Lower Leg Muscle Stiffness on Two-Dimensional Shear Wave Elastography in Subjects With Medial Tibial Stress Syndrome.

OBJECTIVES: We aimed to explore, which muscle stiffness changes may be related to medial tibial stress syndrome (MTSS) and the correlation between the medial tibial periosteal thickness and lower leg muscle stiffness. METHODS: This study included 63 subjects distributed into 3 groups: the symptomless group, the MTSS group, and the control group. The lower leg muscle stiffness of the tibialis anterior (TA), extensor digitorum longus (EDL), peroneus longus (PL), soleus (SOL), lateral gastrocnemius (LG), medial gastrocnemius (MG), tibialis posterior (TP), and flexor digitorum longus (FDL) in the 3 groups was obtained by two-dimensional shear wave elastography. Differences in the muscle stiffness and medial tibial periosteal thickness in the 3 groups were determined by one-way analysis of variance (ANOVA) and least significant difference tests. The relationships between the periosteal thickness and the muscle stiffness were assessed using Pearson correlations. RESULTS: The shear wave velocity (SWV) of all lower leg muscles except the EDL was higher in the symptomless and MTSS groups than in the control group (TA, P = .001; PL, P = .006; SOL, P < .001; LG, P < .001; MG, P < .001; TP, P < .001; FDL, P = .013; and ANOVA). A significant difference was found in the SWV of the SOL, TP, and FDL between the control and symptomless groups (P = .041, P < .001, and P = .013, respectively). Moreover, the medial tibial periosteum was thickened after running training, and its thickness was positively correlated with muscle stiffness. CONCLUSION: The medial tibia periosteal thickness is positively correlated with the lower leg muscles stiffness. Changes in SOL, TP, and FDL stiffness may be related to the occurrence of MTSS.

Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in athletes.

PURPOSE: Medial tibial stress syndrome (MTSS) represents a common diagnosis in individuals exposed to repetitive high-stress loads affecting the lower limb, e.g., high-performance athletes. However, the diagnostic approach and therapeutic regimens are not well established. METHODS: Nine patients, diagnosed as MTSS, were analyzed by a comprehensive skeletal analysis including laboratory bone turnover parameters, dual-energy X-Ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT). RESULTS: In 4/9 patients, bilateral pseudofractures were detected in the mid-shaft tibia. These patients had significantly lower levels of 25-hydroxycholecalciferol compared to patients with MTSS but similar levels of bone turnover parameters. Interestingly, the skeletal assessment revealed significantly higher bone mineral density (BMD) Z-scores at the hip (1.3 ± 0.6 vs. - 0.7 ± 0.5, p = 0.013) in patients with pseudofractures and a trend towards higher bone microarchitecture parameters measured by HR-pQCT at the distal tibia. Vitamin D supplementation restored the calcium-homeostasis in all patients. Combined with weight-bearing as tolerated, pseudofractures healed in all patients and return to competition was achieved. CONCLUSION: In conclusion, deficient vitamin D levels may lead to pseudofractures due to localized deterioration of mineralization, representing a pivotal component of MTSS in athletes with increased repetitive mechanical loading of the lower limbs. Moreover, the manifestation of pseudofractures is not a consequence of an altered BMD nor microarchitecture but appears in patients with exercise-induced BMD increase in combination with reduced 25-OH-D levels. The screening of MTSS patients for pseudofractures is crucial for the initiation of an appropriate treatment such as vitamin D supplementation to prevent a prolonged course of healing or recurrence. LEVEL OF EVIDENCE: III.

Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen.

Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented.

Are ultrasonographic findings like periosteal and tendinous edema associated with medial tibial stress syndrome? A case-control study.

OBJECTIVES: Medial tibial stress syndrome (MTSS) is one of the most common sporting injuries. As of yet, the development of effective therapeutic interventions to treat MTSS is hindered by the fact that its pathology is unknown. Our aim was to explore the pathology of MTSS, by assessing whether the presence of MTSS is related to periosteal, bony or tendinous abnormalities in the lower leg. DESIGN: Case-control study. METHODS: Participants with MTSS and athletic control participants were recruited from the same (high-risk) base population. Musculoskeletal ultrasonography was performed on the posteromedial tibial border and deep plantar flexor muscles by an experienced radiological specialist who was blinded to group membership. Associations between MTSS and tissue abnormalities were expressed in odds ratios (OR). RESULTS: A total of 42 participants, 15 MTSS cases and 27 control athletes completed the study. Overall, periosteal and tendinous abnormalities were common in cases with and without MTSS. Periosteal edema was present in 8 (53.3%) MTSS cases and in 10 (37.0%) control athletes, in specific painful spots in the distal 2/3 of the posteromedial tibial border OR=1.9 (95% CI 0.54-6.99, p=0.35). Also, tendinous abnormalities in the tibialis posterior muscle were frequently seen in MTSS cases (N=7, 46.7%) and in control athletes (N=13, 48.1%) (OR=0.97, 95% CI 0.27-3.51, p=0.96). No bone abnormalities were observed in either group. CONCLUSIONS: Periosteal and tendinous findings seem to be common in both athletes with and without MTSS, and consequently are not associated with MTSS.

Shear Modulus of the Lower Leg Muscles in Patients with Medial Tibial Stress Syndrome.

This study aimed to investigate the in vivo kinematics of shear modulus of the lower leg muscles in patients with medial tibial stress syndrome (MTSS). The study population included 46 limbs with MTSS and 40 healthy limbs. The shear modulus of the medial head of the gastrocnemius, lateral head of the gastrocnemius, soleus, peroneus longus and tibialis anterior muscles were measured using shear wave ultrasound elastography. As a result, the shear modulus of the lower leg muscles was significantly greater in patients with MTSS than in healthy patients (p < 0.01). Based on the differences in shear modulus of lower leg muscles between the patients with MTSS and healthy patients, the measurements obtained via shear wave ultrasound elastography could be used to evaluate risk factors of MTSS.

17-year-old runner with shin pain.

Stress injury is a common cause of exercise-induced anterior shin pain. It is important to distinguish between the various causes of stress injury in a timely manner in order to optimize favorable treatment outcomes. Here, we will discuss a case of medial tibial stress syndrome, or shin splints, as one of the causes of shin pain, as well as how to approach shin pain for a successful diagnosis.

Os trigonum syndrome on bone SPECT/CT.

A 16-year-old female athlete presented with increased pain in the distal left lower extremity. A possible stress fracture or shin splint of the left tibia was first considered. A 3-phase bone scintigraphy showed a very small focus of increased activity in the posterior left foot. A diagnosis of os trigonum syndrome was made after SPECT/CT images pinpointed the activity at the left os trigonum.

"Shin splint" syndrome and tibial stress fracture in the same patient diagnosed by means of (99m)Tc-HMDP SPECT/CT.

We show a patient who presented leg pain triggered by intense exercise. The most likely diagnosis was a possible tibial stress fracture or a "shin splint" syndrome (soleus enthesopathy). We performed a bone scintigraphy including SPECT/CT that revealed the presence of the two concomitant pathologies. SPECT/CT identified the hot spot superimposed with bone lesion in the tibial stress fracture and only remodeling activity without evidence of cortical lesions in the enthesopathy processes.