Skip to main content
Log in

Treatment of Medial Tibial Stress Syndrome: A Systematic Review

Sports Medicine Aims and scope Submit manuscript

Abstract

Background

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.

Objective

The objective of this systematic review was to assess the effectiveness of any intervention in the treatment of MTSS.

Study Selection

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.

Data Sources

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.

Study Appraisal

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.

Results

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).

Conclusion

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome; a critical review. Sports Med. 2009;39(7):523–46.

    Article  PubMed  Google Scholar 

  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 

  4. Gaeta M, Minutoli F, Vinci S et al. High resolution CT grading of tibial stress reactions in distance runners. AJR. 2006;187(3):789–93.

    Article  PubMed  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 

  6. Frost HM. From Wolff’s law to the Utah paradigm: in-sights about bone physiology and its clinical applications. Anat Rec. 2001;262(4):398–419. doi:10.1002/ar.1049.

    Article  CAS  PubMed  Google Scholar 

  7. Moen MH, Bongers T, Bakker EW, et al. The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study. J R Army Med Corps. 2010;156(4):236–40.

    Article  CAS  PubMed  Google Scholar 

  8. Rompe JD, Cacchio A, Furia JP, et al. Low-energy extracorporeal shock wave therapy as a treatment for medial tibial stress syndrome. Am J Sports Med. 2010;38(1):125–32.

    Article  PubMed  Google Scholar 

  9. Moen MH, Rayer S, Schipper M, et al. Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. Br J Sports Med. 2012;46(4):253–7.

    Article  CAS  PubMed  Google Scholar 

  10. Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4(1):12.

    Article  PubMed  Google Scholar 

  11. Edwards PH Jr, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sports Med. 2005;33(8):1241–9.

    Article  PubMed  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.

  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 

  16. Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg Am. 1974;56(8):1697–700.

    CAS  PubMed  Google Scholar 

  17. Subotnick SI. The shin splints syndrome of the lower extremity. J Am Podiatry Assoc. 1976;66(1):43–5.

    CAS  PubMed  Google Scholar 

  18. Ijzerman JC, Kuipers H. Tibial stress syndrome, shin splints. Geneeskunde en Sport June. 1978;11(3):56–8.

    Google Scholar 

  19. Glelis NC. Treatment of shin splints. Postgrad Med. 1988;83(7):43.

    CAS  PubMed  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.

  23. Smith W, Winn F, Parette R. Comparative study using four modalities in shinsplint treatments. J Orthop Sports Phys Ther. 1986;8(2):77–80.

    CAS  PubMed  Google Scholar 

  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.

  25. Nissen LR, Astvad K, Madsen L. Low-energy laser therapy in medial tibial stress syndrome. Ugeskr Laeger. 1994;156(49):7329–31.

    CAS  PubMed  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.

  27. Johnston E, Flynn T, Bean M, et al. A randomized controlled trial of a leg orthosis versus traditional treatment for soldiers with shin splints: a pilot study. Mil Med. 2006;171(1):40–4.

    PubMed  Google Scholar 

  28. Piantanida A, Fields KB, Sturdivant R. Application of Pneumatic Pressure in Lower Extremity Pain Improvement and Eradication (APPLE PIE). Unpublished article.

  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).

  30. Milgrom M, Miligram M, Simkin A, et al. A home exercise program for tibial bone strengthening based on in vivo strain measurements. Am J Phys Med Rehabil. 2001;80(6):433–8.

    Article  CAS  PubMed  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 

  32. Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology. 2007;18(6):805–35.

    Article  PubMed  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 

Download references

Acknowledgments

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.

Authors’ contributions

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

None reported.

Source of funding

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Marinus Winters.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Supplementary material (DOCX 57 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Winters, M., Eskes, M., Weir, A. et al. Treatment of Medial Tibial Stress Syndrome: A Systematic Review. Sports Med 43, 1315–1333 (2013). https://doi.org/10.1007/s40279-013-0087-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40279-013-0087-0

Keywords

Navigation