May 2013

Medial shin pain in runners: Evidence for orthosis use

iStock14695365MD4Studies of the kinematic variables associated with medial tibial stress syndrome suggest possible targets for prevention and intervention, including the use of foot orthoses.

By Janice K. Loudon, PT, PhD, SCS, ATC, and Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Various overuse musculoskeletal injuries, including shin pain, can hamper participation in a running exercise program.1-3 A number of terms have been introduced in the literature to describe medial shin pain, and medial tibial stress syndrome (MTSS) is one of the most descriptive terms.4 MTSS describes a specific overuse injury that produces pain along the posteromedial aspect of the distal two-thirds of the tibia.5 It excludes other types of exercise-related leg pain, such as tendinopathy, stress fracture, and exertional compartment syndrome.6-9

Researchers have reported a range of the incidence of MTSS in high school cross-country runners from 10.7% to 16.8%.1,10,11 Clement et al11 found incidence was higher in female runners (16.8%) than in male runners (10.7%). The sports in which athletes are most commonly afflicted are cross country, track, basketball, and volleyball.3 In the military, the incidence has been reported to be as high as 35%, and, again, higher in women than in men.5,12

iStock12387823Cntrsprd3The pathogenesis of MTSS is controversial, with some authors describing the condition as a periostitis (inflammation of the periosteum) due to strain of the medial tibial fascia, while others describe it as a tearing of the muscle-bone interface.2,4,13 Bouche and Johnson found that in fresh cadaver limbs contraction of the superficial and deep posterior compartment muscles creates a traction force in the distal tibia fascia.13  Muscles identified as possible culprits include the posterior tibialis,14,15 soleus,16,17 and flexor digitorum longus.16

Tweed et al18 proposed that MTSS “is not an inflammatory process of the periosteum but instead a stress reaction of the bone that has become painful.” Further evidence that MTSS involves changes in the bone was revealed by Magnusson et al,19 who found that male soccer players with MTSS had lower bone density than those without the condition. It is possible that MTSS and tibial stress fractures are on a single continuum, but this has yet to be established.16,20

Clinical history and symptoms form the primary diagnostic basis for MTSS. Normal radiographs and compartment pressures decrease the likelihood of MTSS.2,4 Pain and tenderness are usually diffuse and located along the medial distal two-thirds of the tibia. Commonly, athletes will complain of pain at the beginning of a run that may subside midway but recur at the end of the run. Provocative tests to rule in MTSS include pain with passive ankle dorsiflexion, resisted plantar flexion, toe raises, or single-leg hops.18 Recently, Newman et al found that positive pain with shin palpation and the shin edema test were predictive of MTSS development.21

iStock13694010bThe etiology of MTSS has been discussed in the literature.1,7,22 Potential contributing factors are diverse, and some are contradictory. They can be divided into three subsets of etiology, including structure/pathomechanics, training error, and body mass. The most widely studied subset is structure/pathomechanics. Examples of all factors include pes cavus,23 pes planus,22,24,25 pronation velocity,26 time to maximum pronation,26 prolonged rearfoot pronation,26 limited ankle motion,7,27 sex,1 bone mineral density,28 menstrual dysfunction,28 previous injury,29,30 and increased impact forces while running.31 Of all these factors, the only ones consistently linked to MTSS are a history of previous injury and high body mass index (BMI).

The literature is scarce regarding preferred evidence-based interventions for MTSS. Basic treat­ment consists of rest from the offending activity, cross training, and cryotherapy.17 Other recommendations include ankle muscle strengthening and stretching.4,32 Eickhoff et al surveyed cross-country runners who were prescribed foot orthoses and found the devices improved symptoms of MTSS.33 Plisky et al10 reported that runners with MTSS injury were three times as likely to report orthosis use, but the researchers did not mention the effectiveness of the devices.

The lead author of this paper has investigated factors related to the foot and ankle and the pelvis and hip in individuals with MTSS. In 2010, Loudon and Dolphino34 published an article investigating the effectiveness of a combination of gastroc-soleus stretching and foot orthoses in diminishing pain in individuals with MTSS. Twenty-three people (11 women) participated in the study, ranging in age from 22 to 44 years (mean = 28.8, SD = 6.3). Participants were runners or walkers who ran or walked at least 10 miles per week and experienced MTSS.

We assessed navicular drop, dorsiflexion range of motion, BMI, duration of symptoms, and pain score on the first visit. All participants were then given a stretching program for the gastroc-soleus and a pair of flexible off-the-shelf orthoses made with an upper layer of Aliplast and a supportive layer of Plastazote with a neutral base.

iStock_000014695365mediumAfter three weeks of the intervention, pain level and the Global Rating of Change (GROC) were obtained for each participant.35 All subjects reported they were compliant with the intervention. We then dichotomized the participants into a successful group (determined as a 50% improvement in pain level) and an unsuccessful group. Fifteen had a successful outcome (65.2%), while eight individuals did not meet the threshold for success (34.8%).

Table 2 displays the variables of this study. Both postintervention pain level and GROC score were statistically different between groups. The 65.2% success rate in our study was less than the 88% rate that Eickhoff et al33 found in collegiate cross-country runners prescribed off-the-shelf orthoses for MTSS.

The two initial impairment measures, ankle dorsiflexion and navicular drop test, were not different between the two groups. However, these were not measured at the completion of the study, which would have been ideal. The mean duration of symptoms for the participants in our study was 262.1 ± 225.6 weeks. For the successful group, the duration was 181.6 ± 180.1 weeks, which was significantly less than the unsuccessful group (412.8 ± 225.9 weeks). These outcomes would support early intervention, which can make a difference in the success of using orthoses and stretching. Age was not significantly different between groups.

BMI has been identified as a contributing factor to MTSS. Plisky et al10 found that, after adjusting for gender and orthotic use, runners with a higher BMI had an increased risk of MTSS compared with their lower-weight counterparts. The study by Loudon and Dol- ­phino34 is in agreement with these findings, with the average BMI for both groups equalling 25.2, which meets the World Health Organization defintion for overweight.36 The successful group did have a slightly lower BMI (24.6) than the unsuccessful group (26.2), but this difference was not significantly different.

coverTable1In a second study, published in 2012, Loudon and Reiman37 investigated differences in pelvic, hip, and knee kinematics during running between two groups: uninjured athletes and those with a history of MTSS. Secondary analyses investigated differences in limbs between groups and differences between female and male athletes.

Fourteen runners with a history of MTSS and 14 controls matched for sex, age, and training mileage took part in the study. We examined 3D kinematics of the pelvis, hip, and knee while the athletes ran on a treadmill at a self-selected speed. Runners with a history of MTSS demonstrated significantly greater frontal plane pelvic tilt (P = .002, effect size = .55) and peak hip internal rotation (P = .004, effect size = .51) and less knee flexion (P = .02, effect size = .46) than the control group (Table 3).


Clinical implications

During running, the lower leg segments should work in sequence. At initial contact the subtalar joint pronates until about midstance, at which time it begins to supinate to ready the limb for push-off. In conjunction with subtalar joint pronation, the tibia and femur rotate internally.38 In addition to pronation, the talocrural joint needs to dorsiflex, which facilitates knee flexion. This mechanism is needed for force absorption from the ground. Interestingly, maximal calcaneal eversion motion (a component of pronation) and maximal knee flexion motion peak at the same time during the midstance phase of running.39

The foot strikes the ground approximately 600 times per kilometer for every running mile. There is evidence that these ground reaction forces are particularly high along the medial and posterior aspects of the tibia.40 This posteromedial force may be exacerbated by limited ankle (talocrural joint) motion and/or limited knee flexion. As presented in the lead author’s studies, a lack of mobility at the ankle, knee, or both is associated with MTSS.34,37 The addition of a full-contact flexible orthosis may help with force distribution and pain symptoms in MTSS. Improving dorsiflexion motion would also help with load distribution.

Kinematically, it has been demonstrated that lack of knee flexion motion during landing from a jump is associated with increased frontal and transverse plane motion.41 In runners, Souza and Powers reported that, compared with control group, women with patello­femoral pain syndrome exhibited significantly greater peak hip internal rotation during running and other functional tasks.42 We saw this same phenomenon again in our running athletes with a history of MTSS. Runners with less peak knee flexion motion had an increase in peak hip internal rotation and frontal plane pelvic drop to the swing side. Increased levels of hip internal rotation have been found previously in runners with tibial stress fractures.43

coverTable3Although the runners in the current study did not have tibial stress fracture, MTSS may be a precursor for such fractures, so one might expect to see the same mechanism of injury. Knee flexion is one of the main mechanisms for shock absorption and, when it is lacking, compensations will be seen proximally and distally.

Clinicians can gain valuable insight by considering the entire lower extremity in a runner with MTSS. Whether the proximal or distal segment is the primary offender has yet to be determined. It is interesting to note that the pathomechanical pattern seen in MTSS is similar to one that is seen in anterior cruciate ligament injury and patellofemoral pain syndrome.44,45 Treatment for these two conditions has also focused on the foot and the hip.46,47


Despite its high prevalence, little is known regarding the kinematic factors associated with MTSS. It is likely a combination of variables that distinguish individuals with MTSS. There is a need to understand the risk factors associated with MTSS so that effective prevention strategies can be developed and implemented. Our research has found both distal and proximal malalignments that may contribute to MTSS. Based on our research we would recommend ankle stretching (gastroc-soleus complex), hip strengthening (gluteus medius, gluteus maximus), improvement in running technique to increase knee flexion at foot contact, and use of a full-contact insert during the pain period of MTSS.

Janice K. Loudon, PT, PhD, SCS, ATC, is an associate professor and Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS, is an assistant professor in the Division of Physical Therapy at Duke University Medical Center in Durham, NC.


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One Response to Medial shin pain in runners: Evidence for orthosis use

  1. Harvey Johnson C.O. says:

    I might agree with “Tweed et al18 proposed that MTSS “is not an inflammatory process of the periosteum but instead a stress reaction of the bone that has become painful” but I have had many early MTSS athletes with MRIs revealing early periosteal involvement.
    BMI may have a secondary role as it increase ground reaction forces but it sure is not a primary role. I see far too many distance runners with low BMI and MTSS to believe BMI is a primary factor. Repetitive ground reaction forces in the distance runner is a multiplier that makes up for low BMI. I find that football players in the first month to 6 weeks of training show up in droves with MTSS. Virtually all the athletes I have treated (considerable over the last 25 year period servicing major university athletic program as well as a private practice with a large athletic population) with posterior tibial stress reactions and stress fractures all report a common history of classical MTSS that begins with a painful area about 2″ in length. As it progress to a stress reaction/fracture that painful area narrows considerably to just directly at the point where the reaction/fracture is involved. This area is at most 3/8″ long, often is swollen and is extremely pain to palpation.
    I cannot imagine using any foot orthoses with plastazote and a neutral base on MTSS athletes. Plastazote has a life expectancy of about 2 weeks in any athlete. My experience is that the common denominator in all MTSS, stress reactions/fractures is that they all are pronators. Using a neutral base orthotic on a pronator does not correct for any pronation. Combined with a Plastazote “supportive layer” and I can see why the authors improvement rate was only 50%. I would suggest custom orthotics with better materials management: 275# football players destroy plastazote in a matter of days and a 140# distance runner will compress it in a few weeks. One has to adjust materials for the level of activity, size of the athlete and shoe limitations. I stress biomechanical correct first and add shock absorption if the shoe allows it. Obviously soccer shoes would not accommodate an extra layer of polyurethane like a training shoe.

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