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Medial tibial stress syndrome: diagnosis, treatment and outcome assessment (PhD Academy Award)
  1. Marinus Winters1,2
  1. 1 Rehabilitation, Physiotherapy Sciences and Sports Department, University Medical Center Utrecht, Utrecht, The Netherlands
  2. 2 Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
  1. Correspondence to Dr Marinus Winters, Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg 9220, Denmark ; marinuswinters{at}

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What did I do?

My PhD consisted of three principal studies: (1) I investigated the reliability of diagnosing medial tibial stress syndrome (MTSS) using history and physical examination. (2) Then, I examined if there is an evidence-based treatment for MTSS in a systematic review. (3) Finally, I developed and validated a new patient-reported outcome measure (PROM) for athletes with MTSS: the MTSS score.

Why did I do it?

MTSS is one of the most common conditions in running athletes. Yet, it was unknown how to best diagnose (1) or treat it (2) and there was no PROM for athletes with MTSS (3). In particular:

  1. MTSS: a clinical diagnosis?

    The pathology of MTSS is equivocal; it’s a clinical pain condition. Therefore, making the diagnosis based on history and physical examination is the most logical approach. However, it was unclear if this can be done reliably between clinicians.

  2. Treatment of MTSS

    Shockwave, lower leg braces and strengthening exercises are some of the treatments available for athletes with MTSS. Prior to this thesis, a number of controlled trials had been performed. Which intervention was most effective was unclear.

  3. Measuring outcomes from a patient’s perspective

    PROMs are nowadays considered the cornerstone of outcome assessment. No PROM existed for MTSS; various outcome measures were used making it hard to compare outcomes between studies.

How did I do it?

  1. Inter-rater reliability of diagnosing MTSS clinically

    Two clinicians used a standardised history and physical examination to diagnose 49 athletes with non-traumatic lower leg pain as having MTSS (yes/no). They were blinded to each other’s diagnoses while assessing the athletes. They also evaluated the presence of concurrent lower leg injuries.1

  2. Treatment of MTSS: a systematic review

    Conventional and grey literature resources were searched for controlled trials. The risk of bias in the studies included was appraised, and meta-analyses were done if possible.2

  3. Development and validation of the MTSS score

    Fifteen MTSS experts developed items for the new PROM. They reached consensus on the relevance of items in a Delphi study. Twenty patients were consulted to judge the relevance and comprehension of the items.3 The MTSS score was tested in the largest prospective study in the field of MTSS until now. The best items for the MTSS score were selected from the item pool, based on their reliability and responsiveness. Then, the MTSS score’s validity, reliability and responsiveness was tested.4

What did I find?

  1. MTSS can be diagnosed reliably using history and physical examination

    MTSS can be diagnosed with almost perfect reliability between clinicians, using history and physical examination. Thirty-two per cent of the athletes with MTSS have a concurrent lower leg injury which clinicians are able to identify reliably.1

  2. No evidence for any treatment for athletes with MTSS

    My systematic review shows that none of the trials (n=11) are sufficiently free from bias to recommend any treatment for use in clinical practice.2

  3. MTSS score: valid, reliable and responsive

    The MTSS score measures pain at rest, pain while performing activities of daily living, limitations in sporting activities and pain while performing sporting activities. The MTSS score specifically measures pain along the shin and limitations due to shin pain. The MTSS score is a valid, reliable and responsive PROM. The MTSS score is designed to evaluate treatment outcomes in clinical studies.3 4

What are the most important clinical impacts/practical applications

  • MTSS should be diagnosed based on history and physical examination.

  • There is no treatment proven to be effective for athletes with MTSS. Patient education and a graded loading exposure programme seem the most logical treatments.5

  • The MTSS score should be used as a primary outcome measure in clinical studies into MTSS.5


I would like to thank Professor Dr Frank Backx, Dr Eric Bakker, Dr Maarten Moen and Dr Adam Weir for their valuable contributions to the work in my thesis. I would like to refer to the ‘dankwoord’ in my thesis for all those who contributed to the work.



  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.