What is the treatment for medial tibial stress syndrome?

Treatment for Medial Tibial Stress Syndrome (MTSS)

The treatment for medial tibial stress syndrome should begin with a graduated walk-run program on alternate days, combined with addressing biomechanical abnormalities and strengthening exercises, while monitoring for pain during the recovery process. 1

Initial Management

• Activity Modification:

  • Rest from aggravating activities until pain-free walking is achieved 2
  • Complete cessation of running during the acute phase 1
  • Pain is the primary indicator for progression - any pain during activity indicates overloading 1

• Pain Management:

  • Ice application to the affected area 3
  • Pain-relieving medication as needed 3

Graduated Return to Running

Walk-Run Progression

• Begin with a walk-run program on alternate days 1
• Start with 30-60 second running increments interspersed with walking 1
• Maintain alternate-day training for 2-4 weeks 1
• Progress only when pain-free during and after activity 1

Running Progression Guidelines

• Increase distance before increasing speed 1, 2
• Follow the 10% rule for weekly increases in distance or time 1, 2
• If pain occurs during running, rest until symptoms resolve and resume at a lower level 1
• Achieve approximately 50% of pre-injury running distance before introducing speed work 1

Surface Considerations

• Begin on level surfaces and avoid hills initially 1, 2
• Avoid hard surfaces during early rehabilitation 1
• Limit multiple terrains initially, then gradually vary terrain as recovery progresses 1

Addressing Biomechanical Factors

Strength Training

• Implement lower extremity strengthening exercises 1, 2:
  • Calf strengthening exercises 1
  • Hip strengthening exercises 1
  • Core strengthening 1, 2
  • Foot intrinsic muscle strengthening 1

Gait Retraining

• Consider gait modifications 1, 2:
  • Reduce stride length or increase cadence to reduce tibial stress 1, 2
  • Modify initial foot contact if necessary 1
  • Address excessive hip adduction and rearfoot eversion angles 1

Flexibility

• Include stretching exercises for:
  • Calf muscles 1
  • Hamstrings 1

Additional Interventions

Footwear and Orthotics

• Ensure appropriate running shoes with adequate support 2
• Replace shoes every 300-500 miles 2
• Consider orthotics for biomechanical issues like excessive pronation or supination 1, 2

Advanced Treatment Options

• Extracorporeal shockwave therapy (ESWT) may be beneficial in addition to a graded running program 4
  • Has shown to reduce recovery time (59.7±25.8 days with ESWT vs. 91.6±43.0 days without) 4

Common Pitfalls and Caveats

1. Premature Return: Returning to running before pain-free walking is achieved can prolong recovery 1, 2

2. Overtraining: Weekly training time exceeding 16 hours correlates with increased injury risk, especially in younger athletes 2

3. Ignoring Pain: Pain during activity indicates overloading; continuing through pain can lead to worsening of the condition 1

4. Inadequate Rest: Bone cells require 24 hours to regain 98% of mechanosensitivity; insufficient rest between sessions can impair healing 1

5. Neglecting Nutrition: Low energy availability increases risk of bone stress injuries; adequate nutrition relative to exercise demands is essential 2

6. Focusing Only on Symptoms: Failing to address underlying biomechanical issues and training errors can lead to recurrence 1, 2

By following this structured approach to MTSS treatment with careful progression based on pain response, most athletes can expect to return to full activity, though complete recovery may take 8-12 weeks depending on severity.