Cause:

The exact pathology is still unknown. The pain may be contributed to inflammation of periosteum or an avulsion of the periosteum of the medial distal tibia. The soleus, tibialis posterior and flexor digitorum longus muscles originate from the tibia. The forces transmitted through these muscles with chronic overuse results in periosteal reactive micro-tearing of Sharpey’s fibers (thread like processes of the periosteum woven together with the muscle and bone junction. MTSS may progress into a stress fracture if not treated properly. Contributing factors are varus hindfoot, excessive forefoot pronation, genu valgum, and external tibial torsion.

Clinical Symptoms:

Patients experience point tenderness approximately 5 centimeters above the tip of the tibial malleolus and may experience a radiating pain along the medial posterior aspect of the tibia when activity is induced. In severe cases there is no need of activity to induce the pain.

Physical Examination:

Point tenderness along the posterior-medial edge of the distal third of the tibia. The tenderness is not well localized. Minimal swelling can be present. The pain can be induced with resistance to active plantar and dorsiflexion of the foot. Pain may also be reproduced with US and/or tuning fork testing. Neurovascular examination of the extremity should be normal. It is necessary to rule out anterior compartment syndrome or stress fracture. X-ray is usually normal. A positive bone scan appears as early within 5 days demonstrated by a linear streak over the medial aspect of the tibia.

Treatment:

MTSS must be recognized early, so that the injury can be properly controlled before it reaches an advanced state (stress fracture). Reduction in activity is the first step in treatment. Athletes must return to a symptomatic level of training and can gradually increase their program as long as they remain pain free. Ice massage, NSAIDS and/or biolase treatments may be beneficial. Athletic activities should be avoided for 4-6 weeks, after which time a progressive training schedule can be resumed, increasing no more than 10% per week. Low-impact activities, such as “aquatic running”, swimming or cycling should be utilized. In resistant cases, casting and/or e-stim may be helpful.