Symptoms Runners with medial tibial stress syndrome experience exercise induced pain along the posteromedial border of the tibia, most commonly in the distal one-third. Pain is often described as dull and unpleasant. Pain increases with activity and decreases with rest. Pain is at a higher intensity at the start of a workout and lessens as the workout continues (Deshmukh & Phansopkar, 2022). Examination Tenderness along the posteromedial aspect of the tibia is the most sensitive sign of medial tibial stress syndrome. Tenderness with percussion of the tibia may be present along with discomfort with hopping. Edema may be noted at the injury site (Deshmukh & Phansopkar, 2022). Compared with matched asymptomatic runners, runners with medial tibial stress syndrome have weaker flexor hallucis longus, tibialis anterior, soleus, and peroneal strength as well as decreased plantar flexor strength (Mattock et al., 2021). Manual muscle testing can be used to assess strength and to determine which structures are painful with resistance to function. Specific resistance to posterior tibialis function (resistance to ankle inversion with the foot in plantarflexion) typically elicits pain. As mentioned previously, overpronation is a risk factor for onset of medial tibial stress syndrome. The posterior tibialis is a deep muscle in the posterior compartment. It originates on the posterior surface of the tibia and fibula and the interosseous membrane and inserts on the medial cuneiform, navicular, and other foot bones. It functions to support the longitudinal arch and is subject to increased tensile load with overpronation (Menendez et al., 2020). Video analysis can be used to assess the timing and degree of pronation. Biomechanical assessment for rearfoot/ forefoot varus and/or any other conditions that might be contributing to this injury should be completed. Completion Compartment syndrome Chronic exertional compartment syndrome (CECS) is more common in ultra-marathoners than in other runners (Kakouris et al., 2021). CECS is characterized by an activity-related, reversible increase in pressure within the compartments of the lower leg. This pressure leads to compression of blood vessels, nerves, and muscle tissue within the compartment (Salzer et al., 2020). The cause of CECS is multifactorial with muscle hypertrophy, decreased venous return, microtrauma, myopathies, and noncompliant fascia identified as potentially playing a role as well as training errors, lower extremity malalignment, and impaired muscle control (Buerba et al., 2019). The anterior compartment of the lower leg is most commonly affected, and it typically occurs bilaterally Running mechanics variances that have been associated with CECS include overstriding, limited dorsiflexion angle, more upright posture, and greater step length (Salzer et al., 2020). Symptoms The primary symptom with CECS is diffuse leg pain. Some patients also experience neurological symptoms such as paresthesia, hypoesthesia, or paraparesis (Salzer et al., (Bosnina et al., 2023). Running mechanics
of the navicular drop test can help to quantify the amount of pronation. Treatment Acute phase Rest, ice, and anti-inflammatory medications are often used to manage pain in the acute phase of pain with medial tibial stress syndrome. Ultrasound and electrical stimulation can be used, but there is no evidence to support their effectiveness (Deshmukh & Phansopkar, 2022). A study by Deshmukh and Phansopkar (2023) found that both cupping and Graston techniques (a form of instrument-assisted soft tissue mobilization) are effective in alleviating pain and improving range of motion and function in individuals with medial tibial stress syndrome, with cupping proving to yield faster and more pronounced effects. Subacute phase This phase begins when the pain subsides. Pain-free strengthening to muscles that decelerate pronation (i.e., initiate supination) can be initiated. This includes the posterior tibialis and anterior tibialis as well as the extensor hallucis longus, flexor hallucis longus, and flexor digitorum longus. Stretching should address tight lower extremity muscles, especially heel cord tightness. Core, hip, and gluteal muscle strengthening is recommended to improve running mechanics. Balance and proprioceptive exercises for neuromuscular education may be helpful (via single leg standing and/or a balance board) (Deshmukh & Phansopkar, 2022). Running shoes that provide increased stability or medial support can help control pronation. Orthotics to address overpronation may be helpful. Recommending running shoes and orthotics are areas that are not addressed in this course. As pain continues to subside, guidance for return to running should be offered with attention to titration of frequency, duration, and speed. 2020). Symptoms become worse with exercise, but with rest they rapidly improve (Buerba et al., 2019). Physical examination The clinical examination is often unremarkable. For runners with prolonged CECS, point tenderness and atrophy may be noted in the affected compartment. Dynamic intracompartmental pressure measurements at rest and with activity has been considered the gold standard for accurate diagnosis (van der Kraats, 2023). Without needle measurements of compartment pressure, clinical diagnosis is one of exclusion (D’Amore et al., 2022). Treatment Open or endoscopic fasciotomy is considered the treatment of choice for CECS, with success rates between 65 and 100% (D’Amore et al., 2022). Clinicians working with runners should be aware of the signs and symptoms of this diagnosis for purposes of differential diagnosis. Initial rehabilitation post fasciotomy focuses on decreasing swelling and pain and restoration of knee and ankle range of motion. Further rehabilitation should focus on proprioception, strengthening, mobilization to joints and soft tissue as indicated, and guidance for return to running (Schubert, 2011).
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