Treatment of Medial Tibial Stress Syndrome: A Systematic Review
- 5.9k Downloads
Medial tibial stress syndrome (MTSS) is a common exercise-induced leg injury among athletes and military personnel. Several treatment options have been described in the literature, but it remains unclear which treatment is most effective.
The objective of this systematic review was to assess the effectiveness of any intervention in the treatment of MTSS.
Published or non-published studies, reporting randomized or non-randomized controlled trials of any treatment in subjects with MTSS were eligible for inclusion. Treatments were assessed for effects on pain, time to recovery or global perceived effect.
Computerized bibliographic databases (MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro and SPORTDiscus) and trial registries were searched for relevant reports, from their inception to 1 June 2012. Grey literature was searched for additional relevant reports.
The Cochrane Risk of Bias Tool was used to appraise study quality of randomized clinical trials (RCTs) whereas the Newcastle Ottawa Scale was used to appraise non-randomized trials. The ‘levels of evidence’, according to the Oxford Centre for Evidence-Based Medicine, addressed the impact of the assessed trials. Two reviewers independently performed the search for articles, study selection, data extraction and appraised methodological quality.
Eleven trials were included in this systematic review. All RCTs revealed a high risk of bias (Level 3 of evidence). Both non-randomized clinical trials were found to be of poor quality (Level 4 of evidence). RCTs, studying the effect of a lower leg brace versus no lower leg brace, and iontophoresis versus phonophoresis, were pooled using a fixed-effects model. No significant differences were found for lower leg braces (standardized mean difference [SMD] −0.06; 95 % CI −0.44 to 0.32, p = 0.76), or iontophoresis (SMD 0.09; 95 % CI −0.50 to 0.68, p = 0.76). Iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking and extracorporeal shockwave therapy (ESWT) could be effective in treating MTSS when compared with control (Level 3 to 4 of evidence). Low-energy laser treatment, stretching and strengthening exercises, sports compression stockings, lower leg braces and pulsed electromagnetic fields have not been proven to be effective in treating MTSS (level 3 of evidence).
None of the studies are sufficiently free from methodological bias to recommend any of the treatments investigated. Of those examined, ESWT appears to have the most promise.
KeywordsMilitary Population Athletic Population Pulse Electromagnetic Field Medial Tibial Stress Syndrome Chronic Exertional Compartment Syndrome
We thank Faridi van Etten – Jamaludin of the Academic Medical Centre, Amsterdam, for developing a bibliographic database search strategy, and Steve McMahon for his help to retrieve two relevant studies. We also thank Karl Bert Fields and Nicholas Piantanida for providing the manuscript of their unpublished study, and Marieke Brinkman and co-authors for providing us with their submitted manuscript.
Marinus Winters came up with the idea for this study, he performed the study search and selection, data extraction, quality assessment and wrote the manuscript.
Michel Eskes performed the study search and selection, data extraction and quality assessment.
Adam Weir and Maarten H. Moen both co-wrote the protocol and provided feedback on the manuscript.
Frank J.G. Backx provided feedback and assisted in managing the study.
Eric W.P. Bakker co-wrote the manuscript, assisted in methodological aspects and managed the study.
Conflict of interest
Source of funding
- 2.Yates B, While S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med. 2004;32(3):772–80.Google Scholar
- 3.Franklyn M, Oakes B, Field B, et al. Section modulus is the optimum geometric predictor for stress fractures and medial tibial stress syndrome in both male and female athletes. Am J Sports Med. 2008;36 (6):1179–8.Google Scholar
- 5.Magnusson HI, Ahlborg HG, Karlsson C et al. Low regional tibial bone density in athletes normalizes after recovery from symptoms. Am J Sports Med. 2003;31(4):596–600.Google Scholar
- 12.Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011.Google Scholar
- 13.Wells GA, Shea B, O’Connell D et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (last visited on June 15th, 2012).
- 14.Levels of Evidence Working Group. “The Oxford 2011 Levels of Evidence”. 2011: Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 (last visited on June 15th, 2012).
- 15.Rasmussen W. Shin splints: definition and treatment. J Sports Med. 1974;2(2):111–7.Google Scholar
- 18.Ijzerman JC, Kuipers H. Tibial stress syndrome, shin splints. Geneeskunde en Sport June. 1978;11(3):56–8.Google Scholar
- 20.Callison M. Acupuncture & tibial stress syndrome (shin splints). J Chinese Med. 2002;70:54–7.Google Scholar
- 21.Mladenoff E. Acupuncture treatment of shin splints. Am J Acupuncture. 1980;8(3):245–8.Google Scholar
- 22.Samueli Institute for Information Biology. A study of monochromatic near-infrared light energy in subjects with tibial stress reaction [ClinicalTrials.gov identifier NCT00253981]. US National Institutes of Health, ClinicalTrials.gov [online]. Available from URL: http://www.clinicaltrials.gov. Accessed 20012 June 1.
- 24.Singh A, Sethy GB, Sandhu JS et al. A comparative study of the efficacy of iontophoresis and phonophoresis in the treatment of shin splint. Physiotherapy. 2002–2003(1):17–20.Google Scholar
- 26.Robertson ME. The relative effectiveness of periosteal pecking combined with therapeutic ultrasound compared to therapeutic ultrasound in the treatment of medial tibial stress syndrome type II. Faculty of Health at the Durban Institute of Technology, Durban, South-Africa. Available from URL: http://ir.dut.ac.za/bitstream/handle/10321/166/Robertson_2003.pdf?sequence=5. Accessed 2012 June 1.
- 28.Piantanida A, Fields KB, Sturdivant R. Application of Pneumatic Pressure in Lower Extremity Pain Improvement and Eradication (APPLE PIE). Unpublished article.Google Scholar
- 29.Brinkman MJL, Buist I, Bredeweg SW. The treatment effect of pulsed electromagnetic field in sports athletes with medial tibial stress syndrome; a pilot study (in press 2013).Google Scholar
- 31.Moher D, Hopewell S, Schulz KF, et al., for the CONSORT Group. CONSORT 2010 Explanation and elaboration: updated guidelines for reporting parallel group randomised trial. BMJ. 2010;340:c869.Google Scholar
- 33.Deeks JJ, Dinnes J, D’Amico R et al. Evaluating non-randomised intervention studies. Health Technol Assess. 2003;7(27):iii–x, 1–173.Google Scholar