Abstract
The work contained is this thesis discusses aetiology, imaging and treatment of a common leg injury: medial tibial stress syndrome (MTSS). Although a common injury, the number of scientific articles on this topic is relatively low as is explained in chapter 1. This chapter also highlights that the most probable
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cause of MTSS is bone overload and not traction induced periostitis. In chapter 2 a review of the literature on MTSS is provided until 2009. Chapters 3 and 4 discuss different common and more uncommon aetiological factors that may contribute to the development of MTSS. The case-control study in chapter 3 showed that decreased hip internal range of motion, increased ankle plantar flexion and a positive navicular drop test were associated with MTSS. A rare cause of MTSS (treatment with methotrexate) is presented in a case study in chapter 4. An MRI scan was performed in 52 athletes with MTSS in chapter 5. In 43,5% of the symptomatic legs bone marrow or periosteal oedema was found, while in the other legs the findings were normal. When bone marrow or periosteal oedema was present, the time to recovery was less compared to patients in which the MRI scan was normal. Due to the frequent absence of findings on MRI in MTSS patients, MRI scans are not recommended to establish the diagnosis. Chapter 6-9 discuss different treatment options for MTSS. Two patients with MTSS were treated with bisphosphonates in chapter 6. This new method of treatment for MTSS has not been published on before, but more evidence is needed, before this treatment can be broadly recommended. A prospective controlled treatment trial is presented in chapter 7, in which one group is treated with a graded running program and one group with a graded running program and focussed shockwave (5 treatment sessions). The time to full recovery (able to complete 18 min high intensity running without pain) was significantly shorter in the group that combined the graded running program with shockwave therapy (59.7±25.8 v 91.6±43.0 days; p=0.008). In chapter 8 a small randomized controlled trial is described conducted in a military setting. Group 1 was treated with a graded running program and exercises of the calves, while group 2 performed a graded running program / exercises and wore a pneumatic leg brace. No significant differences between the groups for time to complete a running program were found. Furthermore, wearing the pneumatic brace was not feasible, since the wearing comfort was low. In chapter 9 a randomized controlled trial is presented on athletes with MTSS, in which three treatment options were compared (running program, running program with exercises, running program with a sport compression stocking). No significant differences for time to full recovery (able to complete 18 min high intensity running without pain) were found between the groups. The mean time to full recovery was between 102.1±52.3 and 117.6±4.3 days. In chapter 10 the different ideas on aetiology, imaging and treatment are discussed in depth and recommendations for clinical practise are made.
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