Altered Neuromuscular Control in Individuals with Exercise-Related Leg Pain

How Medial Tibial Stress Syndrome Is Affected by Alignment, Range of Motion, Strength, and Gait Biomechanics: A Systematic Review and Meta-Analysis

CONTEXT

Medial tibial stress syndrome (MTSS) is a common chronic injury of the lower-extremity in the physically active population. However, the risk factors for MTSS remain unclear.

OBJECTIVE

This study identified the risk factors for MTSS and established the continuum model of lower-extremity alignments, range of motion, muscular strength, and gait kinematics affecting each other and MTSS development.

EVIDENCE ACQUISITION

Online databases including PubMed, CINAHL, SPORTDiscus, and Web of Science were used to retrieve studies related to risk factors for MTSS. The study eligibility criteria were studies that used the MTSS definition of the Yates and White criteria, or included participants with MTSS, except for stress fracture and compartment syndrome. A total of 2099 papers were retrieved during the initial search stage. After screening, based on eligibility criteria and cross-reference, 21 papers were included in this study. Data on lower-extremity alignments, range of motion, muscular strength, and gait biomechanics were extracted as outcome variables for this meta-analysis. Publication bias was assessed using funnel plots and Egger's regression analysis.

EVIDENCE SYNTHESIS

Foot posture index (standardized mean difference [SMD] = 1.23; 95% CI, 0.02-2.43), intercondylar interval (SMD = 0.29; 95% CI, 0.10-0.48), inversion range of motion (SMD = 0.37; 95% CI, 0.10-0.63), eversion strength (SMD = 0.37; 95% CI, 0.10-0.65), and dynamic arch height change during walking (SMD = 1.05; 95% CI, 0.49-1.60) were significant risk factors for MTSS. Egger's regression analysis revealed asymmetry in several variables, which indicates publication bias. The trim-and-fill method was applied to these variables. A comparison between the SMD and adjusted SMD showed that the variables had minimal impacts on the meta-analysis.

CONCLUSIONS

Based on our results, health care professionals should assess the significant risk factors in patients before participation in physical activities and treat them to prevent and rehabilitate MTSS.

A Method-Comparison Study Highlighting the Disparity between Osseous- and Skin-Based Measures of Foot Mobility

PURPOSE

This study examined the validity of standard clinical measures of arch height mobility, midfoot width mobility (MWM), and foot mobility magnitude (FMM) relative to skin-based and osseous measures derived from radiographs.

METHODS

Skin-based clinical indices of foot mobility were calculated from standard, caliper-based measures of foot length, midfoot width, and dorsal arch height of the left limb of 20 healthy participants (8-71 yr) during non-weight-bearing and weight-bearing. Skin-based radiographic and osseous indices were derived from concurrent anteroposterior and lateral radiographs. Agreement between skin-based clinical and skin-based radiographic measures of foot mobility with those of osseous measures was investigated using the Bland and Altman approach.

RESULTS

Foot mobility indices derived from clinical measures were significantly higher (20%-50%) than skin-based radiographic measures ( P < 0.01), which were, in turn, significantly higher (200%-250%) than osseous measures ( P < 0.01). Clinical measures demonstrated significant levels of proportional bias compared with radiographic measures of foot mobility ( P < 0.01). The contribution of osseous movement to skin-based clinical measures of mobility was highly variable between individuals, ranging between 19% and 81% for arch height mobility, between 4% and 87% for MWM, and between 14% and 75% for FMM. The limits of tolerance for clinical measures of foot mobility ranged from ±3.2 mm for MWM to ±6.6 mm for measures of FMM. The limits of tolerance for skin-based clinical and skin-based radiographic measures were generally larger than osseous movement with weight-bearing.

CONCLUSIONS

Skin-based measures of foot mobility, whether clinical or radiographic methods, are not interchangeable and are poor indicators of osseous mobility. Although further research regarding the utility of osseous measures is warranted, these findings strongly caution against the use of skin-based clinical measures of foot mobility in clinical and research settings.

Are Leg Muscle, Tendon and Functional Characteristics Associated with Medial Tibial Stress Syndrome? A Systematic Review

Background

Medial tibial stress syndrome (MTSS) is a common overuse injury that lacks effective evidence-based treatment options. Reduced leg girth has been associated with MTSS development because it is hypothesised to impair the ability of the leg to modulate tibial loading generated during foot–ground contact. Measuring total leg girth, however, does not provide specific information about the structural composition or functional capacity of individual leg muscles. Consequently, uncertainty remains as to which specific muscles are compromised and contribute to MTSS development. Therefore, this paper aimed to systematically review the body of literature pertaining to how the structure and function of the leg muscles are thought to be associated with MTSS injury.

Methods

The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). Medline, PubMed, SCOPUS, SPORTDiscus with Full-texts and Web of Science were searched until March 2021 to identify articles in which lower limb muscle structural or functional variables associated with MTSS injury were investigated.

Results

Seventeen studies, which were predominately case–control in design and captured data from 332 individuals with MTSS symptoms and 694 control participants, were deemed appropriate for review. The average Downs and Black Quality Assessment score was 71.7 ± 16.4%, with these articles focussing on leg girth, tendon abnormalities, muscle strength and endurance, shear modulus and neuromuscular control. Of the risk factors assessed in the 17 studies, decreased lean leg girth and higher peak soleus muscle activity during propulsion were most strongly correlated with MTSS development. Individuals with MTSS also displayed deficits in ankle plantar flexor endurance, greater isokinetic concentric eversion strength, increased muscle shear modulus and altered neuromuscular recruitment strategies compared to asymptomatic controls.

Conclusions

Future prospective studies are required to confirm whether decreased lean leg girth and higher peak soleus muscle activity during propulsion are associated with MTSS development and to elucidate whether these structural and functional differences in the leg muscles between MTSS symptomatic and asymptomatic controls are a cause or effect of MTSS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00362-2.

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COMMON THERAPEUTIC EXERCISES THAT GENERATE HIGHEST MUSCLE ACTIVITY IN THE GLUTEUS MEDIUS AND GLUTEUS MINIMUS SEGMENTS

Background

The gluteus medius (GMed) and gluteus minimus (GMin) muscle segments demonstrate different responses to pathology and ageing, hence it is important in rehabilitation that prescribed therapeutic exercises can effectively target the individual segments with adequate exercise intensity for strengthening.

Purpose

The purpose of this systematic review was to evaluate whether common therapeutic exercises generate at least high ( > 40% maximum voluntary isometric contraction (MVIC)) electromyographic (EMG) activity in the GMed (anterior, middle and posterior) and GMin (anterior and posterior) segments.

Methods

Seven databases (MEDLINE, EMBASE, CINAHL, AusSPORT, PEDro, SPORTdiscus and Cochrane Library) were searched from inception to May 2018 for terms relating to gluteal muscle, exercise, and EMG. The search yielded 6918 records with 56 suitable for inclusion. Quality assessment, data extraction and data analysis were then undertaken with exercise data pooled into a meta-analysis where two or more studies were available for an exercise and muscle segment.

Results

For the GMed, different variations of the hip hitch/ pelvic drop exercise generated at least high activity in all segments. The dip test, and isometric standing hip abduction are other options to target the anterior GMed segment, while isometric standing hip abduction can be used for the posterior GMed segment. For the middle GMed segment, the single leg bridge; side-lying hip abduction with hip internal rotation; lateral step-up; standing hip abduction on stance or swing leg with added resistance; and resisted side-step were the best options for generating at least high activity. Standing isometric hip abduction and different variations of the hip hitch/ pelvic drop exercise generated at least high activity in all GMin segments, while side-lying hip abduction, the dip test, single leg bridge and single leg squat can also be used for targeting the posterior GMin segment.

Conclusion

The findings from this review provide the clinician with confidence in exercise prescription for targeting individual GMed and GMin segments for potential strengthening following injury or ageing.

Level of Evidence

Level 1.

What is known about the subject

Previous reviews on GMed exercises have been based on single electrode, surface EMG measures at middle GMed segment. It is not known whether these exercises effectively target the other segments of GMed or the GMin at a sufficient intensity for strengthening.

What this study adds to existing knowledge

This review provides the clinician with confidence in exercise prescription of common therapeutic exercises to effectively target individual GMed and GMin segments for potential strengthening.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

Risk Factors Associated With Musculoskeletal Injury: A Prospective Study of British Infantry Recruits

Background:

Musculoskeletal Injury (MSKI), a common problem in both military and physically active civilian populations, has been suggested to result from both extrinsic and intrinsic factors.

Objective:

To investigate prospectively whether gait biomechanics, aerobic fitness levels and smoking status as well as entry military selection test variables can be used to predict MSKI development during recruit training.

Methods:

British infantry male recruits (n = 562) were selected for the study. Plantar pressure variables, smoking habit, aerobic fitness as measured by a 1.5 mile run time and initial military selection test (combination of fitness, Trainability score) were collected prior to commencement of infantry recruit training. Injury data were collected during the 26 week training period.

Results:

Incidence rate of MSKI over a 26 week training period was 41.28% (95 % CI: 37.28 - 45.40%). The injured group had a higher medial plantar pressure (p < 0.03), shorter time to peak heel rotation (p < 0.02), current smoking status (p < 0.001) and a slower 1.5 mile run time (p < 0.03). In contrast, there were no significant differences (p > 0.23) in lateral heel pressure, age, weight, height, BMI and military selection test. A logistic regression model predicted MSKI significantly (p= 0.03) with an accuracy of 34.50% of all MSK injury and 76.70% of the non-injured group with an overall accuracy of 69.50%.

Conclusion:

The logistic regression model combining the three risk factors was capable of predicting 34.5% of all MSKI. A specific biomechanical profile, slow 1.5 mile run time and current smoking status were identified as predictors of subsequent MSKI development. The proposed model could include evaluation of other potential risk factors and if validated then further enhance the specificity, sensitivity and applicability.

Spatial variability of muscle activity during human walking: the effects of different EMG normalization approaches

Human leg muscles are often activated inhomogeneously, e.g. in standing. This may also occur in complex tasks like walking. Thus, bipolar surface electromyography (sEMG) may not accurately represent whole muscle activity. This study used 64-electrode high-density sEMG (HD-sEMG) to examine spatial variability of lateral gastrocnemius (LG) muscle activity during the stance phase of walking, maximal voluntary contractions (MVCs) and maximal M-waves, and determined the effects of different normalization approaches on spatial and inter-participant variability. Plantar flexion MVC, maximal electrically elicited M-waves and walking at self-selected speed were recorded in eight healthy males aged 24-34. sEMG signals were assessed in four ways: unnormalized, and normalized to MVC, M-wave or peak sEMG during the stance phase of walking. During walking, LG activity varied spatially, and was largest in the distal and lateral regions. Spatial variability fluctuated throughout the stance phase. Normalizing walking EMG signals to the peak value during stance reduced spatial variability within LG on average by 70%, and inter-participant variability by 67%. Normalizing to MVC reduced spatial variability by 17% but increased inter-participant variability by 230%. Normalizing to M-wave produced the greatest spatial variability (45% greater than unnormalized EMG) and increased inter-participant variability by 70%. Unnormalized bipolar LG sEMG may provide misleading results about representative muscle activity in walking due to spatial variability. For the peak value and MVC approaches, different electrode locations likely have minor effects on normalized results, whereas electrode location should be carefully considered when normalizing walking sEMG data to maximal M-waves.

A comparison of rigid tape and exercise, elastic tape and exercise and exercise alone on pain and lower limb function in individuals with exercise related leg pain: a randomised controlled trial

Background

Exercise related leg pain (ERLP) is a common lower limb overuse injury characterised by pain located between the knee and ankle that occurs during activity. The high incidence of the condition, subsequent interference with participation in physical activity and substantial recovery time, highlights a need for effective interventions. Whilst many interventions have been described for the management of ERLP, currently there is a lack of high quality evidence for an effective intervention for the condition.

Methods/Design

A single-blinded randomised controlled clinical trial will be conducted in a community setting. Forty-five female volunteers aged between 18 and 40 years with a history of insidious onset of pain located between the knee and ankle of at least one month duration that is aggravated by weight bearing activities will be recruited for the study. Suitable participants will be randomly allocated to one of three treatment groups for the 6 week intervention period: (i) exercise only, (ii) rigid anti-pronation tape and exercise, (iii) elastic anti-pronation tape and exercise. Outcomes will be measured at baseline, 1, 2 and 6 weeks using primary outcome measures of usual and worst pain visual analogue scale and global perceived improvement. Secondary outcome measures will include Foot and Ankle Ability Measure, Patient Specific Functional Scale and amount of activity in the previous week. In addition, participants will be contacted by phone to obtain primary and secondary outcome measures at 12, 18, 24 and 30 weeks.

Discussion

This article describes a single-blinded randomised controlled clinical trial that will utilise high quality methodologies in accordance with CONSORT guidelines. The results of this study will contribute to the limited knowledge regarding effective interventions for the management of ERLP.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12613000914763)

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-328) contains supplementary material, which is available to authorized users.

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.

Reliability of a new supination resistance measurement device and validation of the manual supination resistance test

BACKGROUND

Kinematic observations are inconsistent in predicting lower-extremity injury risk, and research suggests that kinetic variables may be more important in this regard. Before kinetics can be prospectively investigated, we need reliable ways of measuring them clinically. A measurement instrument was manufactured that closely mirrors a manual test used to clinically estimate supination resistance force. The reliability of the instrument and the validity of the clinical test were investigated.

METHODS

The left feet of 26 healthy individuals (17 men and 9 women; mean ± SD age, 25.9 ± 9.2 years; mean ± SD weight, 77.7 ± 13.3 kg) were assessed. Foot Posture Index (FPI-6), manual supination resistance, and machine supination resistance were measured. Intrarater and interrater reliability of all of the measurements were calculated. Correlations of the supination resistance measured by the device with FPI-6, the manual supination resistance test, and body weight were investigated.

RESULTS

Interrater reliability of all of the measurements was generally poor. The supination resistance machine correlated highly with the manual supination test for the rater experienced with its use. Supination resistance measurements correlated poorly with the FPI-6 and weakly with body weight.

CONCLUSIONS

The supination resistance machine was shown to have sufficient limits of agreement for the study, but improvements need to be made for more meaningful research going forward. In this study, the force required to supinate a foot was independent of its posture, and approximately 12% of it was explained by body weight. Further work is required with a much larger sample size to build regression models that sufficiently predict supination resistance force and that will be of clinical use. The manual supination test is a valid clinical test for clinicians experienced in its use.

A comparison of augmented low-Dye taping and ankle bracing on lower limb muscle activity during walking in adults with flat-arched foot posture

OBJECTIVE

To compare the effect of taping and bracing on lower limb muscle activity during gait.

DESIGN

Cross-sectional laboratory study.

METHODS

Twenty-seven asymptomatic adults with flat-arched foot posture were recruited to this study. They walked over-ground under three randomly allocated conditions: (i) barefoot; (ii) augmented low-Dye taping; (iii) replaceable ankle brace. Electromyographic (EMG) activity from tibialis posterior, tibialis anterior, peroneus longus and medial gastrocnemius was measured for each condition. Peak EMG amplitude and time of peak EMG amplitude were assessed from stance phase data. A series of one-way repeated measure analysis of variance followed by Bonferroni post hoc tests were undertaken (α=0.05).

RESULTS

Tibialis posterior peak EMG amplitude decreased by 22% and 33% with bracing and taping (respectively), compared to barefoot. Peak amplitude was also decreased for peroneus longus by 34% and 30% and for tibialis anterior by 19% and 13% with bracing and taping (respectively), compared to barefoot. Small significant changes in time of peak EMG amplitude were found for tibialis posterior and tibialis anterior with taping and bracing compared to barefoot. The effect of taping and bracing was only different for tibialis posterior peak EMG amplitude, with tape producing a 15% reduction compared to bracing.

CONCLUSION

The augmented low-Dye tape and replaceable ankle brace used in this study could be useful in managing overuse and dysfunction of selected leg muscles, particularly tibialis posterior, by reducing their level of activation during walking.