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Medial tibial stress syndrome can be diagnosed reliably using history and physical examination
  1. M Winters1,
  2. E W P Bakker2,
  3. M H Moen3,4,5,
  4. C C Barten6,
  5. R Teeuwen7,
  6. A Weir8,9
  1. 1 Department of Rehabilitation, Nursing Science & Sports, University Medical Centre Utrecht, Utrecht, The Netherlands
  2. 2 Division of Clinical Methods and Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
  3. 3 Bergman Clinics, Naarden, The Netherlands
  4. 4 The Sport Physician Group, OLVG West, Amsterdam, The Netherlands
  5. 5 Department of Elite Sports, National Olympic Committee and National Sports Federation, Arnhem, The Netherlands
  6. 6 Academic Physical Education, The Hague, The Netherlands
  7. 7 Physiotherapy and Rehabilitation Diepeveen, Haarlem, The Netherlands
  8. 8 Orthopaedic and Sports Medicine Hospital, Aspetar, Doha, Qatar
  9. 9 Amsterdam Centre for Evidence Based Sports Medicine (ACES), Academic Medical Centre, Amsterdam, The Netherlands
  1. Correspondence to Dr M Winters, Department of Rehabilitation, Nursing Science & Sports, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands; marinuswinters{at}


Background The majority of sporting injuries are clinically diagnosed using history and physical examination as the cornerstone. There are no studies supporting the reliability of making a clinical diagnosis of medial tibial stress syndrome (MTSS).

Aim Our aim was to assess if MTSS can be diagnosed reliably, using history and physical examination. We also investigated if clinicians were able to reliably identify concurrent lower leg injuries.

Methods A clinical reliability study was performed at multiple sports medicine sites in The Netherlands. Athletes with non-traumatic lower leg pain were assessed for having MTSS by two clinicians, who were blinded to each others’ diagnoses. We calculated the prevalence, percentage of agreement, observed percentage of positive agreement (Ppos), observed percentage of negative agreement (Pneg) and Kappa-statistic with 95%CI.

Results Forty-nine athletes participated in this study, of whom 46 completed both assessments. The prevalence of MTSS was 74%. The percentage of agreement was 96%, with Ppos and Pneg of 97% and 92%, respectively. The inter-rater reliability was almost perfect; k=0.89 (95% CI 0.74 to 1.00), p<0.000001. Of the 34 athletes with MTSS, 11 (32%) had a concurrent lower leg injury, which was reliably noted by our clinicians, k=0.73, 95% CI 0.48 to 0.98, p<0.0001.

Conclusion Our findings show that MTSS can be reliably diagnosed clinically using history and physical examination, in clinical practice and research settings. We also found that concurrent lower leg injuries are common in athletes with MTSS.

  • medial tibial stress syndrome
  • diagnosis
  • history
  • physical examination
  • reliability

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  • Competing interests MW received a small grant from The Dutch National Olympic Committee during the course of this study for the performance of a prospective cohort study in athletes at risk for medial tibial stress syndrome (MTSS), investigating the relation between local tibial bone changes and MTSS.

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