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MCSM Athletic Training Services Team
MCSM — Texas Medical Center/San Jacinto
Jeff Collins, LAT
Jace Duke, ATC, LAT
Emery Hill, ATC, LAT
Michelle Leget, ATC, LAT
Lashelle Brown Okonkwo, ATC, LAT
Scott Tidwell, LAT
MCSM — Sugar Land
Angela Byrd, LAT
Jerry Meins, ATC, LAT
Brandon Roberts, ATC, LAT
Bill Wissen, ATC, LAT
MCSM — West Houston
Richard Gregoire, ATC, LAT
Layne Schramm, ATC, LAT
MCSM — Willowbrook
Dwight Adsit, ATC, LAT
Paula Douglas, ATC, LAT
Keith Jahn, ATC, LAT
Mike Pace, ATC, LAT
Medial Tibial Stress Syndrome
Medial tibial stress syndrome (MTSS), often mistakenly referred to as shin splints, involves pain along the medial tibial crest that can extend proximally from the pes anserinus distally to the medial malleolus of the tibia. On the other hand, shin splints generally refer to pain along the anterior tibia. With MTSS, the pain and effusion is most commonly palpable at the origin of the flexor hallucis longus and posterior tibialis along the posteromedial tibia. The classic site of tenderness is at the junction of the distal one-half and proximal two-thirds of the medial tibia.
Diagnoses for Medial Tibial Shin Pain
There is a wide range of diagnoses for medial tibial shin pain. The most common are MTSS, chronic exertional compartment syndrome (CECS), stress fracture, nerve entrapment and popliteal artery entrapment syndrome. Inflamation within lower leg compartments is commonly the source of pain.
Notice in Figure 1, the close relationship of anatomical factors within the cross-section of the lower leg and the structures compromised by inflammation.
A Review of the Literature
Mild irritation of the medial shin is common in up to 50 percent of weight bearing athletes. Distance runners are most susceptible to MTSS. In the article Chronic Lower Leg Pain in Athletes, Rachel Brewer, M.D., and Andrew Gregory, M.D., reviewed and published symptoms, diagnostic testing, physical examination and a differential diagnosis for the pathologies listed above. To read this article, click here.
In 2009, Debbie Craig, PhD, LAT, ATC, examined 199 studies to identify a prevention strategy for MTSS. No single strategy was better than others in preventing MTSS; however, there is some evidence that shock absorbing insoles may be a wise choice in preventing medial shin pain. Read the study here.Causal Factors for MTSS
Several factors are associated with MTSS in the literature. The following biomechanical forces are identified as causal factors for medial shin pain:
- Volume and duration
- Running experience
Several published studies mention ground reaction forces. However, there is no conclusive evidence that forces generated at foot strike are the cause of medial tibial pain. The ability of a runner's anatomy to absorb and transfer ground forces through pronation of the foot at the mid foot seem to prevent MTSS.
Interestingly, evidence exists that runners with pronation of the midfoot, but minimal pronation of the rear foot may have less medial shin pain as compared with pronators of the rear foot. Control of the rear foot with an orthotic device may help with MTSS by limiting the rear foot pronation, thereby reducing the tissue elongation of the medial ankle, foot and toes.Preventing MTSS
To prevent MTSS, a multi-factorial approach is necessary.
- Proper biomechanically correct running techniques are essential.
- Alignment of all body segments to absorb landing forces at the foot/ground interface is necessary.
- Control of the mid foot drop and rear foot stability seems to help avoid medial shin pain.
- Control of body composition and strength to weight ratio may contribute to reduction of ground forces.
- Control of inflammation in the lower leg through the application of cold and the careful use of anti-inflammatory medication may serve a purpose in the multi-factorial approach to controlling MTSS.
Learning how to properly jump and land can help female athletes avoid serious knee injuries
Female athletes tear their anterior cruciate ligament (ACL) six to eight times more than male athletes who play the same sport. A leading sports medicine surgeon believes incorporating a jumping and landing program into a regular training regimen can help keep women on the field and out of the operating room.
"Studies have shown up to a 50 percent decrease in ACL tears in female soccer players who took part in a jumping and landing program," said Dr. Patrick McCulloch, an orthopedic surgeon with the Houston Methodist Orthopedics & Sports Medicine in Houston. "Most of these injuries occur in sports with a lot of cutting and pivoting such as basketball and soccer."
McCulloch says many women land with their knees straight and their kneecaps pointing inward and this puts an incredible amount of stress on the ACL, while men tend to land with their feet further apart with more bend in the knees. He believes a jumping/landing program involving plyometric exercises can help women train their muscles to develop a "muscle memory" that will alert their hamstrings to fire off at the right time and help them land with a bend in their knees.
The program lasts six weeks. The first two are spent on form and control. During this phase, the athlete begins to build confidence in performing more sport-specific exercises. Weeks three and four mark the start of jumping off of a single leg. The athletes continue to focus on jump control, but they are also learning how to transition more quickly and effectively between jumps. Weeks five and six are considered the performance stage in which quickness and explosiveness are emphasized.
"The jump program not only strengthens the knee, but it also help teach female athletes the motor control required to cut, jump and land properly," said Kelly Osburn, a Houston Methodist physical therapist who helps female athletes recover from ACL injuries. "Most of my patients leave physical therapy stronger than they were before their injury."
"Women's college basketball coaches usually recruit more women each year because they know one or two will most likely tear their ACL," McCulloch said. "I believe if schools and clubs would incorporate a jumping/landing program into their in-season and off-season training programs they will lessen the chances that their athletes will be put on the disabled list with an ACL tear."