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196: MEDIAL TIBIAL STRESS SYNDROME

Eric Shamus, PhD, DPT, PT, CSCS; Jennifer Shamus, PhD, DPT, COMT, CSCS

CONDITION/DISORDER SYNONYMS

  • Medial tibial stress syndrome

  • Posterior medial tibial periostitis

  • Posterior medial tibial stress fracture

ICD-9-CM CODE1

  • 733.93 Stress fracture of the tibia

ICD-10-CM CODE2

  • M84.369A Stress fracture, unspecified tibia and fibula, initial encounter for fracture

PREFERRED PRACTICE PATTERN3

  • 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion (ROM) Associated with Localized Inflammation

PATIENT PRESENTATION

A 25-year-old female presents with right medial shin pain. She indicates that 3 weeks earlier she began an exercise program that involves jogging 3 miles per day. The patient just bought new sneakers. The pain starts about mile 2 and has to stop running. The X-ray was positive for a stress fracture. The left lower extremity (LE) measures 2 cm longer. Palpable swelling along the medial tibia.

KEY FEATURES

Description

  • Bone pain is localized in the medial aspects of the tibia

  • Stress-reaction inflammation of the periosteal and musculotendinous fascial junctions

  • Attributed to a loss in bone mineral density

  • Recurring dull ache along the posterior medial aspect of the lower tibia

Essentials of Diagnosis

  • Diagnosis is usually made by bone scan and x-ray

  • Muscle length and strength imbalances, especially a tight gastrocnemius-soleus muscle group

General Considerations

  • Looks like tibilais posterior tendinitis, but does not respond to treatment

  • Tendinopathy

  • Periostitis

  • Periosteal remodeling

  • Nutritional imbalance

  • No relief with conservative treatment

FIGURE 196-1

Intramedullary screw (white arrow) fixation of bilateral anterior medial tibial stress fractures. (From South-Paul JE, Matheny SC, Lewis EL. Current Diagnosis & Treatment in Family Medicine. 3rd ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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Demographics

  • College athletes

CLINICAL FINDINGS

SIGNS AND SYMPTOMS

  • Pain: Mild to severe with weight-bearing activities and gait

  • Described as a dull ache to LEs

  • Point tenderness to tibia at posterior medial aspect

  • Possible localized swelling

Functional Implications

  • Pain with standing or during activity

  • Inability of injured LE to bear weight

  • Pain with closed chain ankle movements (i.e., driving)

Possible Contributing Causes

  • Running/standing on a hard surface

  • Leg-length inequality

  • Compensation from an injury on the opposite limb

  • History of high/repetitive impact activities

  • Overtraining

Differential Diagnosis

  • Fracture of the tibia or fibula

  • Contusion

  • Gastrocnemius/soleus muscle strain

  • Cellulitis

  • Referred pain from sciatic nerve, spinal stenosis, or Baker’s cyst

  • Deep vein thrombosis (DVT): Homan’s test

  • Superficial thrombophlebitis

  • Peripheral arterial disease

  • Venous insufficiency

  • Myofascial pain

  • Fibromyalgia

    ...

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