Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors

The pediatric knee: current concepts in sports medicine

As the popularity and intensity of children's athletics have increased, so has the risk for knee injuries. Fractures of the tibial eminence may be treated operatively or nonoperatively depending on fracture classification, but arthrofibrosis is a potentially significant complication. Anterior cruciate ligament rupture presents treatment challenges as regards the optimal timing and method of reconstruction. A number of novel reconstructive techniques have been developed to minimize risks to the physes in this population. Recent studies have focused on the prognosis, surgical indications, and operative techniques for osteochondritis dissecans in children. A number of authors have also sought to better-define the optimal diagnostic testing and management of patellar dislocation. In this review, we provide an update on current concepts for tibial eminence fractures, anterior cruciate ligament injuries, osteochondritis dissecans of the knee, and patellar dislocation in young athletes.

Overweight and obesity are associated with musculoskeletal complaints as early as childhood: a systematic review

In order to examine (i) the association between weight status and musculoskeletal complaints (MSC) in children, and (ii) whether overweight and obese children have a higher risk of developing MSC than normal-weight children Medline, Embase, Web of Science and Cochrane were searched (all years up to 2 January 2013) for observational studies studying direct associations between body mass index (or weight status) and MSC in children. Forty studies, together studying over one million children, were included. There was moderate quality of evidence that being overweight in childhood is positively associated with musculoskeletal pain (risk ratio [RR] 1.26; 95% confidence interval [CI]: 1.09-1.45). In addition, low quality of evidence was found for a positive association between overweight and low back pain (RR 1.42; 95% CI: 1.03-1.97) and between overweight and injuries and fractures (RR 1.08; 95% CI: 1.03-1.14). Although the risk of developing an injury was significantly higher for overweight than for normal-weight adolescents (RR: 2.41, 95% CI: 1.42 to 4.10), this evidence was of very low quality. Overweight and obesity are associated with musculoskeletal pain, injuries and fractures as early as childhood. More high-quality prospective cohort studies are needed to study the nature of this relationship.

Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis

Background

Medial tibial stress syndrome (MTSS) affects 5%–35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners.

Methods

Medical research databases were searched for relevant literature, using the terms “MTSS AND prevention OR risk OR prediction OR incidence”.

Results

A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI), ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29–1.04, P<0.001); prior use of orthotics (risk ratio [RR] 2.31, 95% CI 1.56–3.43, P<0.001); fewer years of running experience (SMD −0.74, 95% CI −1.26 to −0.23, P=0.005); female gender (RR 1.71, 95% CI 1.15–2.54, P=0.008); previous history of MTSS (RR 3.74, 95% CI 1.17–11.91, P=0.03); increased body mass index (SMD 0.24, 95% CI 0.08–0.41, P=0.003); navicular drop (SMD 0.26, 95% CI 0.02–0.50, P=0.03); and navicular drop >10 mm (RR 1.99, 95% CI 1.00–3.96, P=0.05).

Conclusion

Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed. These data can inform both screening and countermeasures for the prevention of MTSS in runners.

Prevention of overuse sports injuries in the young athlete

The purpose of this article is to review the current theories regarding prevalence, mechanism, and prevention strategies for overuse injuries in a young athletic population. This information provides valuable insight into the state of the current evidence regarding overuse injuries in young athletes as well as the potential future directions in the development of overuse injury prevention interventions.

Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners

PURPOSE

Medial tibial stress syndrome (MTSS) and tibial stress fracture (SF) are common lower leg disorders in runners. A prospective study was done to identify the incidence of MTSS and SF in high school runners and to determine risk factors.

METHODS

A total of 230 runners participating in high school running teams were evaluated. All runners aged 15 years as first grade of high school were involved in the study. They were followed up for 3 years. The measured items included height, weight, body mass index (BMI), range of hip and ankle motion, straight leg raising (SLR), intercondylar and intermalleolar interval, Q-angle, navicular drop test, hip abductor strength and physical conditioning. Each runner was followed for 3 years to report occurrence of MTSS and SF.

RESULTS

A total number of 102 MTSS (0.29 athlete exposures) and 21 SF (0.06 athlete exposures) were identified. In females, BMI significantly increased the risk of MTSS after adjustment for the other variables in this study (adjusted odds ratio, 0.51; 95 % confidence interval, 0.31-0.86). Increased internal rotation of the hip significantly increased the risk of MTSS (adjusted odds ratio, 0.91; 95 % confidence interval, 0.85-0.99). In males, limited SLR also significantly increased the risk of SF with adjustment for the other variables in this study (adjusted odds ratio, 1.38; 95 % confidence interval, 1.04-1.83).

CONCLUSION

A significant relationship was found between BMI, internal hip rotation angle and MTSS in females, and between limited SLR and SF in males.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Dynamic midfoot kinematics in subjects with medial tibial stress syndrome

BACKGROUND

Medial tibial stress syndrome (MTSS) is a common diagnosis. Several studies have demonstrated that excessive static navicular drop (ND) is related to the diagnosis. However, no studies have yet investigated ND and the velocity of ND during dynamic conditions. The aim of this study was to evaluate ND characteristics in patients with MTSS in dynamic and static conditions.

METHODS

In a case-control study, 14 patients diagnosed as having MTSS were included from an orthopedic outpatient clinic. A control group consisting of 14 healthy participants was matched regarding age, sex, and typical sporting activity. Navicular drop was evaluated during treadmill walking by a two-dimensional video analysis. Static foot posture, static ND, dynamic ND (dND), and velocity of dND were compared.

RESULTS

The two groups were comparable in relation to age, sex, height, weight, and foot size. No significant difference was found in static foot posture. Static ND showed a mean difference of 1.7 mm between the groups (P = .08). During treadmill walking, patients with MTSS had, on average, a 1.5-mm-larger dND (P =.004) and a 2.4-mm/sec-larger mean velocity of dND (P = .03).

CONCLUSIONS

Patients with MTSS display a larger ND and a higher ND velocity during treadmill walking. Increased ND velocity may be important to this condition. Future studies should include velocity of dND to investigate the mechanisms of dND in relation to overuse injuries.

Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment

Context:

Chronic lower leg pain in athletes can be a frustrating problem for patients and a difficult diagnosis for clinicians. Myriad approaches have been suggested to evaluate these conditions. With the continued evolution of diagnostic studies, evidence-based guidance for a standard approach is unfortunately sparse.

Evidence Acquisition:

PubMed was searched from January 1980 to May 2011 to identify publications regarding chronic lower leg pain in athletes (excluding conditions related to the foot), including differential diagnosis, clinical presentation, physical examination, history, diagnostic workup, and treatment.

Results:

Leg pain in athletes can be caused by many conditions, with the most frequent being medial tibial stress syndrome; chronic exertional compartment syndrome, stress fracture, nerve entrapment, and popliteal artery entrapment syndrome are also considerations. Conservative management is the mainstay of care for the majority of causes of chronic lower leg pain; however, surgical intervention may be necessary.

Conclusion:

Chronic lower extremity pain in athletes includes a wide differential and can pose diagnostic dilemmas for clinicians.

National Athletic Trainers' Association position statement: prevention of pediatric overuse injuries

OBJECTIVE

To provide certified athletic trainers, physicians, and other health care professionals with recommendations on best practices for the prevention of overuse sports injuries in pediatric athletes (aged 6-18 years).

BACKGROUND

Participation in sports by the pediatric population has grown tremendously over the years. Although the health benefits of participation in competitive and recreational athletic events are numerous, one adverse consequence is sport-related injury. Overuse or repetitive trauma injuries represent approximately 50% of all pediatric sport-related injuries. It is speculated that more than half of these injuries may be preventable with simple approaches.

RECOMMENDATIONS

Recommendations are provided based on current evidence regarding pediatric injury surveillance, identification of risk factors for injury, preparticipation physical examinations, proper supervision and education (coaching and medical), sport alterations, training and conditioning programs, and delayed specialization.

Biomechanical and lifestyle risk factors for medial tibia stress syndrome in army recruits: a prospective study

Medial tibial stress syndrome (MTSS) is a common injury in active populations and has been suggested to be a result of both biomechanical and lifestyle factors. The main aim of this study was to determine prospectively whether gait biomechanics and lifestyle factors can be used as a predictor of MTSS development. British infantry male recruits (n=468) were selected for the study. Plantar pressure variables, lifestyle factors comprising smoking habit and aerobic fitness as measured by a 1.5 mile timed-run were collected on the first day of training. Injury data were collected during the 26 week training period and incidence rate was 7.9% (n=37). A logistic regression model for membership of the MTSS and non-MTSS groups was developed. An imbalance in foot pressure with greater pressure on the medial side than on the lateral side was the primary risk factor. Low aerobic fitness, as deduced from a 1.5 mile timed-run and smoking habit were also important, but were additive risk factors for MTSS. In conclusion, "poor" biomechanics were the strongest predictors of MTSS development but lifestyle factors were also important. The logistic regression model combining all three risk factors was capable of predicting 96.9% of the non-injured group and 67.5% of the MTSS group with an overall accuracy of 87.7%. While the model has yet to be validated against an external sample and limitations exist with regards to the quality of the data collected, it is nonetheless suggested that the combined analysis of biomechanical and lifestyle factors has the potential to improve the prediction of MTSS.

Risk factors for self-reported exercise-related leg pain in high school cross-country athletes

CONTEXT

Prevention of exercise-related leg pain (ERLP) has not been successful because ERLP risk factors are not well known.

OBJECTIVE

To determine the percentage of high school cross-country (XC) athletes who reported a history of ERLP in their running careers, to identify the percentage of athletes who reported an occurrence of ERLP during 1 XC season, and to investigate the association of selected factors (age, high school year, years of high school running, sex, ERLP history, body mass index [BMI], foot type, and training distance) and the occurrence of ERLP.

DESIGN

Prospective cohort study.

SETTING

Six local high schools.

PATIENTS OR OTHER PARTICIPANTS

One hundred twenty-five high school XC athletes (62 females, 63 males).

MAIN OUTCOME MEASURE(S)

All athletes completed an initial ERLP questionnaire, and foot type was visually assessed. After the season, athletes were asked to complete a Web-based questionnaire regarding the seasonal occurrence of ERLP. Statistical analyses of differences (t tests) and associations (chi(2), relative risk) were conducted.

RESULTS

A total of 103 of the 125 athletes (82.4%) reported a history of ERLP, with 81 athletes reporting ERLP occurrence within the month preceding completion of the initial questionnaire. Bilateral medial leg pain was the most common ERLP presentation. More than half of the athletes (58.4%) with an ERLP history reported that the pain had interfered with XC participation. Ninety-three athletes responded to the postseason questionnaire, and 45 (48.0%) reported ERLP seasonal occurrence. Most athletes (97.8%) who experienced the seasonal occurrence of ERLP had a history of ERLP. No associations were noted between ERLP history or seasonal occurrence and age, high school year, years of high school running, sex, BMI, foot type, or training distance.

CONCLUSIONS

Both a history of ERLP and the seasonal occurrence of ERLP were common among these XC athletes. The only risk factor identified for ERLP season occurrence was ERLP history.

Measures of arch height and their relationship to pain and dysfunction in people with lower limb impairments

BACKGROUND AND PURPOSE

Debate surrounds the theory that foot structure, and more specifically, the attitude of the midfoot as typified by the longitudinal arch, is associated with complaints of pain and injuries of the lower extremity. Recently, two simple clinical measures of arch height, the arch ratio (AR) and the longitudinal arch angle (LAA), have been reported as valid and reliable in the literature. The LAA has been found to approximate the lowest point of the arch during walking and running while the main strengths of the AR are that the measure takes into account foot size and arch mobility. We modified the AR so that the modified AR (mAR) would be measured in a similar fashion as the LAA to investigate if this new measure, which would account for foot size, correlated well with an established measure (LAA) that estimated the behaviour of the arch with walking and running. Also, we hoped to contribute to the literature correlating longitudinal arch height with pain - numeric pain rating scale - and dysfunction - Lower Extremity Functional Scale (LEFS) and Single Assessment Numeric Evaluation (SANE).

METHODS

Thirty-five subjects for this prospective correlational study were recruited from a community based outpatient practice that was part of a tertiary care academic medical centre. Reliability and validity of our investigator and of the mAR was first examined. We then examined the correlation of the clinical classification of arch height (high, normal, or low) produced by these two measures with each other. We also explored the correlation of multiple measures of dysfunction and pain with arch height.

RESULTS

Intrarater reliability and validity of the LAA showed an intraclass correlation (ICC) of 0.978 and Pearson's correlation coefficient (PCC) of 0.885, respectively. Intrarater reliability and validity of the mAR showed an ICC of 0.961 and PCC of 0.827, respectively. The LAA and our new measure, the mAR, were correlated with each other. The self-report measures of general health and activity level were significantly positively correlated (PCC = 0.598). Also significant and positively correlated were the LEFS and the SANE (PCC = 0.617), two measures of function.

CONCLUSIONS

Pain and dysfunction may be positively correlated but longitudinal arch height does not predict either pain or dysfunction.

Use of foot orthoses and calf stretching for individuals with medial tibial stress syndrome

Use of orthotics and calf stretching may alleviate symptoms in runners with medial tibial stress syndrome (MTSS). The objective of this study was to determine which patients with MTSS have a positive response to off-the-shelf foot orthoses and calf stretching based on selected clinical tests to establish a clinical prediction rule. This prospective cohort/predictive validity study enrolled 23 women and men aged 22 to 44 years with symptoms of MTSS. Interventions included off-the-shelf basic foot orthotics and calf stretching. Fifteen of the 23 runners had a 50% reduction of pain in 3 weeks of intervention. Duration was a significant factor that differentiated groups. Although an initial treatment for runners with MTSS may include off-the-shelf orthotics and calf stretching, this regimen should be only one component of an individualized rehabilitation program.

Low-energy extracorporeal shock wave therapy as a treatment for medial tibial stress syndrome

BACKGROUND

Medial tibial stress syndrome (MTSS) is a pain syndrome along the tibial origin of the tibialis posterior or soleus muscle. Extracorporeal shock wave therapy (SWT) is effective in numerous types of insertional pain syndromes.

HYPOTHESIS

Shock wave therapy is an effective treatment for chronic MTSS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Forty-seven consecutive subjects with chronic recalcitrant MTSS underwent a standardized home training program, and received repetitive low-energy radial SWT (2000 shocks; 2.5 bars of pressure, which is equal to 0.1 mJ/mm(2); total energy flux density, 200 mJ/mm(2); no local anesthesia) (treatment group). Forty-seven subjects with chronic recalcitrant MTSS were not treated with SWT, but underwent a standardized home training program only (control group). Evaluation was by change in numeric rating scale. Degree of recovery was measured on a 6-point Likert scale (subjects with a rating of completely recovered or much improved were rated as treatment success).

RESULTS

One month, 4 months, and 15 months from baseline, success rates for the control and treatment groups according to the Likert scale were 13% and 30% (P < .001), 30% and 64% (P < .001), and 37% and 76% (P < .001), respectively. One month, 4 months, and 15 months from baseline, the mean numeric rating scale for the control and treatment groups were 7.3 and 5.8 (P < .001), 6.9 and 3.8 (P < .001), and 5.3 and 2.7 (P < .001), respectively. At 15 months from baseline, 40 of the 47 subjects in the treatment group had been able to return to their preferred sport at their preinjury level, as had 22 of the 47 control subjects.

CONCLUSION

Radial SWT as applied was an effective treatment for MTSS.

Current developments concerning medial tibial stress syndrome

Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in athletes who run. Studies have reported MTSS to occur in 4% to 20% of this population. It can be defined as an overuse injury that creates pain over an area covering the distal to middle third of the posteriomedial tibial border, which occurs during exercise and creates cyclic loading. Differential diagnosis includes ischemic disorders and stress fractures. Although the pathology of this injury is understood, the etiology is less agreed upon. This makes it difficult for clinicians to diagnose and treat this common injury. The purpose of this article is to present health care practitioners with the most current information regarding MTSS so they can better diagnose and treat this common injury. To this end, a literature review was conducted, with the most current results presented. The areas of etiological theories, imaging techniques, and treatment options for MTSS were searched. Five of the most prevalent etiological theories are presented with supporting evidence. Of the imaging tools available to the clinician, magnetic resonance imaging (MRI) and bone scintigraphy have comparable specificity and sensitivity. Clinicians should first make the clinical diagnosis of MTSS, however, because of high percentages of positive MRI scans in asymptomatic patients. There have been few randomized controlled trials investigating treatment options for athletes with MTSS. Those that have been performed rendered no significant findings, leading researchers to conclude that rest is equal to or better than other treatment options. Given the evidence, treatment suggestions for practitioners caring for athletes with MTSS are provided.

Menstrual function in female high school cross-country athletes

Menstrual function in adolescent athletes has received limited investigation.

OBJECTIVE

In a sample of female high school cross-country (XC) athletes, the purposes of the investigation were to (1) describe menstrual function (history and inseason), (2) describe the relationship between menstrual function and variables including body mass index (BMI), high school year, current year of running, total years running, training distance, racing pace, additional organized sport participation other than XC, and participation in XC practices and races, (3) determine the relationship between menstrual function and self-reported interfering exercise related leg pain (ERLP), and (4) determine the relationship between menstrual function history and menstrual function during a XC season.

STUDY GROUP

62 female high school XC athletes.

METHODS

A prospective cohort design was used. Athletes were asked to complete an initial questionnaire querying several variables including menstrual function and ERLP history. At the end of the XC season, athletes were asked to complete a postseason questionnaire regarding menstrual function and ERLP during the XC season.

RESULTS

Of the athletes, 25.8% (16/62) reported abnormal menstrual function history and 34.9% reported abnormal menstrual function inseason. Abnormal menstrual function history was a risk for previous interfering ERLP (RR = 3.00, CI: 1.09, 8.29), and abnormal menstrual function history was a risk for abnormal menstrual function inseason (RR = 4.11, CI: 1.75, 9.62).

CONCLUSIONS

Abnormal menstrual function was present in this sample of athletes and was a risk for previous interfering ERLP and future episodes of abnormal menstrual function.

Medial tibial stress syndrome: a critical review

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.

Differences in static and dynamic measures in evaluation of talonavicular mobility in gait

STUDY DESIGN

Controlled laboratory study using a cross-sectional design.

OBJECTIVES

To compare the measurements of navicular drop during walking and running to those made clinically during a static position in a group of healthy young adults.

BACKGROUND

The navicular drop test is a common clinical measure of foot structure and, more specifically, of talonavicular joint function. Previous work has focused on static measurement to establish the relationship between navicular drop and various overuse injuries. However, loads on foot structure are dramatically increased during gait. Examining navicular drop dynamically is more reflective of the functional demands of the foot when walking and running.

METHODS

The navicular drop of 72 healthy runners was evaluated using 2 static methods. Results were used to classify individuals into groups and compared to dynamic measures of navicular drop made during walking and running. Three-dimensional motion capture and an instrumented treadmill were used to assess dynamic navicular mobility. A repeated-measures analysis of variance (ANOVA) was performed to examine differences between measurement conditions. Between-group differences were assessed with independent-samples t test (P<.05).

RESULTS

Static measures of navicular drop were not found to be uniformly predictive of dynamic function during walking or running. Functional navicular drop measurements underestimated the dynamic measures in all foot types, while subtalar neutral drop overestimated dynamic measures for individuals with neutral and hypermobile foot types. No differences in navicular drop were found between foot types during walking, and small differences were found in running only between the hypomobile and hypermobile foot types. Maximum foot deformation during gait occurs at the time of maximum ground reaction force. Significant differences in navicular drop between foot type groups measured statically become muted when looking at group differences while walking and running.

CONCLUSIONS

Differences in navicular mobility between foot type groups during walking and running indicate that factors other than static alignment affect dynamic foot mobility. Dynamic assessment of navicular mobility may be an effective tool to examine the interplay of how the extrinsic force demands of gait and intrinsic structure and neuromuscular control affect foot function in walking and running.

The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes

Objective

To determine the relationship between lower extremity alignment and MTSS amongst non-professional athletes

Design

In a prospective Study, sixty six subjects were evaluated. Bilateral navicular drop test, Q angle, Achilles angle, tibial angle, intermalleolar and intercondylar distance were measured. In addition, runner's height, body mass, history of previous running injury, running experience was recorded. Runners were followed for 17 weeks to determine occurrence of MTSS.

Results

The overall injury rate for MTSS was 19.7%. The MTSS injury rate in girls (22%) was not significantly different from the rate in boys (14.3%). Most MTSS injuries were induced after 60 hours of exercise, which did not differ between boys and girls. There was a significant difference in right and left navicular drop (ND) in athletes with MTSS. MTSS had no significant correlation with other variables including Quadriceps, Tibia and Achilles angles, intercondylar and intermaleolar lengths and lower extremity lengths.

Limitation

All measurements performed in this study were uniplanar and static. The small sample size deemed our main limitation. The accurate assessment of participants with previous history of anterior leg pain for MTSS was another limitation.

Conclusion

Although a significant relationship between navicular drop and MTSS was found in this study; there was not any significant relationship between lower extremity alignment and MTSS in our sample study.

Medial tibial stress syndrome: evidence-based prevention

REFERENCE

Thacker SB, Gilchrist J, Stroup DF, Kimsey CD. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34(1):32-40.

CLINICAL QUESTION

Among physically active individuals, which medial tibial stress syndrome (MTSS) prevention methods are most effective to decrease injury rates?

DATA SOURCES

Studies were identified by searching MEDLINE (1966-2000), Current Contents (1996-2000), Biomedical Collection (1993-1999), and Dissertation Abstracts. Reference lists of identified studies were searched manually until no further studies were identified. Experts in the field were contacted, including first authors of randomized controlled trials addressing prevention of MTSS. The Cochrane Collaboration (early stage of Cochrane Database of Systematic Reviews) was contacted.

STUDY SELECTION

Inclusion criteria included randomized controlled trials or clinical trials comparing different MTSS prevention methods with control groups. Excluded were studies that did not provide primary research data or that addressed treatment and rehabilitation rather than prevention of incident MTSS.

DATA EXTRACTION

A total of 199 citations were identified. Of these, 4 studies compared prevention methods for MTSS. Three reviewers independently scored the 4 studies. Reviewers were blinded to the authors' names and affiliations but not the results. Each study was evaluated independently for methodologic quality using a 100-point checklist. Final scores were averages of the 3 reviewers' scores.

MAIN RESULTS

Prevention methods studied were shock-absorbent insoles, foam heel pads, Achilles tendon stretching, footwear, and graduated running programs. No statistically significant results were noted for any of the prevention methods. Median quality scores ranged from 29 to 47, revealing flaws in design, control for bias, and statistical methods.

CONCLUSIONS

No current evidence supports any single prevention method for MTSS. The most promising outcomes support the use of shock-absorbing insoles. Well-designed and controlled trials are critically needed to decrease the incidence of this common injury.

Foot medial longitudinal-arch deformation during quiet standing and gait in subjects with medial tibial stress syndrome

The objective of this study was to investigate (1) if subjects with medial tibial stress syndrome demonstrate increased navicular drop and medial longitudinal-arch deformation during quiet standing and gait compared with healthy subjects, and (2) the relationship between medial longitudinal-arch deformation during quiet standing and gait. Thirty subjects aged 20 to 32 years were included (15 with medial tibial stress syndrome and 15 controls). Navicular drop and medial longitudinal-arch deformation were measured during quiet standing with neutral and loaded foot using a ruler and digital photography. Medial longitudinal-arch deformation was measured during walking gait using 3-dimensional gait analysis. Subjects with medial tibial stress syndrome demonstrated a significantly larger navicular drop (mean +/- 1 SD, 7.7 +/- 3.1 mm) and medial longitudinal-arch deformation (5.9 +/- 3.2 degrees) during quiet standing compared with controls (5.0 +/- 2.2 mm and 3.5 +/- 2.6 degrees, P < .05). Subjects with medial tibial stress syndrome also demonstrated significantly larger medial longitudinal-arch deformation (8.8 +/- 1.8 degrees) during gait compared with controls (7.1 +/- 1.7 degrees, P = .015). There was no correlation between medial longitudinal-arch deformation during quiet standing and gait in either of the 2 groups (r < 0.127, P > .653). The subjects with medial tibial stress syndrome in this study demonstrated increased navicular drop and medial longitudinal-arch deformation during quiet standing and increased medial longitudinal-arch deformation during gait compared to healthy subjects. Medial longitudinal-arch deformation during quiet standing did not correlate with medial longitudinal-arch deformation during gait in either of the 2 groups. ACFAS Level of Clinical Evidence: 5.

Exercise-related leg pain in collegiate cross-country athletes: extrinsic and intrinsic risk factors

STUDY DESIGN

Prospective cohort design.

OBJECTIVES

To determine in a sample of collegiate cross-country athletes (1) the percentage of athletes with history of exercise-related leg pain (ERLP) associated with running, (2) the incidence of ERLP during 1 season, (3) if factors including years of collegiate running, training distance, and gender are associated with ERLP, and (4) if there is a relationship between foot type and ERLP.

BACKGROUND

ERLP is a common overuse pain syndrome, but little evidence exists regarding the prevalence, incidence, and risk factors.

METHODS AND MEASURES

Eighty-eight collegiate cross-country athletes (44 male, 44 female) from 5 Midwest universities consented to participate, Prior to the season, athletes completed a questionnaire and 3 measures of foot type were performed: navicular drop, medial longitudinal arch angle, and visual assessment of foot type. Athletes completed a postseason questionnaire regarding the season incidence of ERLP Statistical analyses of differences (t test, proportion test) and relationships (chi-square, relative risk) were conducted.

RESULTS

Prior to the season, 60 of the 88 athletes (68%) reported a history of ERLP with bilateral medial leg pain the most common ERLP presentation. Over 50% of the athletes with a history of ERLP reported that the pain had interfered with cross-country participation. Of the 67 postseason respondents, 38.8% reported ERLP incidence during the season. Most athletes (80.8%) who reported season incidence of ERLP had a previous history of ERLP There were no differences between athletes with and without a history of ERLP or season incidence of ERLP regarding years of collegiate running, training distance, gender, and foot measures.

CONCLUSION

ERLP history and season incidence was common among these cross-country athletes. The only risk factor identified for season incidence of ERLP was a history of ERLP.