Medial Tibia Stress Syndrome

Fig. 69 The area usually affected by medial tibial stress syndrome

SYMPTOMS There is gradual onset of diffuse or localised exercise-induced pain at the posterior medial aspect of the mid and distal tibia. This condition is common during pre-season training. It typically occurs as a result of sudden changes in training habits, such as increase in intensity or amount of impact.

AETIOLOGY This is a stress reaction of the tibia to excessive jumping or running exercises. The location of pain is around the origin of the flexor digitorum longus or posterior tibial muscles at the medial posterior part of the tibia. The anatomy can vary substantially between the left and right leg. Symptoms can also therefore vary correspondingly. CLINICAL FINDINGS There is tenderness on palpation over the posterior medial tibia along the the tibial border over the site of origin of the above-mentioned muscles. Pain can be provoked by repetitive jumping on the forefoot on hard ground.

INVESTIGATIONS X-ray is normal. MRI may show sub-cortical oedema along the posterior medial tibia and can usually exclude a more localised stress fracture.

TREATMENT This injury most often responds to conservative treatment including modification of training and stretching exercises over three months. There is seldom any indication of immobilisation or surgery but if symptoms persist for more than three months a fasciotomy, releasing the tibial fascia overlying the flexor muscles from the tibial border may be indicated.

REFERRALS Refer to physiotherapist for planning of three months' return programme back to full sport. Refer to orthopaedic surgeon if non-operative treatment fails.

EXERCISE PRESCRIPTION Cycling and swimming and most other low-impact activities are good alternatives to keep up general fitness. Running on soft ground is usually acceptable. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Posterior chronic compartment syndrome; Shin splints (superficial periostitis-cortical micro-fractures); Medial posterior tibia stress fracture (more localised pain and swelling, X-ray or MRI will differentiate). PROGNOSIS Excellent but symptoms can last for months.

Fig. 70 Most ruptures occur in the musculotendinous junction

Fig. 71 Active plantar flexion with straight knee against resistance demonstrates the strength of the gastrocnemius and localised pain/weakness if there is a rupture

Fig. 70 Most ruptures occur in the musculotendinous junction

SYMPTOMS There is an acute onset of sharp tearing pain in the calf during activity. This injury often occurs in middle-aged recreational athletes in sports such as tennis or squash or other sprinting and jumping sports.

AETIOLOGY This is usually a partial (Grade I-II) rupture of the medial or lateral bulk of the gastrocnemius or soleus muscles. The rupture usually occurs at the musculo-tendinous junction. A complete (Grade III-IV) rupture on this location is rare. CLINICAL FINDINGS There is tenderness on palpation over a localised area of the muscle bulk. Resistance tests of the muscle in question will cause further pain. Jumping and landing on the forefoot with a straight knee is most painful for a gastrocnemius rupture while landing with a flexed knee causes more pain if the deeper soleus muscle is ruptured. INVESTIGATIONS This diagnosis is made from patient history and clinical findings. Ultrasound or MRI can demonstrate the rupture and haematoma. These investigations are important when the initial

Fig. 71 Active plantar flexion with straight knee against resistance demonstrates the strength of the gastrocnemius and localised pain/weakness if there is a rupture

Fig. 72 Active plantar flexion with flexed knee against resistance demonstrates the strength of the soleus muscle and localised pain/weakness if there is a rupture o

Fig. 72 Active plantar flexion with flexed knee against resistance demonstrates the strength of the soleus muscle and localised pain/weakness if there is a rupture diagnosis has been missed, to rule out an intramuscular haematoma that may require surgical evacuation and to grade the rupture, which is important for rehabilitation and length of absence from sport.

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