Sports Medicine

, Volume 39, Issue 7, pp 523–546 | Cite as

Medial Tibial Stress Syndrome

A Critical Review
  • Maarten H. Moen
  • Johannes L. Tol
  • Adam Weir
  • Miriam Steunebrink
  • Theodorus C. De Winter
Review Article

Abstract

Medial tibial stress syndrome (MTSS) is one of the most common leg injuries in athletes and soldiers. The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. The name given to this condition refers to pain on the posteromedial tibial border during exercise, with pain on palpation of the tibia over a length of at least 5 cm. Histological studies fail to provide evidence that MTSS is caused by periostitis as a result of traction. It is caused by bony resorption that outpaces bone formation of the tibial cortex. Evidence for this overloaded adaptation of the cortex is found in several studies describing MTSS findings on bone scan, magnetic resonance imaging (MRI), high-resolution computed tomography (CT) scan and dual energy x-ray absorptiometry.

The diagnosis is made based on physical examination, although only one study has been conducted on this subject. Additional imaging such as bone, CT and MRI scans has been well studied but is of limited value. The prevalence of abnormal findings in asymptomatic subjects means that results should be interpreted with caution.

Excessive pronation of the foot while standing and female sex were found to be intrinsic risk factors in multiple prospective studies. Other intrinsic risk factors found in single prospective studies are higher body mass index, greater internal and external ranges of hip motion, and calf girth. Previous history of MTSS was shown to be an extrinsic risk factor.

The treatment of MTSS has been examined in three randomized controlled studies. In these studies rest is equal to any intervention. The use of neoprene or semi-rigid orthotics may help prevent MTSS, as evidenced by two large prospective studies.

References

  1. 1.
    Clanton TO, Solcher BW. Chronic leg pain in the athlete. Clin Sports Med 1994 Oct; 13 (4): 743–59PubMedGoogle Scholar
  2. 2.
    Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg Am 1974 Dec; 56A (8): 1697–700Google Scholar
  3. 3.
    Bennett JE, Reinking MF, Pluemer B, et al. Factors contributing to the development of medial tibial stress syndrome in high school runners. Orthop Sports Phys Ther 2001 Sep; 31 (9): 504–10Google Scholar
  4. 4.
    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 Apr-May; 32 (3): 772–80PubMedCrossRefGoogle Scholar
  5. 5.
    Arendt EA, Griffiths H. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high performance athletes. Clin Sports Med 1997 Apr; 16 (2): 291–306PubMedCrossRefGoogle Scholar
  6. 6.
    Lassus J, Tulikoura I, Konttinen Y, et al. Bone stress injuries of the lower extremity. Acta Orthop Scand 2002 Jun; 73 (3): 359–68PubMedCrossRefGoogle Scholar
  7. 7.
    Devas MB. Stress fracture of the tibia in athletes or “shin soreness”. J Bone Joint Surg Br 1958 May; 40B (2): 227–39Google Scholar
  8. 8.
    Clement DB. Tibial stress syndrome in athletes. J Sports Med 1974 Mar-Apr; 2 (2): 81–5PubMedCrossRefGoogle Scholar
  9. 9.
    Puranen J. The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. J Bone Joint Surg Br 1974 Nov; 56-B (4): 712–5PubMedGoogle Scholar
  10. 10.
    Mubarak SJ, Gould RN, Lee YF, et al. The medial tibial stress syndrome: a cause of shin splints. Am J Sports Med 1982 Jul-Aug; 10 (4): 201–5PubMedCrossRefGoogle Scholar
  11. 11.
    Slocum DB. The shin splints syndrome: medical aspects and differential diagnosis. Am J Surg 1967 Dec; 114 (6): 875–81PubMedCrossRefGoogle Scholar
  12. 12.
    Devas MB. Shin splints, or stress fractures of the metacarpal bone in horses, and shin soreness, or stress fractures of the tibia, in man. J Bone Joint Surg Br 1967 May; 49 (2): 310–3PubMedGoogle Scholar
  13. 13.
    American Medical Association. Standard nomenclature of athletic injuries presented by subcommittee on classification of sports injuries [abstract]. Chicago (IL): AMA, 1966: 122Google Scholar
  14. 14.
    Detmer DE. Chronic shin splints: classification and management of medial tibial stress syndrome. Sports Med 1986 Nov-Dec; 3 (6): 436–46PubMedCrossRefGoogle Scholar
  15. 15.
    Institute for Quality and Healthcare. Indeling van methodologische kwaliteit van individuele studies: 2006 Jan [online]. Available from URL: http://www.cbo.nl/product/richtlijnen/handleiding_ebro/article20060207153532/view [Accessed 2009 May 12]Google Scholar
  16. 16.
    Holder LE, Michael RH. The specific scintigraphic pattern of “shin splints in the lower leg”: concise communication. J Nucl Med 1984 Aug; 25 (8): 865–9PubMedGoogle Scholar
  17. 17.
    Chisin R, Milgrom C, Giladi M, et al. Clinical significance of nonfocal findings in suspected tibial stress fractures. Clin Orthop Relat Res 1987 Jul; 220: 200–5PubMedGoogle Scholar
  18. 18.
    Batt ME, Ugalde V, Anderson MW, et al. A prospective controlled study of diagnostic imaging for acute shin splints. Med Sci Sports Exerc 1998 Nov; 30 (11): 1564–71PubMedCrossRefGoogle Scholar
  19. 19.
    Gaeta M, Minutoli F, Scribano E, et al. CT and MRI imaging findings in athletes with early tibial stress injuries: comparison of bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005 May; 235 (2): 553–61PubMedCrossRefGoogle Scholar
  20. 20.
    Gaeta M, Minutoli F, Vinci S, et al. High resolution CT grading of tibial stress reactions in distance runners. AJR 2006 Sep; 187 (3): 789–93PubMedCrossRefGoogle Scholar
  21. 21.
    Fredericson M, Gabrielle Bergman A, Hoffman KL, et al. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995 Jul-Aug; 23 (4): 472–81PubMedCrossRefGoogle Scholar
  22. 22.
    Arendt EA, Agel J, Heikes C, et al. Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. Am J Sports Med 2003 Nov-Dec; 31 (6): 959–68PubMedGoogle Scholar
  23. 23.
    Rupani HD, Holder LE, Espinola DA, et al. Three-phase radionuclide bone imaging in sports medicine. Radiology 1985 Jul; 156 (1): 187–96PubMedGoogle Scholar
  24. 24.
    Nielsen M, Hansen K, Holmer P, et al. Tibial peristeal reaction in soldiers: a scintigraphic study of 29 cases of lower leg pain. Acta Orthop Scand 1991 Dec; 62 (6): 531–4PubMedCrossRefGoogle Scholar
  25. 25.
    Anderson MW, Ugalde V, Batt M, et al. Shin splints: MR appearance in a preliminary study. Radiology 1997 Jul; 204 (1): 177–80PubMedGoogle Scholar
  26. 26.
    Matilla KT, Komu MES, Dahlstrom S, et al. Medial tibial pain: a dynamic contrast-enhanced MRI study. Magn Reson Imaging 1999 Sep; 17 (7): 947–54CrossRefGoogle Scholar
  27. 27.
    Aoki Y, Yasuda K, Tohyama H, et al. Magnetic resonance imaging in stress fractures and shin splints. Clin Orthop Relat Res 2004 Apr; 421: 260–7PubMedCrossRefGoogle Scholar
  28. 28.
    Delacerda FG. A study of anatomical factors involved in shin splints. J Orthop Sports Phys Ther 1980 Fall; 2 (2): 55–9PubMedGoogle Scholar
  29. 29.
    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 Aug; 38(4): 441–5PubMedCrossRefGoogle Scholar
  30. 30.
    Plisky MS, Rauh MJ, Heiderscheit B, et al. Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. J Orthop Sports Phys Ther 2007 Feb; 37 (2): 40–7PubMedCrossRefGoogle Scholar
  31. 31.
    Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors to medial tibial stress syndrome; a prospective investigation. Med Sci Sports Exer 2009 Mar; 41 (3): 490–6CrossRefGoogle Scholar
  32. 32.
    Gehlsen GM, Seger A. Selected measures of angular displacement, strength and flexibility in subjects with and without shin splints. Res Q Excerc Sport 1980 Oct; 51 (3): 478–85Google Scholar
  33. 33.
    Viitasalo JK, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sports Med 1983 May-Jun; 11 (3): 125–30PubMedCrossRefGoogle Scholar
  34. 34.
    Sommer HM, Vallentyne SW. Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc 1995 Jun; 27 (6): 800–4PubMedGoogle Scholar
  35. 35.
    Madeley LT, Munteanu SE, Bonanno DR. Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: a case-control study. J Sci Med Sport 2007 Dec; 10 (6): 356–62PubMedCrossRefGoogle Scholar
  36. 36.
    Tweed JL, Avil SJ, Campbell JA. Biomechanical risk factors in the development of medial tibial stress syndrome indistance runners. J Am Podiatr Med Assoc 2008 Nov-Dec; 98 (6): 436–44PubMedGoogle Scholar
  37. 37.
    Bandholm T, Boysen L, Haugaard S, et al. Foot medial longitudinal arch deformation during quiet standing and gait in subjects with medial tibial stress syndrome. J Foot Ankle Surg 2008 Mar-Apr; 47 (2): 89–95PubMedCrossRefGoogle Scholar
  38. 38.
    Taunton JE, Ryan MB, Clement DB. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002 Apr; 36 (2): 95–101PubMedCrossRefGoogle Scholar
  39. 39.
    Verhagen AP, de Vet HCW, de Bie RA, et al. The Delphi list: a criteria list for quality assessment of randomised clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998 Dec; 51 (12): 1235–41PubMedCrossRefGoogle Scholar
  40. 40.
    Nissen LR, Astvad K, Madsen L. Low-energy laser treatment of medial tibial stress syndrome. Ugeskr Laeger 1994 Dec; 156 (49): 7329–31PubMedGoogle Scholar
  41. 41.
    Johnston E, Flynn T, Bean M, et al. A randomised controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med 2006 Jan; 171 (1): 40–4PubMedGoogle Scholar
  42. 42.
    Bensel CK, Kish RN. Lower extremity disorders among men and women in army basic training and effects of two types of boots. Natick (MA): United States Army Natick Research & Development Laboratories, 1983Google Scholar
  43. 43.
    Bensel CK. Wear test of boot inserts: memorandum for the record. Natick (MA): United States Army Natick Research & Development Laboratories, 1986: 1–8Google Scholar
  44. 44.
    Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990 Nov-Dec; 18 (6): 636–41PubMedCrossRefGoogle Scholar
  45. 45.
    Schwellnus MP, Jordaan G. Does calcium supplementation prevent bone stress injuries? A clinical trial. Int J Sports Nutr 1992 Jun; 2 (2): 165–74Google Scholar
  46. 46.
    Pope RD, Herbert RP, Kirwan JD, et al. A randomised trial of preexercise stretching for prevention of lower limb injury. Med Sci Sports Exer 2000 Feb; 32 (2): 271–7CrossRefGoogle Scholar
  47. 47.
    Larsen K, Weidich F, LeBoeuf-Yde C. Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? a randomised controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther 2002 Jun; 25 (5): 326–31PubMedCrossRefGoogle Scholar
  48. 48.
    Brushöy C, Larsen K, Albrecht-Beste E, et al. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load; a randomized controlled trial of 1020 army recruits. Am J Sports Med 2008 Apr; 36 (4): 663–70CrossRefGoogle Scholar
  49. 49.
    Michael RH, Holder LE. The soleus syndrome: a cause of medial tibial stress syndrome (shin splints). Am J Sports Med 1985 Mar-Apr; 13 (2): 87–94PubMedCrossRefGoogle Scholar
  50. 50.
    Saxena A, O’Brien T, Bruce D. Anatomic dissection of the tibialis posterior muscle and its correlation to the medial tibial stress syndrome. J Foot Surg 1990 Mar-Apr; 29 (2): 105–8PubMedGoogle Scholar
  51. 51.
    Beck BR, Osterig LR, Oregon E. Medial tibial stress syndrome: the location of muscles in the leg in relation to symptoms. J Bone Joint Surg Am 1994 Jul; 76 (7): 1057–61PubMedGoogle Scholar
  52. 52.
    Garth WP, Miller ST. Evaluation of claw toe deformity, weakness of the foot intrinsics, and posteromedial shin pain. Am J Sports Med 1989 Nov-Dec; 17 (6): 821–7PubMedCrossRefGoogle Scholar
  53. 53.
    Bouché RT, Johnson CH. Medial tibial stress syndrome (tibial fasciitis): a proposed pathomechanical model involving fascial traction. J Am Podiatr Med Assoc 2007 Jan-Feb; 97 (1): 31–6PubMedGoogle Scholar
  54. 54.
    Hayes WC. Biomechanics of cortical and trabecular bone: implications for assessment of fracture risk. In: Mow VC, Hayes WC, editors. Basic orthopaedic biomechanics. New York: Raven Press, 1991: 93–142Google Scholar
  55. 55.
    Goodship AE, Lanyon LE, McFie H. Functional adaptation of bone to increased stress. J Bone Joint Surg Am 1979 Jun; 61 (4): 539–46PubMedGoogle Scholar
  56. 56.
    Beck BR. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med 1998 Oct; 26 (4): 265–79PubMedCrossRefGoogle Scholar
  57. 57.
    Judex S, Gross T, Zernicke RF. Strain gradients correlate with sites of exercise-induced bone-forming surfaces in the adult skeleton. J Bone Min Res 1997 Oct; 12 (10): 1737–45CrossRefGoogle Scholar
  58. 58.
    Gross TS, Edwards J, McLeod KJ, et al. Strain gradients correlate with sites of periosteal bone formation. J Bone Min Res 1997 Jun; 12 (6): 982–8CrossRefGoogle Scholar
  59. 59.
    Milgrom C, Giladi M, Simkin A, et al. The area moment of inertia of the tibia: a risk factor for stress fractures. J Biomech 1989; 22 (11-12): 1243–8PubMedCrossRefGoogle Scholar
  60. 60.
    Cordey J, Gautier E. Strain gauges used in the mechanical testing of bones: part I, theoretical and technical aspects. Int J Care Inj 1999; 30 Suppl. 1; A7–13Google Scholar
  61. 61.
    Frost HM. From Wolff’s law to the Utah paradigm: insights about bone physiology and its clinical applications. Anat Rec 2001 Apr; 262 (4): 398–419PubMedCrossRefGoogle Scholar
  62. 62.
    Frost HM. A 2003 update of bone physiology and Wolff’s law for clinicians. Angle Orthod 2004 Feb; 74 (1): 3–15PubMedGoogle Scholar
  63. 63.
    Frost HM. From Wolff’s law to the mechanostat: a new “face” of physiology. J Orthop Sci 1998; 3 (5): 282–6PubMedCrossRefGoogle Scholar
  64. 64.
    Forwood MR, Turner CH. The response of rat tibiae to incremental bouts of mechanical loading: a quantum concept for bone formation. Bone 1994 Nov-Dec; 15 (6): 603–9PubMedCrossRefGoogle Scholar
  65. 65.
    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 Jun; 36 (6): 1179–89PubMedCrossRefGoogle Scholar
  66. 66.
    Paul IL, Murno MB, Abernethy PJ, et al. Musculo-skeletal shock absorption: relative contribution of bone and soft tissues at various frequencies. J Biomech 1978; 11 (5): 237–9PubMedCrossRefGoogle Scholar
  67. 67.
    Radin EL. Role of muscles in protecting athletes from injury. Acta Med Scand Suppl 1986; 711: 143–7PubMedGoogle Scholar
  68. 68.
    Winter DA. Moments of force and mechanical power in jogging. J Biomech 1983; 16 (1): 91–7PubMedCrossRefGoogle Scholar
  69. 69.
    Hill DB. Production and absorption of work by muscle. Science 1960 Mar; 131 (3404): 897–903PubMedCrossRefGoogle Scholar
  70. 70.
    Milgrom C, Radeva-Petrova DR, Finestone A. The effect of muscle fatigue on in vivo tibial strains. J Biomech 2007; 40 (4): 845–50PubMedCrossRefGoogle Scholar
  71. 71.
    Bhatt R, Lauder I, Finlay DB, et al. Correlation of bone scintigraphy and histological findings in medial tibial syndrome. Br J Sports Med 2000 Feb; 34 (1): 49–53PubMedCrossRefGoogle Scholar
  72. 72.
    Johnell O, Rausing A, Wendeberg B, et al. Morphological bone changes in shin splints. Clin Orthop Relat Res 1982 Jul; 167: 180–4PubMedGoogle Scholar
  73. 73.
    Bonewald LF. Mechanosensation and transduction in osteocytes. Bone Key-Osteovision 2006 Oct; 3 (10): 7–15CrossRefGoogle Scholar
  74. 74.
    Han Y, Cowen SC, Schaffler MB, et al. Mechanotransduction and strain amplification in osteocyte cell processes. Proc Natl Acad Sci USA 2004 Nov 23; 101 (47): 16689–94PubMedCrossRefGoogle Scholar
  75. 75.
    Nicolella DP, Moravits DE, Gale AM. Osteocyte lacunae tissue strain in cortical bone. J Biomech 2006; 39 (9): 1735–43PubMedCrossRefGoogle Scholar
  76. 76.
    Noble B. Microdamage and apoptosis. Eur J Morphol 2005 Jan-Feb; 42 (1-2): 91–8PubMedCrossRefGoogle Scholar
  77. 77.
    Magnusson HI, Westlin NE, Nyqvist F, et al. Abnormally decreased regional bone density in athletes with medial tibial stress syndrome. Am J Sports Med 2001 Nov-Dec; 29 (6): 712–5PubMedGoogle Scholar
  78. 78.
    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 Jul-Aug; 31 (4): 596–600PubMedGoogle Scholar
  79. 79.
    Kortebein PM, Kaufman KR, Basford JR, et al. Medial tibial stress syndrome. Med Sci Sports Exerc 2000 Mar; 32Suppl. 3: S27–33Google Scholar
  80. 80.
    Andrish JT. The shin splint syndrome. In: De Lee JC, Drez D, editors. Orthopaedic sports medicine. 2nd ed. Amsterdam: Elsevier, 2003: chapter 29, 2155–8Google Scholar
  81. 81.
    Edwards PH, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med 2005 Aug; 33(8): 1241–9PubMedCrossRefGoogle Scholar
  82. 82.
    Puranen J, Alavaikko A. Intracompartmental pressure increase on exertion in patients with chronic compartment syndrome. J Bone Joint Surg Am 1981 Oct; 63 (8): 1304–9PubMedGoogle Scholar
  83. 83.
    Wallensten R, Eklund B. Intramuscular pressures in exercise-induced lower leg pain. Int J Sports Med 1984 Feb; 5 (1): 31–5PubMedCrossRefGoogle Scholar
  84. 84.
    D’Ambrosia RD, Zelis RF, Chuinard RG, et al. Interstitial pressure measurements in the anterior and posterior compartments in athletes with shin splints. Am J Sports Med 1977 May-Jun; 5 (3): 127–31PubMedCrossRefGoogle Scholar
  85. 85.
    Greaney RB, Gerber FH, Laughlin RL, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 1983 Feb; 146 (2): 339–46PubMedGoogle Scholar
  86. 86.
    Kiuru MJ, Pihlajamaki HK, Hietanen HJ, et al. MR imaging, bone scintigraphy and radiography in bone stress injuries of the pelvis and lower extremity. Acta Radiol 2002; 43: 207–12PubMedCrossRefGoogle Scholar
  87. 87.
    Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001 Jan-Feb; 29 (1): 100–11PubMedGoogle Scholar
  88. 88.
    Brukner P. Exercise related lower leg pain: bone. Med Sci Sports Exerc 2000 Mar; 32 Suppl. 3: S15–26Google Scholar
  89. 89.
    Zwas ST, Elkanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med 1987 Apr; 28 (4): 452–7PubMedGoogle Scholar
  90. 90.
    Matin P. Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries. Semin Nucl Med 1988 Apr; 18 (2): 90–112PubMedCrossRefGoogle Scholar
  91. 91.
    Roub LW, Gumerman LW, Hanley EN, et al. Bone stress: a radionuclide imaging perspective. Radiology 1979 Aug; 132 (2): 431–8PubMedGoogle Scholar
  92. 92.
    Drubach LA, Connoly LP, D’Hemecourt PA, et al. Assessment of the clinical significance of asymptomatic lower extremity uptake abnormality in young athletes. J Nucl Med 2001 Feb; 42 (2): 209–12PubMedGoogle Scholar
  93. 93.
    Bergman AG, Fredericsson M, Ho C, et al. Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners. AJR 2004 Sep; 183 (3): 635–8PubMedGoogle Scholar
  94. 94.
    Redmond AC, Crosbie J, Ouvrier RA. Development and validation of a novel rating system for scoring standing foot posture: the Foot Posture Index. Clin Biomech 2006 Jan; 21 (1): 89–98CrossRefGoogle Scholar
  95. 95.
    Keenan AM, Redmond AC, Horton M, et al. The Foot Posture Index: Rasch analysis of a novel, foot-specific outcome measure. Arch Phys Med Rehabil 2007 Jan; 88(1): 88–93PubMedCrossRefGoogle Scholar
  96. 96.
    Bamman MM, Newcomer BR, Larson-Meyer DE, et al. Evaluation of the strength-size relationship in vivo using various muscle size indices. Med Sci Sports Exerc 2000 Jul; 32 (7): 1307–13PubMedCrossRefGoogle Scholar
  97. 97.
    Morris RH. Medial tibial syndrome: a treatment protocol using electric current. Chiropractic Sports Med 1991; 5 (1): 5–8Google Scholar
  98. 98.
    Schulman RA. Tibial shin splints treated with a single acupuncture session: case report and review of the literature. J Am Med Acupuncture 2002; 13 (1): 7–9Google Scholar
  99. 99.
    Järvinnen M, Niittymaki S. Results of the surgical treatment of the medial tibial stress syndrome in athletes. Int J Sports Med 1989 Feb; 10 (1): 55–7PubMedCrossRefGoogle Scholar
  100. 100.
    Holen KJ, Engebretsen L, Grondvedt T, et al. Surgical treatment of medial tibial stress syndrome (shin splints) by fasciotomy of the superficial posterior compartment ofthe leg. Scand J Med Sci Sports 1995 Feb; 5 (1): 40–3PubMedCrossRefGoogle Scholar
  101. 101.
    Wallenstein R. Results of fasciotomy in patients with medial tibial stress syndrome or chronic anterior compartment syndrome. J Bone Joint Surg Am 1983 Dec; 65 (9): 1252–5Google Scholar
  102. 102.
    Abramowitz AJ, Schepsis A, McArthur C. The medial tibial stress syndrome: the role of surgery. Orthop Rev 1994 Nov; 23 (11): 875–81PubMedGoogle Scholar
  103. 103.
    Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. J Bone Joint Surg Am 2003 Oct; 85 (10): 1974–80PubMedGoogle Scholar
  104. 104.
    O’Brien FJ, Hardiman DA, Hazenberg JG, et al. The behaviour of microcracks in compact bone. Eur J Morphol 2005 Feb-Apr; 42 (1-2): 71–9PubMedCrossRefGoogle Scholar
  105. 105.
    Raesi Najafi A, Arshi AR, Eslami MR, et al. Micro-mechanics fracture in osteonal cortical bone: a study of the interactions between microcrack propagation, microstructure and the material properties. J Biomech 2007; 40 (12): 2788–95CrossRefGoogle Scholar
  106. 106.
    Wang X, Masse DB, Leng H, et al. Detection of trabecular bone microdamage by micro-computed tomography. J Biomech 2007; 40 (15): 3397–403PubMedCrossRefGoogle Scholar
  107. 107.
    Cole GK, Nigg BM, van den Bogert AJ. Transfer of eversion to internal leg rotation in running [abstract]. J Biomech 1994; 27 (6): 659. Presented at International Society of Biomechanics XIV Congress 1993CrossRefGoogle Scholar
  108. 108.
    Hintermann B, Nigg BM. Pronation in runners: implications for injuries. Sports Med 1998 Sep; 26 (3): 169–76PubMedCrossRefGoogle Scholar
  109. 109.
    DeSouza MJ, Williams NI. Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women. Hum Reprod Update 2004 Sep-Oct; 10(5): 433–48PubMedCrossRefGoogle Scholar
  110. 110.
    DeSouza MJ, Williams NI. Beyond hypoestrogenism in amenorrheic athletes: energy deficiency as a contributing factor for bone loss. Curr Sports Med Rep 2005 Feb; 4 (1): 38–44PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2009

Authors and Affiliations

  • Maarten H. Moen
    • 1
  • Johannes L. Tol
    • 2
  • Adam Weir
    • 2
  • Miriam Steunebrink
    • 2
  • Theodorus C. De Winter
    • 2
  1. 1.Department of Sports Medicine of the University Medical Centre Utrecht and Rijnland HospitalLeiderdorpthe Netherlands
  2. 2.Department of Sports Medicine of the Medical Centre Haaglandenthe Haguethe Netherlands

Personalised recommendations