International Emergency Nursing (2009) 17, 233–236

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CASE STUDY

Medial tibial stress syndrome – A case report

Matthew Crabtree BSc (Hons) DipHe RN (Charge Nurse/EmergencyNurse Practitioner) *

Emergency Department/Minor Injury Unit, North Bristol NHS Trust, Bristol BS16 1LE, United Kingdom

Received 25 November 2008; received in revised form 11 March 2009; accepted 17 March 2009

Introduction

The role of the Emergency Nurse Practitioner (ENP) is anongoing educational one for the nurse. The practitioner willat some point encounter situations and cases that they havehad little or no experience of before in their career. Thiscase report is an example of just such a presentation forthe author who examined a patient with Medial Tibial StressSyndrome (MTSS) who came to an ENP led minor injury unit(MIU) in Bristol.

MTSS is a term which is used to describe the three maincauses of MTSS. These are: stress fractures, periostitis anddeep posterior compartment syndrome (DPCS) ( Detmer,1986). It is noted that while still popular, the term ‘shinsplints’ will not be discussed due to many authors consider-ing it to be an ill defined lay term used to describe overuseinjuries in the lower leg (Beck and Osternig, 1994; Ugaldeand Batt, 2001; Story andCymet, 2006; Bouche and Johnson,2007)) and should therefore be disregarded as a finaldiagnosis.

Case presentation

A 32 year old male presented to the MIU complaining of painto his right lower leg which had started 4 weeks ago and hadgradually been getting worse especially after finishing a run.There was no history of trauma and the patient was other-wise fit and well with no known allergies. On examinationthe patient was found to have point tenderness approxi-

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mately 7 cm above his medial malleolus with slight localisedswelling. The area was not hot or inflamed and had nowounds. He had full range of movement to knee and anklewhile the only movement to cause increase tenderness tothe area was eversion of the ankle. There was no neurolog-ical or vascular deficit to his leg. A provisional diagnosis ofMTSS was made and the patient was advised to rest fromrunning for three weeks, take a course of anti-inflammatorymedicine and return at the end of the three weeks to assessany improvement. A physiotherapy review was offered ifthere was no improvement. Although this can be considereda reasonable and safe treatment plan, a lack of underlyingknowledge of this condition was highlighted and reflectedon. The following discussion examines the condition ofMTSS, its causes, diagnosis and treatments.

Discussion

Medial tibial stress syndrome (MTSS) is a commonly usedterm to define pain along the posteriomedial aspect of thedistal two thirds of the tibia (Kortebein et al., 2000; Boucheand Johnson, 2007).

Sakryd (1998) notes that MTSS encompasses a group ofterms and conditions used to describe pain along the medialtibial border. These include shinsplints, stress fractures,stress reactions, periostitis, fasciitis and deep posteriorcompartment syndrome. Edwards et al. (2005) add thatnerve entrapment, popliteal artery entrapment syndromeand bone tumours should all be part of an examiners differ-ential diagnosis.

The available literature describes many causes of MTSSand often a clinician will find more than one intrinsic or

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234 M. Crabtree

extrinsic factor in their patient’s history and examination.Couture and Karlson (2002) describe intrinsic factors asbeing unique to the patient. These include previous injuries,anatomical malalignment and poor exercise technique.Extrinsic factors include training methods, surface typeand footwear (Pell et al., 2004).

Beck (1998) emphasises that running is most commonlyassociated with tibial stress injuries. Edwards et al. (2005)acknowledge that the highest incidence of MTSS occurs inrunners but advises caution not to overlook other sportssuch as tennis and basketball as potential causes of MTSS.Couture and Karlson (2002) recommend careful attentionto the patients anatomical characteristics that may havecaused their pain such as hind foot and forefoot varus.These cause subtalar pronation which in turn increases thestress generated by the soleus.

Beck and Osternig (1994) report the soleus is a contribu-tor to stress on the medial tibial border. Their study of fiftycadaverous legs found the soleus, flexor digitorum longus(FDL) and deep crural fascia most frequently attached atthe site of pain described in MTSS. Other earlier work bySaxena et al. (1990) also implicated the tibialis posterioras causing pain in MTSS.

A study by Beck and Osternig (1994) refutes this and of-fers mistakes in the dissection of the cadavers and smallsample size (10 legs) as potential weaknesses in the study.However, Bouche and Johnson (2007) in their study of threecadaverous legs attached to a load frame and strain gaugefound that the tibialis posterior, soleus and the FDL allhad a similar exertional force on the tibial fascia which isthe only structure to insert into the medial tibial crest.These findings support Couture and Karlson (2002) whofound patients which pronate their ankle excessively haveincreased leg flexor contractions stressing the tibial fasciaand symptoms are localised to the medial tibial crest. Thisis also supported by Yates and White (2004) who studied riskfactors for developing MTSS among navel recruits. Theyfound using a foot posture index which has been shown pre-viously to have a good intratester and intertester reliabilityshowed statistically significant (p = .002) results, findingpersons with a pronated foot type as having a higher riskof developing MTSS.

Wilder and Sethi (2004) and Pell et al. (2004) acknowl-edge other risk factors such as hard surfaces and changesin inclination as effecting and causing MTSS. Bouche andJohnson (2007) also emphasise that hard surfaces can addto the contractions of leg muscles and thereby increasethe strain on the tibial fascia. Story and Cymet (2006) sup-port this by describing changes in activity, surface typeand route inclination as contributing factors to MTSS. Wornout shoes are also discussed and noted that after approxi-mately 300 miles shoes can lose their shock absorbing abilityand should therefore be changed.

The forces created by the fascial pull in any of the abovescenarios are transmitted to underlying bone via the Shar-pey’s fibres (Couture and Karlson, 2002). Ugalde and Batt(2001) describe a stress/bone time continuum where overtime increases in stress/repetition cause normal boneremodelling to accelerate. If the stress/repetition is not re-duced then bone fatigue is likely and may result in a possiblestress fracture. Wilder and Sethi (2004) describe this periodof time as the most likely to develop micro damage in the

bone if excessive strain is not reduced. If this damage accu-mulates then a stress fracture may result. However, if theSharpey’s fibres tear instead of applying a continued pres-sure, a condition called periostitis occurs (Sakryd, 1998).Detmer (1986) explains that this inflammation of the perios-tium can result in an avulsion of the periostium away fromthe bone (likely to be caused by the soleus muscle) and inchronic cases adipose tissue may be found between theperiostium and bone. Stretching the fibres located in theavulsed periostium is likely to produce medial tibial pain.Detmer (1986) suggests that in this situation periostalgiamay be a more accurate term to describe the condition thanperiostitis.

Exertional compartment syndrome (ECS) is another causeof medial tibial pain and is described by Wilder and Sethi(2004) as recurrent exercise induced leg discomfort that oc-curs at a well defined period in exercise and relief of symp-toms only occurs with the stopping of activity. They refer toincreased pressures in the two posterior compartments ofthe lower leg as being responsible for possible causes ofmedial tibial pain. This is previously supported by Ugaldeand Batt (2001), Beck and Osternig (1994) and Detmer(1986) in their anatomical placement of structures whichapply stress to the medial tibial border.

Ugalde and Batt (2001) summarise that the deep andsuperficial crural fascia from the soleus and deep posteriorcompartments are a realistic cause of pain along the medialtibia in exertional compartment syndrome.

Classification

As discussed, the literature has yielded three main condi-tions (stress fracture, periostitis/periostalgia and raisedposterior compartment pressures) as the major causes ofmedial tibial pain. Detmer (1986) has attempted to classifythe causes into three categories. MTSS type I is the stressmicro fracture and bone stress reactions. Type II is the avul-sion of the periostium with possible depositing of adiposetissue. Type III is the chronic compartment syndrome. Co-existence between types was noted. This study and classifi-cation by Detmer (1986) has been widely used and cited inother articles throughout this paper and subject matterand is therefore considered valid despite its age. However,it is not without its criticisms and Kortebein et al. (2000)make two evaluations. They first note that the classificationis only a clinical stratagem since each disorder may be dif-ferentiated by clinical evaluation and laboratory studies.Secondly the findings of adipose tissue between the avulsedperiostium and bone had not been replicated in subsequentstudies to date Kortebein et al. (2000).

Diagnostic procedures

To differentiate between the causes of medial tibial painCouture and Karlson (2002) advocate using these three diag-nostic tools. They are plain film X-rays, triple phase bonescan (TPBS) and magnetic resonance imaging (MRI). Ugaldeand Batt (2001) agree that using these three tests offerthe best diagnostic potential for identifying the cause ofthe pain.

Medial tibial stress syndrome – A case report 235

Pell et al. (2004) and Ugalde and Batt (2001) alsoacknowledge that these tests are not without their limita-tions and especially note that X-rays are invariably normal.This is reflected by Wilder and Sethi (2004) who state that inapproximately two thirds of symptomatic patients X-raysare initially negative with only half ever going on to developpositive findings. Despite their low diagnostic value Edwardset al. (2005) value X-ray’s and advocate obtaining them toexclude other abnormalities including tumours.

Wilder and Sethi (2004) acknowledge the most commonpositive finding on an X-ray is a focal region of periostealthickening suggesting a stress fracture.

Kortebein et al. (2000) note that the TPBS is very usefulin differentiating between a stress fracture (Detmers type I)and a tibial stress reaction (Detmers type II). Couture andKarlson (2002) agree and describe a classic longitudinal ori-entated diffuse tracer uptake visible only on the delayedphase for tibial stress reactions. This is in comparison to astress fracture which appears as a focal fusiform tracer up-take. The negative side to TPBS is the exposure of the pa-tient to radiation and its inability to image tendonpathology (Ugalde and Batt, 2001). Brukner (2000) adds dif-ficulty in identifying specific fracture sites, tumours, osteo-myelitis and other bony abnormalities as weaknesses to itseffectiveness. Using an MRI is the alternative choice toTPBS. Although slightly less available and more expensivethe MRI has advantages in that the patient is not exposedto radiation, has excellent anatomical visualisation andcan therefore differentiate between conditions such as tu-mours and stress fractures while pinpointing any fractureorigins (Brukner 2000).

Kortebein et al. (2000), Ugalde and Batt (2001), Coutureand Karlson (2002) and Wilder and Sethi (2004) agree thatTPBS and MRI have very similar sensitivity in identifyingstress fractures. However, Story and Cymet (2006) add thatMRI has the added advantage of showing acute changes suchas periosteal fluid and bone marrow oedema.

To effect a diagnosis of compartment syndrome Ugaldeand Batt (2001) describe using either a wick or slit catheterto measure the compartment pressure during exercise or aneedle manometer for resting pressures post exercise.These tests are not without their disadvantages and canyield different results depending on limb placement, cathe-ter placement in the muscle and patient compliance. Wilderand Sethi (2004) agree with the disadvantages and recom-mend using a battery powered, hand held digital fluid pres-sure monitor. They found their device to be more accurate,versatile, convenient and less time consuming while alsoproviding reproducible measurements among differentoperators. Both Ugalde and Batt (2001) and Wilder and Sethi(2004) agree that with examination and history consistentwith compartment syndrome, finding one or more pressureP15 mm hg pre-exercise; P30 mm hg 1 min post exerciseor P20 mm hg 5 min post exercise constitutes a diagnosis.Additionally, Wilder and Sethi (2004) note that TPBS andMRI also have roles to play in diagnosis. The TPBS may showa decreased radionuclide concentration near the area of in-creased pressure with an increase of concentration in thesoft tissues both superior and inferior to the abnormality.An MRI can show swelling within a compartment, which, ifhas not returned to baseline by 25 min post exercise is con-sidered diagnostic.

Because of the overlap of pathophysiology between thethree main causes of medial tibial pain, treatment shouldbe similar for each cause (Ugalde and Batt, 2001). Storyand Cymet (2006) recommend an appropriate period of restand using appropriate footwear designed to correct runningabnormalities such as hyperpronation if appropriate. Alsousing appropriate surfaces for the chosen type of sport oractivity, for example using a padded dirt surface for runninginstead of concrete or grass (too hard/soft, respectively).

If conservative methods fail then a surgical alternativemay be required. Detmer (1986) found encouraging resultson patients with types II, III and combined II/III. He foundthat that by performing a periosteal cauterisation and faci-otomy on type II and type II/III patients while performingonly faciotomy on type III patients the following improve-ments were recorded (non-surgical treatment for type I,surgical procedures were under local anaesthetic on an out-patients basis – follow up on average at 6 months). Im-proved performance documented as follows: type II 93%,type III 100%, type II/III 86%. Complete cures as follows:type II 78%, type III 75%, type II/III 57% (Detmer 1986).

Yates et al. (2003) enrolled patients with a positive TPBSfor MTSS (diffuse linear uptake consistent with periostitis)and a 12 month history of failed conservative treatment.

Their study was different to Detmer (1986) in that pa-tients were operated on under general anaesthetic andhad a slightly different surgical technique. However, Yateset al. (2003) found a significant decrease in symptoms fol-lowing surgical intervention (p < 0.001) with a mean reduc-tion in pain of 71.6%. Although these two studies have theirweaknesses (Detmer (1986) had a relatively small studywhile no purpose for the cauterisation was noted. Yates etal. (2003) had only a 59% response rate to follow up) resultsshow that if conservative methods fail then surgery can beoffered as a treatment with an evidence based foundationof improving symptoms.

Conclusions

It can be acknowledged that although MTSS is not a frequentpresentation for Emergency Nurse Practitioners it is stillvaluable to be able to diagnose, treat and refer potentialcases. The literature suggests the diagnosis may be relianton a thorough examination, detailed history, plain film X-rays, TPBS and MRI. It is recognised that TPBS and MRI testswill not be available for use by ENP’s, therefore the ENP rolein diagnosis of MTSS may be in recognising the differentialdiagnosis of MTSS, excluding more worrying causes andappropriately referring the patient on to others for defini-tive diagnosis and treatment. ENP’s can also safely com-mence an initial conservative treatment plan of rest andanalgesia while also evaluating the patients individualintrinsic and extrinsic factors.

As an ENP it is important to be able to advise a patient onall aspects of possible treatment and outcomes. The patientmay present at any stage of symptoms.

Pell et al. (2004) acknowledge a timely diagnosis andtreatment plan can help ensure the quickest possible returnto activity.

Therefore, an informed ENP will be able to work withthe patient to implement a plan of action to resolve their

236 M. Crabtree

condition, which may involve other multidisciplinary healthcare professionals.

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