Learn From The Allied Health Experts: What is Medial Tibial Stress Syndrome?

Medial tibial stress syndrome (MTSS), also known as ‘shin splints’, is a condition characterised by pain and tenderness along the inner edge of the tibia (also known as your shinbone). MTSS is a common injury among athletes and runners, typically seen in sports that involve repetitive stress on the lower leg bones, such as running, jumping, and dancing.

What causes MTSS?

MTSS is caused by repetitive stress on the lower leg bones, particularly the tibia (shinbone). The stress leads to inflammation and irritation of the muscles, tendons, and periosteum (the membrane that covers the bone). The main contributing factors to MTSS include:

1. Overuse and training errors: overloading the lower leg bones due to training errors such as rapid increases in intensity, duration, or frequency of activity, insufficient rest or recovery between activity, or sudden changes in surface, footwear, or running technique.
2. Changes in muscle function: Changes in the way muscles function e.g., calf or hip weakness, tightness, endurance etc can increase the load on the tibia (shinbone).
3. Biomechanical factors: There are some studies that suggest biomechanical factors such as significant leg length discrepancies, flat feet, or high arches may contribute to MTSS.¹
4. Footwear: Worn-out or improper shoes can exacerbate stress on the lower leg.
5. Training surface: Hard and uneven surfaces such as concrete or asphalt can increase the impact forces born by the shinbone and contribute to MTSS.

What are the symptoms of MTSS?

The most common symptom of MTSS is pain and tenderness along the inner edge of the shinbone, which usually develops gradually and worsens with activity. The pain can be described as a dull ache or a sharp, stabbing sensation and may be accompanied by swelling, redness, or warmth in the affected area. In severe cases, the pain may persist even at rest or with simple activities such as walking.

How is MTSS diagnosed?

The diagnosis of MTSS is usually based on a thorough history and physical assessment performed by your physiotherapist. Your physiotherapist may ask you about your symptoms, training regimen, footwear, and training surface. They may also look at your walking and running technique, assess your foot and ankle mechanics, and test your strength, flexibility, and balance.

Imaging studies such as X-rays or magnetic resonance imaging (MRI) are not usually required for diagnosing MTSS, but may be necessary to rule out other conditions such as a stress fracture.

What is the treatment for MTSS?

The treatment of MTSS is aimed at reducing pain, inflammation, and promoting healing. The initial management includes:

1. Activity modification: avoiding or reducing the activities that aggravate your symptoms for a few days to weeks to allow the tissues to heal. Cross-training or low-impact exercises such as swimming or cycling may be recommended.
2. Ice: applying ice to the affected area for 15-20 minutes, several times a day, can help reduce pain and inflammation.
3. Rehabilitation exercises: strengthening, stretching, and balance exercises for the lower leg muscles can help improve your biomechanics and reduce the risk of recurrence.
4. Manual therapy: a physiotherapist may use techniques like soft tissue mobilisation and joint mobilisations to improve flexibility and reduce pain.
5. Footwear and training modifications: using proper-fitting shoes with appropriate support, and avoiding hard and uneven surfaces can help reduce the impact forces on the lower leg bones.
6. Orthotics: orthotic devices can help correct biomechanical issues and redistribute stress more evenly.
7. Referral: In some cases, a referral to a sports doctor and dietician may be warranted, to address issues related to the bone health of the athlete, especially if it is a recurrent issue.

If you are experiencing pain along your shin bone and concerned it may be MTSS, book a time to see one of our physiotherapists for a comprehensive assessment and treatment plan.

References

1. Menéndez, C., L. Batalla, A. Prieto, et al., Medial tibial stress syndrome in novice and recreational runners: A systematic review. International Journal of Environmental Research and Public Health, 2020. 17(20): p. 7457.
2. Boer, P.-H., M.P. Schwellnus, and E. Jordaan, Chronic diseases and allergies are risk factors predictive of a history of Medial Tibial Stress Syndrome (MTSS) in distance runners: SAFER study XXIV. The Physician and Sportsmedicine, 2022: p. 1-9.
3. Milgrom, C., E. Zloczower, C. Fleischmann, et al., Medial tibial stress fracture diagnosis and treatment guidelines. Journal of science and medicine in sport, 2021. 24(6): p. 526-530.
4. Kuwabara, A., P. Dyrek, E.M. Olson, et al., Evidence-Based Management of Medial Tibial Stress Syndrome in Runners. Current Physical Medicine and Rehabilitation Reports, 2021: p. 1-9.

Author:
Adam Shaw

Tips to avoid developing peroneal tendinopathy

Over 40 and participating in high-intensity activities?

Tips to avoid developing peroneal tendinopathy.

Peroneal tendinitis (or peroneal tendinopathy) is a condition that causes pain around the outer side of the ankle and foot. There are two main tendons on the outside of your ankle – the peroneus longus and peroneus brevis. The role of these tendons is to stabilise the ankle, stabilise the arch of the foot when walking and to turn the foot outwards.

They can become painful when structural changes occur in response to increased load and overuse of the tendons, without ensuring sufficient recovery time between activities. Around the ankle and foot, tendons are often protected by layers of connective tissue known as tendon sheaths. If symptoms are left to progress, inflammation of this tendon sheath worsens, and this causes greater ankle pain, and dysfunction.

Typical symptoms of peroneal tendinitis include:

• Pain
• Swelling
• Pain on turning the foot outwards (eversion) or stretching the foot inwards (inversion)
• Pain that worsens with activity and improves with rest
• Pain when calf raising (ie rising up onto your toes)

There are a number of risk factors that can predispose someone to developing symptoms. Peroneal tendinitis is most common in running athletes, particularly endurance runners, as well as dancers and jumping athletes. Risk factors also include:

• Over the age of 40 years.
• Overweight.
• Smoking.
• Tight and/or weak calf muscles.
• Poor control of training load ie “too much too soon”- especially after a period of extended rest.
• Poor foot mechanics.
• Inappropriate footwear.
• Other factors include having had previous foot or ankle surgery or a previous history of cortisone injections to the lateral ankle. Some medical conditions also increase the likelihood of developing peroneal tendinitis, these include rheumatoid arthritis, psoriasis, hyperparathyroidism, diabetic neuropathy and ankle fractures.

If you have some of these risk factors or are involved in activities such as endurance running, dancing or jumping sports, how can you prevent developing symptoms?

1. Gradual progression of training load and physical activity. For example, we often go through periods where we don’t do as much exercise and then we feel motivated and race from the couch to running longer distances very quickly. Our muscles can cope with this relatively well, however tendons tend to take longer to adapt and this can lead to problems. A good guide is not to increase your overall training load by more than 10% per week. This can seem slow at first, but it goes a long way to prevent overload of the tendon.
2. Another helpful strategy is implementing regular rest periods between your activity. For example, initially you may only exercise every second day, to allow the tendon to heal and adapt to the activity.
3. Maintaining a healthy bodyweight will help take pressure and load off the tendon.
4. Ensure you are wearing supportive footwear or consider the use of orthotics, especially for those with high arches in their feet.
5. Quit smoking. Smoking affects our vascular system, which plays a role in helping repair our tissues. Smoking also promotes inflammatory processes in our body.

If you are suffering from peroneal tendinitis symptoms, there are some simple treatment options you can commence straight away. These include:

• Apply ice over the painful region
• Rest from aggravating activities
• Anti-inflammatory medication may be beneficial (it is important you discuss this with your doctor, to determine if these would be suitable for you).

Call us for help on peroneal tendinitis
If symptoms continue or you are unsure if you have peroneal tendinitis, book a time to see one of our podiatrists or physiotherapists, who can perform a comprehensive assessment and work with you to develop the best treatment plan for you.

Author:
Adam Shaw
Musculoskeletal Physiotherapist
Physiologic (Allsports Robina)

References

Bagley, C., & Parker, L. (2023). Diagnosis and treatment of peroneal tendon disorders. Orthopaedics and Trauma.
Folmar, E., & Gans, M. (2020). Conservative Treatment of Peroneal Tendon Injuries: Rehabilitation. The Peroneal Tendons: A Clinical Guide to Evaluation and Management, 143-171.
van Dijk, P. A., Kerkhoffs, G. M., Chiodo, C., & DiGiovanni, C. W. (2019). Chronic disorders of the peroneal tendons: current concepts review of the literature. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 27(16), 590-598.

Here’s why late-stage rehab is essential in getting you back in the game

Recovering from an ACL injury? Here’s why late-stage rehab is essential in getting you back in the game.

Anterior cruciate ligament (ACL) injuries are one of the most common knee injuries in the active population. There are both surgical and non-surgical management options following ACL injury with a rehabilitation period recommended with both management pathways. The rehabilitation process is designed to run in phases over 9-12 months and begins early after injury. Throughout rehabilitation, there is a gradual increase in activity and function as you progress from one phase to the next. Each phase has specific goals, with consistent completion of the rehabilitation program being key to a successful recovery.

Do I need to complete late-stage rehab?

Not all of those who suffer an ACL injury return to sport, with only 65% returning to their pre-injury level of activity. Persistent symptoms, repeated ACL injuries and impaired quality of life are also reported during long term follow up. Inadequate rehabilitation has been proposed as a factor in reduced activity levels in those with who have experienced an ACL injury. To ensure a return to full function and activity with the best possible outcome, it is highly beneficial to complete all stages of rehabilitation following ACL injury.

It can be easy to fall off the ‘rehab bandwagon’ for several reasons: loss of motivation, juggling competing commitments, pain free daily activities and return of adequate function. Tracking your progress is a great way to keep motivated, by setting ‘mini challenges’ for yourself throughout what can seem a lengthy rehabilitation process. Each phase has milestones or benchmarks that need to be achieved, to allow you to progress to the next level. Your physiotherapist will use a combination of clinical tests and equipment to assess a selection of criteria, including range of motion and muscle strength. This is valuable information and can determine:

• Your current capacity and status of your rehabilitation
• How your knee compares to your non-injured knee
• How you compare to standard values
• If you have met the current phase milestones and are ready to progress to the next phase of your rehabilitation

What does late-stage rehabilitation involve?

Late-stage rehabilitation is the term given to the rehabilitation phase from 6 months, until return to sport. This is the fun stage of rehabilitation in which your physiotherapist will tailor your program to you and the sport you love. Consultations with your physiotherapist will include discussions about your goals for rehabilitation, specifically what activity or sport you intend to return to. For example, this may be participating in Parkrun each week, cycling on weekends with the family, social tennis with friends, or academy level soccer. Plyometrics are explosive jumping-type exercises and are only introduced in late-stage rehabilitation once the strength foundations have been achieved earlier in the rehabilitation period. One of the main aims of late-stage rehabilitation is prevention of another ACL injury. Rehabilitation and injury prevention programs that include plyometric exercises have been shown to significantly decrease the risk of subsequent ACL injuries by up to 60%.
Late-stage rehabilitation typically involves a specific strength, plyometric and endurance-based program along with running and integration back into your sport or activity. This phase of rehab can be based around your usual sport schedule and in familiar environments. For example, if you are aiming to return to soccer, late-stage rehab could incorporate the following aspects prescribed by your physiotherapist:

• A gym or home-based program targeting lower limb strength and endurance
• Plyometric, jump and landing drills such as box jumps
• Field based conditioning, sprint, and agility drills at your usual soccer fields
• Noncontact ball drills with the team at the regular scheduled training sessions
• Specific warmups incorporating Football Australia’s Injury Prevention Perform+ Program

When can I return to play sport?

The decision and clearance to return to play pivoting and cutting sport, such as soccer or netball, is made in conjunction with your physiotherapist and orthopaedic surgeon. Return to play decisions are made 12-months following surgery at the end of late-stage rehabilitation. Part of this final process includes additional benchmarks and a structured return to play testing protocol performed by your physiotherapist. The return to play testing involves a series of physical knee focused tests, neuromuscular control and landing drills, power measurements and mental readiness questionaries. Those who complete a battery of functional tests prior to a return to sport have a reduced risk of re-injury. Upon return to sport, your physiotherapist will discuss and tailor an ongoing injury prevention program for you. There are a range of sport specific programs, such as the FIFA 11+ and Football Australia Perform+ for soccer and the KNEE program for netball, that have been shown to reduce the risk of injuries when completed two to three times a week.

Completing ACL rehabilitation?

If you are currently completing ACL rehabilitation and would like to track your progress, have lost motivation, or are unsure about whether you are ready to return to sport, book an appointment with your physiotherapist to help you get back in the game with a successful recovery.

Author:
Jessica Norton
Senior Physiotherapist
Physiologic (Allsports Robina)

References
Al Attar, W. S. A., Bakhsh, J. M., Khaledi, E. H., Ghulam, H., & Sanders, R. H. (2022). Injury prevention programs that include plyometric exercises reduce the incidence of anterior cruciate ligament injury: a systematic review of cluster randomised trials. Journal of physiotherapy, 68(4), 255–261. https://doi.org/10.1016/j.jphys.2022.09.001

Andrade, R., Pereira, R., van Cingel, R., Staal, J. B., & Espregueira-Mendes, J. (2020). How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II). British journal of sports medicine, 54(9), 512–519. https://doi.org/10.1136/bjsports-2018-100310

Arundale, A. J. H., Bizzini, M., Dix, C., Giordano, A., Kelly, R., Logerstedt, D. S., Mandelbaum, B., Scalzitti, D. A., Silvers-Granelli, H., & Snyder-Mackler, L. (2023). Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. The Journal of orthopaedic and sports physical therapy, 53(1), CPG1–CPG34. https://doi.org/10.2519/jospt.2023.0301

Brinlee, A. W., Dickenson, S. B., Hunter-Giordano, A., & Snyder-Mackler, L. (2022). ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline. Sports health, 14(5), 770–779. https://doi.org/10.1177/19417381211056873

Culvenor, A. G., Girdwood, M. A., Juhl, C. B., Patterson, B. E., Haberfield, M. J., Holm, P. M., Bricca, A., Whittaker, J. L., Roos, E. M., & Crossley, K. M. (2022). Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. British journal of sports medicine, 56(24), 1445–1453. https://doi.org/10.1136/bjsports-2022-105495

Whittaker, J. L., Culvenor, A. G., Juhl, C. B., Berg, B., Bricca, A., Filbay, S. R., Holm, P., Macri, E., Urhausen, A. P., Ardern, C. L., Bruder, A. M., Bullock, G. S., Ezzat, A. M., Girdwood, M., Haberfield, M., Hughes, M., Ingelsrud, L. H., Khan, K. M., Le, C. Y., Losciale, J. M., … Crossley, K. M. (2022). OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis. British journal of sports medicine, 56(24), 1393–1405. https://doi.org/10.1136/bjsports-2022-106299

PERSISTENT PAIN

One in five Australians now live with persistent pain. Pain can impact you physically, mentally, emotionally and socially.

Very similar to our general health, the health of the structures in our bodies is maintained through regular movement, keeping strong, exercising regularly, maintaining a healthy body weight, caring for our mental health, regularly sleeping well, remaining social, and not smoking or drinking too much alcohol. So, when these things go wrong, our nervous systems can become sensitised and pain may persist.

Our Musculoskeletal Physiotherapist, Hayley, has a special interest in managing persistent pain. She can help you to understand why you have pain, and get you back moving, active and living again. Call our friendly staff for assistance today.

I have plantar fasciitis what do I do?

Plantar fasciitis which we know refer to as Plantar Heel Pain is a common condition that can cause pain at the bottom of the foot and heel. It Is typically caused due to the irritation of the plantar fascia which is a long and thin ligament which lies directly underneath the skin at the bottom of the foot.Plantar heel pain can be debilitating due to the increased amount of discomfort when going for walks or going up and down stairs.

Fortunately physiotherapy can help alleviate the symptoms that are associated with plantar heel pain and this can be done by either therapeutic taping, footwear advice, strengthening exercises and physical activity management advice.

A common question that we get hear at the clinic is should I see a podiatrist or should I see a physiotherapist for this?

The answer is either or both.

Physiotherapists are well equipped to provide you with some basic pain management and physical activity management advice as well as provide the best exercises to assist you during your recovery.Podiatrists on the other hand are fantastic at providing footwear advice suitable to your problem and potentially arranging some orthotics depending on your requirements.

If you or anyone that you know suffers from Plantar Heel Pain please feel free to contact us here at Physiologic and we will be more than happy to help you out.

Chris Pearson
Physiotherapist.