Source: Winkelmann, Z.K., Anderson, D., Games, K.E., Eberman, L.E. (2016). Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. Journal of Athletic Training, 51(12), 1049-1052.
Research Conclusion: Based on their review of 21 studies, the authors conclude that the greatest risk factors for medial tibial stress syndrome (MTSS) in physically active individuals are an increased body mass index (BMI), increased navicular drop, greater ankle plantar flexion range of motion (ROM), and greater hip external-rotation ROM.
Clinical Pearls
- Pre-participation risk factor screening might reduce risk of MTSS by creating individualized prevention programs.
- Progressive loading of the tibia to reduce MTSS should take into account body mass. Although increased BMI was found to be a risk factor in multiple studies, there was overlap between injured and uninjured individuals, meaning there is no specific BMI related to increased risk. If you consider that MTSS is an issue with overloading the tibia, you can easily deduce that an individual with increased BMI would be putting more load on their tibia and thus would need a different load progression than someone with a smaller BMI.
- A navicular drop greater than 10mm nearly doubles the risk of MTSS.
- Greater plantar flexion may cause excessive navicular drop. The increased ROM may also alter landing mechanics, placing a greater load on the tibia. However, we don’t know if it is the increased ROM or the navicular drop caused by the increased ROM that is the true culprit.
- Greater hip external rotation ROM seems to increase tibial loading, but we don’t exactly know why. Regardless, you can always check hip rotation ranges and strengthen accordingly.
- Incidence rates among runner range from 13.6% to 20%. Incidence rates among military personnel ranged from 7.2% to 35%.
Nerdy Break Down
Level of Evidence: 1a-
I give the “-” indication because 1a research should technically be a systematic review of high-quality randomized control trials. This paper, however, reviewed a lot of other systematic reviews in addition to original research. The authors declare that they methodically checked for research quality of each study they included, but they do not provide any breakdown of the individual studies, so we have to take them at their word (something of which I am always a little skeptical). The authors also seem to inject clinical experience into their recommendations without backing it up with research citations. However, I am inclined to believe that this paper can serve to guide our clinical practice until further research provides additional insight.