MEDIAL TIBIAL SYNDROME

 Medial tibial syndrome (MTS), or tibial periostitis, is a common, yet painful injury among athletes. Generally known as "shin splints", MTS is also classified as any lower-leg pain.

 CAUSES

The cause of medial tibial syndrome is not clear. One theory suggests that tissue fluid pressure increases in the lower leg as a result of excessive training. This compresses muscles, blood vessels and nerves, resulting in an inadequate flow of blood to the muscles, leading to permanent disability if not treated promptly.

Another theory suggests that microfractures are a possible cause, while a third explanation proposes that MTS develops when the connective tissues of the lower legs are pulled away from the bone. Yet another theory suggests that overuse causes an inflammation of the posterior tibia muscle or the flexor muscles of the toes.

Most likely, MTS is caused by a combination of these factors.

 OCCURRENCE

Medial tibial syndrome occurs most often in younger, hard-training athletes, and is especially common in runners and occasionally occurs in participants in bowling, racquet sports, weightlifting and powerlifting. The problem is usually related to excessive activity by the flexor-muscles of the toes, caused by jumping on a hard surface or running on the front of the foot.

Running on hard surfaces, a sudden distance increase, or wearing inappropriate shoes are also common causes of MTS.

 SYMPTOMS

Medial tibial syndrome problems begin with pain and point tenderness over the lower part of the medial tibia and usually occur alter athletic activity. The pain usually continues until the athlete starts the next workout, but then lessens or disappears completely during activity. However, it always returns after finishing the workout.

Gradually, pain and tenderness will worsen and will remain while resting, followed by stiffness. Because the pain often subsides after a period of warming up, the athlete often runs the risk of entering a "pain cycle", in which the condition worsens over time and becomes more and more difficult to treat.

 SIGNS

The signs of MTS are:

Extreme point tenderness on the lower part of the medial tibia. Assuming that the athlete hasn't been resting for a long period of time, a palpable tenderness will be found medially in a 6 to 8 inch long area in the middle and lower third of the tibia.

Some swelling may exist in the painful area.

Muscle tightness in the lower leg.

X-ray may show a growth in the periosteum (dense connective tissue that covers the bone surface) corresponding to the tender area. As a rule, however, an ordinary X-ray seldom shows pathological skeletal changes.

Bone scans may be helpful in diagnosing MTS and may be especially helpful in ruling out (or diagnosing) an impending fracture.

Four grades of pain that can be associated with MTS are:

Grade I occurring after athletic activity.

Grade II occurring before and after activity, but not affecting performance.

Grade III occurring before, during and after athletic activity and affecting performance.

Grade IV so severe that performance is impossible. TREATMENT

For conservative treatment of MTS to be successful, total rest from symptom-causing activities is required. The earlier the athlete stops activity, the faster the condition will heal. Bicycling, with the heel on the pedal, and swimming are recommended as alternative conditioning methods.

If you run, jump, bowl or lift in spite of pain, an inflammatory reaction will always exist in the area. In this case, you will be prescribed appropriate medication.

Always check to make sure you are wearing proper shoes for your specific athletic endeavors.

 REHABILITATION

In the first stage of rehabilitation, the resting stage, ice treatment should be used three to four times daily. Use ice packs (5- 15 minutes) or ice massage (7-10 minutes). The ice treatment should always be followed by stretching .

After one to five weeks or rest (however long it takes to be asymptomatic), you may return to short-distance jogging or light lifting, gradually increasing speed, distance, and/or repetitions. At this stage, ice should be applied twice daily, before and after activity. Analgesic packs may also give relief after exercise.

Strength training should also be included in the rehabilitation phase to strengthen the medial longitudinal arch. Balance and coordination training are also important. This training can begin after one to two weeks of rest and should include:

Towel gather. 10 repetitions, 1-3 sets; progress from no resistance to 10 lbs. resistance; twice daily.

Towel scoop. 10 reps, 1-3 sets; progress to 10 lbs; 3 times daily.

Marble pickup. 3-5 minutes, twice daily.

Standing on balance board. 5-10 min.; daily.

Jogging on mini-trampoline. 5-10 min; daily.

Use of pulley weights with light resistance. The strap is placed around the ankle, while flexing, extending, abducting and adducting the hip. 10 reps, 1-3 sets; daily.

Galvanic (electric) muscle stimulation. (To increase the blood circulation in the area and hasten the healing process) 10 minutes; twice daily.

Other modalities may also be helpful, including Fluidotherapy, Ultrasound, Acuscope, H-wave, Alpha-wave, Iontophoresis, and/or Interferential Treatments.

You should not begin any rehabilitation until you are completely pain-free and until tenderness over the tibia has diminished.

Surgery may be rarely required for chronic cases of medial tibial syndrome, is usually successful, but may require several more weeks of intensive rehabilitation.

 PREVENTION

Measures to prevent further MTS problems are:

As you resume practice (after a period of rest), you should initially run only short distances, then gradually increase distance later. If you have changed running surfaces in connection with the onset of pain, return to running on the former surface. Otherwise, a change to a softer surface is preferable.

A careful and proper warmup of the whole lower extremity should be performed every workout.

You must wear proper shoes (the harder the surface, the more cushion is needed).

An orthotic device can be placed in the shoe to support the medial longitudinal arch.

Correction of leg-length difference is essential if the difference is greater than 0.8 inches, and may be needed even if there is less than this.

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