Proximal Control and the Risk for Medial Tibial Stress Syndrome

Just days after I lament that a recent case control study did not include factors that there is increased interest in when it comes to medial tibial stress syndrome and also noting that prospective studies provide a more powerful conclusion than a case control study, we have a prospective study which included the factors that there is an increased interest in …. go figure!

This was just published in the British Journal of Sports Medicine:

The role of proximal dynamic joint stability in the development of exertional medial tibial pain: a prospective study
Ruth Verrelst, Dirk De Clercq, Jos Vanrenterghem, Tine Willems, Tanneke Palmans, Erik Witvrouw
Br J Sports Med doi:10.1136/bjsports-2012-092126
Objective To prospectively determine risk factors contributing to the development of exertional medial tibial pain (EMTP).
Methods Data were prospectively collected on healthy female students in physical education, who were freshmen in 2010–2011 and 2011–2012. Eighty-six female students aged 19.38±0.85 years, were tested at the beginning of their first academic year. Kinematic parameters in the frontal and transverse plane were measured during a single-leg drop jump (SLDJ). For further analysis, the SLDJ task was divided in two phases: touchdown until maximal knee flexion (MKF) and then MKF until take-off, representing landing and push-off phase, respectively. The injury follow-up of the students was assessed using a weekly online questionnaire and a 3-monthly retrospective control questionnaire. EMTP was diagnosed by an experienced medical doctor. Cox regression analysis was used to identify the potential risk factors for the development of EMTP.
Results During injury follow-up (1–2 years), 22 participants were diagnosed with EMTP. The results of this study identified that increased range of motion (ROM) in the transverse plane of hip and thorax during landing (p=0.010 and 0.026, respectively) and during push off (p=0.019 and 0.045, respectively) are predictive parameters for the development of EMTP in women.
Conclusions Increased ROM values of hip and thorax in the transverse plane, which can be interpreted as impaired ability to maintain dynamic joint stability resulting in increased accessory movements, are significant contributors to the development of EMTP in women.

Basically what these researchers did was get a group of female runners (first year physical education students) and got them to jump off a box to land on one leg and then used a 3D system to measure what I call collectively as ‘proximal control’. They then followed them over time to see who did and did not develop medial tibial stress syndrome (which is what I still call it) or exertional medial tibial pain (which is what they call it). They then looked at what factors were different in the groups that did and did not get the injury. Prospective designs like this carry more weight than other study designs.

What did they find:

  • those that developed the injury had greater transverse plane rotation of the hip and thorax. They interpreted this to mean “impaired ability to maintain dynamic joint stability resulting in increased accessory movements“. This is what I prefer to call impaired proximal control.

Can we extrapolate this to males? I not so sure as I do recall another study that showed being female was also a risk factor for this injury, so there are different issues at play in males and females when it comes to medial tibial stress syndrome. Apart from this reluctance to extrapolate the results to a male population nothing jumps out at me as any other shortcoming in the methodology, analysis and interpretation.

What does it mean?
I guess that will be based on just how much evidence is needed to change clinical practice (I discussed that in the context of anterior compartment syndrome here). This was just a risk factor study. It was not a clinical trial involving the treatment of those proximal structures. That is obviously needed. If memory serves me correctly, this is the 5th study in the last 12 or so months that has identified a proximal issue in medial tibial stress syndrome, so it obviously needs to be taken seriously.

As always, I go where the evidence takes me until convinced otherwise.

Ruth Verrelst, Dirk De Clercq, Jos Vanrenterghem, Tine Willems, Tanneke Palmans, Erik Witvrouw (2013). The role of proximal dynamic joint stability in the development of exertional medial tibial pain: a prospective study Br J Sports Med DOI: 10.1136/bjsports-2012-092126

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3 Responses to Proximal Control and the Risk for Medial Tibial Stress Syndrome

  1. Marc-Antoine Doré October 9, 2013 at 3:12 pm #

    Very good article (and review). I think that we need to look more at the proximal control for various lower extremity injuries. Is there a lot of studies that show the same thing but for patello-femoral syndrome or IT band syndrome? My opinion is that the knee (or tibia) is only a victim when running, if the two extremities (foot and hip) are dysfunctional, stiff, hyper or hypo mobile or whatever the knee will eventually suffer from a compensation thus an injury. So yes shoes (minimalist or traditional) will have an impact, but if the other part is dysfunctional it won’t enough to treat the injury? What do you think?

    Also lot of research is talking about how to reduce impacts (with shoes or without, foot strike…) but do you think impacts are really the cause of the MTSS (I also like to call it that way!). Aren’t they cause by a muscle tension on the periosteum? The tension could come from a compensation, bad running or walking gait etc.

    As an athletic therapist that’s my way of looking at it. Yes I put ice and work on the structures around the pain site, but more importantly I try to understand why there’s pain there and most of the time it comes from the feet or the hips/pelvis. I can spend 45 minutes working on the hips for someone with a MTSS and only a few minutes on the tibia/calf and they get better (anecdotal, yes I should do a study about that!).

    Thanks a lot for your work!

  2. Craig Payne October 13, 2013 at 7:25 am #

    I have had a few emails and facebook comments re this article, so just want to respond to a common misconception here.

    Don’t forget that we also have other equally powerful prospective studies that have linked distal factors (eg arch height) to the development fo MTSS.

    So if anyone is wanting to firmly hang their hat on proximal or distal are barking up the wrong tree.

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