A systematic review of the conservative treatment options and their effectiveness in the treatment of medical tibial stress syndrome (MTSS)

Background: Medial tibial stress syndrome (MTSS) is a frequent lower extremity injury and a common cause of exertional leg pain in athletes and is commonly treated with conservative treatment regimes. However, there is a lack ofconservative treatment options in clinical practice that is not adequately reflected in the literature. An analysis would be able to determine the level of evidence in support of different treatment options for MTSS. Objectives: The aim of this dissertation was to review published literature regarding conservative treatment options for MTSS and provide recommendations to sports medicine clinicians for improved treatment and patient outcomes. Data sources: A systematic review of PubMed, CINAHL, and Scopus was conducted, using the following search terms: shin splint, medial tibial stress syndrome, tibial stress injury, exercise induced leg pain, soleus syndrome, chronic periostalgia, conservative treatment, strapping, stretching, mobilisation, KT tape, electro-modalities, ultrasound, orthoses, chiropractic, shockwave treatment, physical therapy and rehabilitation. Study selection: All electronic or paper English articles, which possessed the required key indexing terms and represented randomised controlled study, non-randomised controlled study and observational study designs were included. Data extraction: Blinded review of the articles was conducted by eight independent reviewers utilising the PEDro (for randomised controlled trials), NOS for (non-randomised controlled trials) and Liddle (for observational studies). This allowed the methodological rigour of the article to be ranked. This ranking was compared to a critical appraisal of the article in order to achieve an overall decision with regards to the contribution of the article to the level of evidence for MTSS. Data synthesis: 30 review outcomes were aggregated around different clinical categories. It was concluded that the use of TENS, needling, electro-dry needling and strengthening programmes with additional interventions are moderately supported for use in the treatment of MTSS TII in clinical practice. There was evidence in support of rehabilitation programmes and conflicting evidence/no support for graded training programmes. The non-standard treatment options provided limited to moderate evidence against the use of the published interventions (orthotic and stretching, ultrasound and periosteal pecking, rest/immobilization cast,rest/phenylbutazone, rest/stretching of heel cord, rest/aspirin) in these studies, indicating that these practices should be excluded from clinical practice protocols until further research has been completed. The evidence was limited forindividual therapies (cryotherapy, iontophoresis, phonophoresis, ultrasound, extracorporeal shockwave therapy and the fascial distortion model), whereas there was no to limited evidence in support of the MYK system of intervention. Conclusion: The systematic review of MTSS TII revealed that the use of TENS, needling, electro-dry needling and strengthening programmes with additional interventions were found to have a moderate level of evidence, which may indicate theirappropriateness in the management of patients suffering from MTSS TII. Combination therapies or the use of individual therapies require future research in order to better define their contribution to the treatment of MTSS TII. Randomised controlled trials are the gold standard for research, as they have the greatest level of methodological quality, and should be used where possible when investigating the efficiency of interventions in the management of MTSS TII.