Shoe Wedging or Gait Retraining for Medial Tibial Stress Syndrome?

Medial tibial stress syndrome is the more common condition that gets lumped under that way overused, meaningless and stupid term, ‘shin splints‘. There is somewhat of a muddled picture as to exactly what medial tibial stress syndrome really is (ie bone stress injury, periostitis, muscle insertion problem, etc or a combination of some those). There are as many experts on the web as there are theories as to what exactly it is and the best way to treat it – you only have to go onto blogs, YouTube, forums and even buy the eBooks to see all those experts, most of which who have had no clinical experience, yet feel strongly about their opinions and have found the magical cure!  More often than not they muddle up the different clinical conditions that are subsumed into the ‘shin splints‘ basket mixing up the diagnoses and treatments.

There is no doubt that medial tibial stress syndrome is an overuse injury. Many different causes have been proposed over the years as to exactly what mechanical factors are involved in the overuse ranging from muscle tension on the tibia to a bone stress. A number of structural alignments problems are often cited as being involved such a lower arch, tibial varus, tight calf muscles and different gait patterns. There has not been any consistent data that points at any one particular mechanical factor over another. The main symptom of medial tibial stress syndrome is pain along the medial border of the tibia made worse by activity. It can be especially tender to palpation.

A lot of recent discussion has been around the potential of the problem being due to bending moments in the tibia. During running, the base of gait is narrower than when walking, giving rise to the co-called, runners varus. This means the tibia during running makes an angled contact with the ground rather than a more vertical contact with the ground during walking. This would result in increased varus bending moments going through the tibia, leading to greater compression forces that modelling has predicted would be were the main symptoms of medial tibial stress syndrome occur (this is either a very big coincidence or is evidence to support the model of bending moments being important).

As a result of this concept more and more clinicians are using varus or medial wedging in the running shoes (with or without a foot orthotic) which modelling shows would reduce that bending moment in the tibia. More and more clinicians are reporting that they are finding it helpful (and yes, a lot of anecdotes does not equal data).

As I noted previously, in the book, Anatomy for Runners by Jay Dichary one comment jumped out at me in relation to medial tibial stress syndrome: “Slightly widen the stance so that the second toe lands on the edge of the white line on track or bike lane“. This would have the exact same effect as adding a wedge in the running shoe as it would reduce the bending moment in the tibia. Jay presented no evidence for his claim to do this, but I assume it is based on his, and maybe others, clinical experiences (and yes, a lot of anecdotes does not equal data).

What does the evidence say? There are no trials of this concept, so it is a matter of looking at evidence that is consistent with the model. An unpublished abstract that was presented at the 2013 APTA conference in January by Stacey Meardon and Tim Derrick in which they did a kinematic and kinetic analysis of 15 runners and looked at tibial bone stress with different base of gait widths. Amoung the findings, they found that as step width decreased, tension on the medial surface of the tibia increased. This is totally consist with the bending moments hypothesis. The work of Milgrom et al on the moment of interia could also be intrepreted in the context of this model of bending moments and tibial stress reaction.

So if this model of medial tibial stress syndrome is correct, then what should a clinician do? Medial wedging in the shoe or gait retraining to run with a wider base of gait? It is all going to come down to personal preferences as there is no evidence either way.

Personally, I tried to run with a slightly wider base of gait, it hurt my hip as the abductors were having to work so hard.

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

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3 Responses to Shoe Wedging or Gait Retraining for Medial Tibial Stress Syndrome?

  1. Christian December 31, 2013 at 1:26 am #

    What’s your take on the wider running base instruction without addressing stability issues in the saggital and transverse planes.

    I.e. Your hips may have got overly sore from synergistic overload of the TFL and ant fibers of gluteus medius as a alignment/movement impairement not addressed at the hips would mean the instruction to “widen” the base of support would simply feed into the dysfunctional movement pattern

  2. Gabe May 11, 2016 at 6:52 am #

    Hi Craig,
    Firstly I’m absolutely loving all of your content. I thoroughly enjoy the way you present the research. Quick question about the wedging, is there any evidence to suggest that the medial wedging results in a widening of the gait in runners and therefore reduced varus bending moments or does the gait width remain the same?

    Gabe

    • Craig Payne May 11, 2016 at 6:55 am #

      I pretty sure there is no evidence; would be interesting to actually know if it does affect width of the base of gait.

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