Medial Tibial Stress Syndrome : Diagnosis, Treatment and Outcome Assessment

Abstract

Medial tibial stress syndrome (MTSS), also known as shin splints, is one of the most common sports injuries. Although 20% of the jumping and running athletes have MTSS at some point while engaging in sporting activities, we know little about it. There is a lack of knowledge regarding making the diagnosis, how to treat it effectively and how to best measure outcomes that are relevant to the patient. The diagnosis MTSS is commonly made using history and physical examination. This seems the logical diagnostic approach because MTSS is a pain syndrome without an established tissue pathology. Whether this approach is reliable between different clinicians is unknown. A number of interventions have been studied in randomised controlled trials over the past 40 years. These include shockwave therapy, lower leg braces, dry needling, lower leg stockings, strengthening exercises, a graded running rehabilitation program and ice massage. Which intervention is most effective, however, has remained unclear. Measuring outcomes that matter to the patient are highly important. These so-called patient-reported outcome measures (PROMs) are considered the cornerstone for outcome assessment and measuring treatment success in medicine. There was no PROM for athletes with MTSS prior to this thesis’ commencement, which prevented the standardised measurement of outcomes in athletes with MTSS. A number of studies, described in this thesis, sought to fill these important gaps in the field. This thesis reports that making the diagnosis MTSS based on history and physical examination has almost perfect reliability among clinicians: k = 0.89 (95% CI 0.74 to 1.00), p<0.000001. This supports making the diagnosis of MTSS clinically, without using additional and expensive imaging. A systematic review showed that the research previously performed on the treatment of MTSS is at such a high risk of bias, it’s impossible to recommend any particular choice for use in clinical practice. At this point in time, the most logical treatment is load management, increasing loading capacity through gradual load exposure and strengthening the calf muscles. Lastly, this thesis describes the development and validation of a new PROM: the MTSS score. Items for this outcome measure were developed together with researchers, clinicians and patients. The items and scale were tested for their validity, reliability and responsiveness in a large population of 133 athletes with MTSS recruited from 15 sports medicine, military medicine and physiotherapy practices in The Netherlands. This study showed that the MTSS score is a valid, reliable and responsive 4-item scale that can be used to assess outcomes relevant to the athlete with MTSS.