World Journal of Orthopedics

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Franklyn M et al . Aetiology and injury mechanisms in MTSS tenderness, with “tightness” in the muscle compartment of the leg indicating the patient may have compartment syndrome. A weakness in one or more muscle compartments or in a myotome may indicate lumbar spinal nerve compression or other isolated motor nerve pathologies including rare entrapment syndromes. A full strength/power assessment of all the muscles of the leg should be performed as well as a full vascular and neural exam. Range of motion in the ankle joint, especially ankle joint dorsiflexion or extension, should be checked to exclude a tight/short gastroc-soleustendon complex; if short, it would increase anteromedial tibial loading on running. Similarly, excess forefoot pronation may indicate tibialis anterior/posterior weakness and thus greater tibial torque on running. Bone pain and tenderness, especially in a nonathletic patient, should be regarded with special care, as bone tumours or infection must be initially excluded. For these patients, plain radiographs of the whole tibia are mandatory. Where other pathologies have been excluded and the patient has clinical indications of a tibial bone stress injury, an MRI exam should be performed of the whole tibia, where the findings and classification of the injury have presented earlier in this review. Treatment of the patient with a confirmed MTSS (or a TSF) will vary according to the cause. While non or reduced weight bearing should be generally prescribed, issues such as leg alignment and forefoot pronation need to be addressed in order to facilitate healing and prevent future re-occurrence. CONCLUSION MTSS is an overuse fatigue injury involving tibial periostitis in conjunction with cortical bone oedema and microtrauma, although the cortical bone response may not occur in all individuals. The two main mechanisms of injury appear to be a traction-induced periostitis, where the cause is likely to be the soleus and/or the FDL, and microtrauma comprising of oedema and microcracks in the cortical bone which result in debonding of the osteons and subcutaneous periostitis on the surface of the tibia. While there are numerous studies in the literature on risk factors, interventions and treatment for MTSS in addition to a number of review papers, studies examining the aetiology are limited, therefore the exact causal mechanisms are still not understood. It is apparent that prospective longitudinal studies are required where athletes or military recruits are monitored by CT or MRI and DEXA in order to quantify precise changes in cortical bone geometry and simultaneously monitor both BMD and cortical bone oedema during the development of MTSS. However, this type of research requires a large cohort where a definite minimum number of individuals will reliably sustain the injury, and consent to perform a large number of scans, some with ionising radiation. This may not occur in the near future as the current focus in many universities and research organisations is for shorter research studies which lead to the development of quick clinical outcomes. Surgically-bonded strain gauges on the tibia offer an alternative approach, although there are ethical considerations with conducting these types of experiments. FE analysis is another technique which should be explored for future studies, as it can be used to examine stresses in the whole tibia under different loading conditions. Contemporary accurate diagnosis of either MTSS or a TSF includes a comprehensive clinical examination to identify signs of bone stress injury and to exclude other pathologies. This should be followed by an MRI study of the whole tibia. The possible cause of the injury should be established and addressed in order to facilitate healing and prevent future long-term re-occurrence. ACKNOWLEDGMENTS The authors would like to gratefully acknowledge Mr Jeff Copeland for compiling and formatting the references and photographing the MRI images. REFERENCES 1 Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC. Medial tibial stress syndrome: a critical review. Sports Med 2009; 39: 523-546 [PMID: 19530750 DOI: 10.2165/00007256-200939070-000 02] 2 Hutchins CP. Explanation of spike soreness in runners. Am Phys Ed Rev 1913; 18: 31-35 3 Devas MB. Stress fractures of the tibia in athletes or shin soreness. J Bone Joint Surg Br 1958; 40-B: 227-239 [PMID: 13539106] 4 American Medical Association. Committee on the Medical Aspects of Sports. Subcommittee on Classification of Sports Injuries. Standard nomenclature of athletic injuries. Chicago: American Medical Association, 1966: 126. 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Page 3 and 4: Denmark Lars C Borris, Arhus Morten
Page 5 and 6: Contents Monthly Volume 6 Number 8
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Page 9 and 10: Anari JB et al . Neuromuscular scol
Page 11 and 12: Gorgey AS et al . Adiposity and SCI
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