How is medial tibial stress syndrome managed?

Management of Medial Tibial Stress Syndrome

The management of medial tibial stress syndrome requires a progressive rehabilitation approach that includes relative rest, graduated return to activity, biomechanical correction, and strength training to prevent recurrence and optimize outcomes. 1, 2

Initial Recovery Phase

• Ensure complete resolution of bony tenderness on palpation before advancing to more demanding exercises 2
• Achieve pain-free walking for 10-14 consecutive days before introducing any running or dance-related loads 2
• Progress to 30-45 minutes of continuous pain-free walking before advancing to the next phase 2
• Assess lower extremity functional movements and strength before introducing higher-impact activities 2
• Consider the location of injury when planning management - anterior tibial cortex injuries (high-risk) require more conservative management than posteromedial (low-risk) injuries 1, 2

Strength Training Components

• Incorporate strengthening exercises targeting local muscles including calf and tibialis anterior 2
• Add proximal strength training for hip and core muscles to improve biomechanics and reduce injury risk 1
• Address muscle flexibility, particularly in the calf and hamstring 2
• Aim for 75-80% lower extremity strength symmetry before introducing higher-impact activities 2
• Progress to plyometric strengthening once the patient can sprint or squat 1.5 times their body weight 2

Graduated Return-to-Activity Protocol

Walk-Run Progression

• Begin with a walk-run program with short running increments (30-60 seconds) interspersed with 60-second walking periods 1, 2
• Perform exercises on alternate days to allow bone cells to regain mechanosensitivity (98% returns after 24 hours of rest) 1
• Start at 30-50% of usual running pace 2
• Monitor for pain during and after exercise - if pain occurs, rest until symptoms resolve, then resume at a lower level 2

Surface and Load Considerations

• Initially use a treadmill or more compliant surface for running exercises 1
• Progress distance before increasing speed, building to 50% of pre-injury distance level before introducing speed work 2
• Increase running distance gradually, with the "10% rule" as a general guideline, though this should be individualized based on injury severity 2
• Female patients may benefit from a slower progression due to higher tibial bone stresses across running speeds compared to males 1
• Avoid hills initially, as running uphill at 10-15% inclines may result in greater tibial stress than level running 1

Biomechanical Correction

• Perform running gait analysis to identify biomechanical abnormalities that may contribute to tibial stress 1
• Consider gait retraining interventions such as reducing stride length or increasing cadence to reduce tibial stresses 1
• Address excessive hip adduction and rearfoot eversion angles, particularly in female runners 1
• Evaluate for excessive pronation of the foot while standing, as this is an identified risk factor for MTSS 3
• Consider the use of neoprene or semi-rigid orthotics for prevention of MTSS in susceptible individuals 3

Nutritional and Metabolic Considerations

• Screen female athletes for Relative Energy Deficiency in Sport (REDs) using validated tools such as the Low Energy Availability in Females Questionnaire (LEAF-Q) 1
• Use the Female Athlete Triad Coalition cumulative risk assessment tool to identify athletes at risk of developing bone stress injuries 1
• Address nutritional factors and energy availability issues, especially in female patients 2
• Consider bone mineral density testing, as MTSS patients have demonstrated lower BMD at the injury site compared to controls 4

Monitoring and Progression

• Use pain as the primary guide for progression - any pain indicates overloading of the bone stress injury site 2
• High-risk tibial stress injuries (anterior cortex) require radiological evidence of healing before return to full activity 1, 2
• Consider MRI for diagnosis and monitoring, as it can identify periosteal edema early and provide prognostic information 1, 4
• The severity/grade of injury should guide progression rate - higher grade injuries require slower progression 2

Common Pitfalls and Cautions

• Avoid progressing too quickly - recurrence rates for tibial stress injuries are high 2, 5
• Don't introduce speed work or higher impact activities before building adequate distance/endurance 2
• Avoid hard surfaces and uneven terrain during early recovery 2, 5
• Avoid continuous high-impact training without rest intervals, as bone cells become desensitized to prolonged mechanical stimulation 1, 2
• Be aware that despite successful pain reduction with treatment, full return to previous activity levels may not always be achieved 6