalities, and compared to the group that participated in the treatment the group that did the treatment always came out with significantly reduced pain compared to the control group part with the exception of the bracing treatment options where no significant difference in pain level was noted
When assessing the generalizability based on what the researchers had available the fact that there is no Gold standard intervention treating MTSS makes it difficult. All the RCT revealed a high risk of bias. The research comparing the modalities didn’t really make a good point of describing their methods. In the Shockwave treatment no randomization had occurred and no placebo treatment was provided to avoid bias. Also the articles failed to mention the severity of the patients with MTSS. Were they experiencing very severe pain, or a little bit of pain and I believe this could affect the results. The standard measure of pain free activity seemed to be running on a treadmill for a certain period of time. None of the treatments assessed for possible reoccurrence or long-tern check ups. This could be a weakness because then they wouldn’t know if those treatments worked post treatment which is a vital part of rehab. There was hypothesis in the studies including bracing and Stretching and running but they all alluded to different return to activity and what constitutes that. There was also limited discussion on confounding factors that felt odd because when dealing with MTSS there are sure to be some confounding factors that affect the study outside of the research facility; for example, any exercise that the subjects did outside of the treatment facility when they were not supposed to. Some found the patients could have been playing sports when they’re not supposed to others could be found to develop further injury. So in the end none of the selected treatments are free from limitations and bias and only shockwave therapy treatment and Modalities (like cryotherapy, Ionto, and ultrasound) showed the most significant difference to the control group from all the reviewed literature. Clinically this means that Shin Splints needs further study in order to come out with a Gold standard of treatment. For future clinical practice the methods mentioned above all have a chance of working it just depends on the patient and how they’re progressing from pain-to pain free. This could be different for clinicians depending on resources and clinical expertise. In conclusion there is yet to be a conservative treatment that reduces pain and inflammation that is considered Gold standard but there are still a variety of ways to treat the condition conservatively that are effective.