SLR - October 2020 - Glenn Griffin

Factors Contributing to Medial Tibial Stress Syndrome in Runners: A Prospective Study

Reference: Becker J, Nakajima M, Wu WFW. Factors Contributing to Medial Tibial Stress Syndrome in Runners: A Prospective Study. Med Sci Sports Exerc. 2018;50(10):2092-2100. doi:10.1249/MSS.0000000000001674

Scientific Literature Review

Reviewed By: Glenn Griffin, DPM
Residency Program: Saint Mary’s Medical Center – San Francisco, CA

Podiatric Relevance: Medial tibial stress syndrome is a common injury that occurs in athletes who regularly run and jump. Understanding the biomechanical characteristics that predispose athletes to this pathology will aid in the application of mechanical treatments that will enable faster recovery to full activity. The authors also suggest that with the results from this study providers may develop evaluation methods to screen runners for risk of injury.

Methods: Twenty-four NCAA Division 1 cross country runners were included in this prospective study. All participants were free of musculoskeletal injury, were part of the same team, and underwent similar training volume and intensity. Evaluations were performed as part of their preseason screening and included range of motion and strength testing, plantar pressure analysis, and 3D motion running kinematics. The participants were then followed for two years. Cases of medial tibial stress syndrome and other over-use injuries were identified by the team’s certified athletic trainer. 

Results: Seven (29 percent) athletes developed medial tibial stress syndrome. Six (25 percent) others developed other overuse running injuries, like plantar fasciitis and Achilles tendinopathy, and were included in the injured group. Runners in the injured group demonstrated tighter iliotibial bands. There was no difference  between the injured and the control groups in hamstring, hip flexor, external/internal hip rotation, or ankle dorsiflexion range of motion. The injured group had weaker hip abductors but were no different compared to the control group in strength exam of external/internal rotation, and extension. The injured group had more pressure under the medial aspect of their foot at initial foot contact and heel off. The injured group experienced greater contralateral pelvic drop, and greater rearfoot eversion and duration of rearfoot eversion during stance phase. Logistic regression indicated that the duration of rearfoot eversion was a significant predictor of overuse injury, and that every 1 percent increase in eversion duration increased the odds of developing injury by 1.38 times. 

Conclusions: In this prospective study, the authors showed that runners who became injured demonstrated greater amounts and durations of rearfoot eversion in stance phase. Logistic regression showed that only the duration of rearfoot eversion was a significant predictor of injury, when comparing the control and the injured group. This is a valuable predictive tool to identify and mechanically treat at-risk patients before they become injured. The use of orthotics to decrease the amount and duration of rearfoot eversion were not discussed in this study but I believe will be a valuable future research endeavor. The authors concluded that runners who develop overuse injury demonstrate deficits in flexibility, strength, foot function, and both proximal and distal kinematics. As podiatrists who evaluate patients, it is critical that we look proximal to the ankle and work to develop further understanding of the proximal anatomy that interrelates with and affects the function of the foot and ankle.  

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