The prevention of shin splints in sports: a systematic review of literature

Biomechanical characteristics of the lower extremities during running in male long-distance runners with a history of medial tibial stress syndrome: a case control study

BACKGROUND

Medial tibial stress syndrome (MTSS) is a running-related injury of the lower extremities. After returning to competition, there are often recurring episodes of MTSS. Therefore, it is important to prevent the onset and recurrence of MTSS among long-distance runners. This case-control study aimed to compare the kinematics and kinetics of runners with and without previous MTSS during running to clarify the biomechanical characteristics of the lower extremity of runners with previous MTSS.

METHODS

Thirteen male long-distance runners aged over 18 years and asymptomatic at the time of measurement were divided into an MTSS group and a non-MTSS group based on their history of MTSS as reported in a questionnaire. The kinetics and kinematics of running were analyzed when participants ran at a speed of 2.0 ± 0.2 m/s by a three-dimensional motion analysis system and two force plates. Data regarding the joint angles, moments, and powers of the ankle, knee, and hip during the stance phase while running were extracted and compared between the two groups using the Mann-Whitney U test.

RESULTS

Of the 13 participants, 5 and 8 were included in the MTSS (10 legs) and non-MTSS (16 legs) groups, respectively. The ankle maximum eversion moment was significantly larger in the MTSS group than in the non-MTSS group (p = 0.04). There were no significant differences in other parameters.

CONCLUSIONS

This study found that the ankle maximum eversion moment during the stance phase of running was larger in the MTSS group than in the non-MTSS group. Even after the disappearance of the symptoms of MTSS, the running biomechanics of participants with previous MTSS differed from those of participants without previous MTSS.

Efficacy of kinesiology taping on the management of shin splints: a systematic review

BACKGROUND

Shin splint is one of the most common sports injuries after strenuous exercise. Kinesiology taping (KT) is a popular noninvasive remedy used in sports-related disorders, with the potential effects of relieving pain, facilitating proprioception, modulating muscle activation and correcting abnormal movement patterns. However, the exact efficacy of KT on shin splints is still unknown, and previous findings are inconsistent. Hence, this study aimed to conduct a systematic review to evaluate the current status of relevant evidence on its efficacy.

METHODS

The review was performed according to the PRISMA guidelines, and a systematic search of the literature was conducted in December 2020. Electronic databases, Embase, Scopus, Medline, Web of Science, PubMed and Biomed Central were searched for the identification of pertinent studies with pre-defined key terms on shin splints and KT.

RESULTS

Four studies with a total sample size of 141 participants were included and analyzed. Two studies had within-subject designs, whereas the other two were randomized clinical trials. Although the positive results of KT were reported by the studies, methodological quality varied from poor to moderate according to the Physiotherapy Evidence Database Scale or Non-Randomized Studies-of Interventions.

CONCLUSION

In conclusion, this review revealed that the efficacy of KT on shin splints remains not clear. Evidence that supports its effectiveness in individuals with shin splints is currently limited. Further studies with good methodological quality and study design are warranted.

Medial Tibial Stress Syndrome: A Review Article

Leg pain caused by recurrent stressors is known as shin pain, also known as the medial tibial stress syndrome (MTSS). Athletes, particularly runners, are more vulnerable. As a result, runners devote little time to practice and avoid exercises completely. The precise cause is yet to be identified. Microdamage caused by recurrent stressors has been proposed as the fundamental mechanism in other investigations. Gender, navicular bone loss, higher body mass index, activities of high intensity, and increased range in external hip rotation in males are all risk factors. A common complaint is a bilateral pain in the distal leg, primarily on the anterior and medial sides. Pain is exacerbated by activity and eased by relaxation. Particularly, pain and swelling in the posterior and medial aspects of the tibia, as well as other causative symptoms, may be discovered during the examination. To rule out alternate origins of the same symptoms, imaging modalities such as computed tomography, radiography, bone scintigraphy, and magnetic resonance imaging might be used. Preventative measures include shock-absorbing insoles, repetitive stress avoidance, and effective treatment of repetitive stress disorder and anatomical abnormalities. Rest, ice, and pain medications are the most common treatments.

Foot Orthoses Enhance the Effectiveness of Exercise, Shockwave, and Ice Therapy in the Management of Medial Tibial Stress Syndrome

OBJECTIVE

Our aim was to assess the effects of adding arch-support foot-orthoses (ASFO) to a multimodal therapeutic intervention on the perception of pain and improvement of recovery from medial tibial stress syndrome (MTSS) in recreational runners.

DESIGN

A prospective randomized controlled trial.

SETTING

Sport training and medical centers.

PARTICIPANTS

Fifty female recreational runners with MTSS were randomized into 2 groups.

INTERVENTIONS

Runners either received ASFO or sham flat noncontoured orthoses. Both groups received a multimodal therapeutic intervention, including ice massage, ankle muscle exercises, and extracorporeal shockwave therapy.

MAIN OUTCOME MEASURES

Pain during bone pressure using a numerical Likert scale (0-10), MTSS severity using an MTSS scale, perceived treatment effect using the global rating of change scale, and quality of life using the short Form-36 questionnaire were determined at week 6, 12, and 18.

RESULTS

Pain intensity and MTSS severity were lower, and the perceived treatment effect and physical function were better in the ASFO than in the sham flat noncontoured orthoses group at week 6 and week 12. Cohen's dz effect size for between-group differences showed a medium difference. However, arch-support foot-orthoses did not add to the benefits of multimodal therapeutic intervention on pain, MTSS severity and perceived treatment effect at week 18.

CONCLUSIONS

Adding ASFO to a therapeutic intervention leads to an earlier diminishment of pain and MTSS severity, and improved PF and perceived therapeutic effects.

Effect of Compression Therapy in the Treatment of Tibial Stress Syndrome in Military Service Members

CONTEXT

Tibial stress syndrome (TSS) is an overuse injury of the lower extremities. There is a high incidence rate of TSS among military recruits. Compression therapy is used to treat a wide array of musculoskeletal injuries. The purpose of this study was to investigate the use of compression therapy as a treatment for TSS in military service members.

DESIGN

A parallel randomized study design was utilized.

METHODS

Military members diagnosed with TSS were assigned to either a relative rest group or compression garment group. Both groups started the study with 2 weeks of lower extremity rest followed by a graduated running program during the next 6 weeks. The compression garment group additionally wore a shin splints compression wrap during the waking hours of the first 2 weeks and during activity only for the next 6 weeks. Feelings of pain, TSS symptoms, and the ability to run 2 miles pain free were assessed at baseline, 4 weeks, and 8 weeks into the study.

RESULTS

Feelings of pain and TSS symptoms decreased during the 8-week study in both groups (P < .05), but these changes were not significantly different between groups (P > .05). The proportion of participants who were able to run 2 miles pain free was significantly different (P < .05) between the 2 groups at the 8-week time point with the compression garment group having a significantly increased ability to complete the run without pain.

CONCLUSIONS

Although perceptions of pain at rest were not different between groups, the functional ability of running 2 miles pain free was significantly improved in the compression garment group. These findings suggest that there is a moderate benefit to using compression therapy as an adjunct treatment for TSS, promoting a return to training for military service members.

Effectiveness of hard inserts in sports mouthguards: a systematic review

Objectives To improve the protective capacity of conventional ethylene-vinyl acetate mouthguards, some authors have suggested reinforcement with a hard material to distribute impact energy more widely. The research question for this systematic review was: 'does the inclusion of a hard insert in mouthguards improve the protection of anterior teeth from a direct blow?'Data sources Three bibliographic databases (PubMed/Medline, Ovid/Embase and the Cochrane CENTRAL databases) were searched up to 20 February 2021. Additional searches included hand searching of key articles and journals.Data selection A systematic search of the literature included studies where the intervention was the incorporation of hard material into sports mouthguards and where the comparator was conventional mouthguard material. Eligibility required the use of anatomical specimens or anatomical analogues which included or represented anterior maxillary teeth. Twelve eligible publications were identified.Data extraction Data extraction was first carried out independently by two reviewers. Discrepancies were resolved by discussion.Data synthesis Results of individual studies were conflicting and methodological diversity created difficulty in making a synthesis of results. All studies employed low-energy impacts that did not represent the potentially high-energy impacts encountered in sport.Conclusion The efficacy of hard inserts in sports mouthguards has not been demonstrated.

Recurrent Tibial Periostitis Due to Blunt Trauma

Periostitis is characterized by periosteal inflammation surrounding tubular bones. The pathophysiology is now considered to be multifactorial and a spectrum of disorders, recently being redefined as medial tibial stress syndrome (MTSS). Current treatment modalities include preventative and conservative measures, such as activity modification and footwear alterations. There is a paucity of literature for more invasive treatments, such as steroid injections. In conflict with the currently available limited literature, this study reports a case of recurrent tibial periostitis due to blunt trauma treated with steroid injections resulting in symptom resolution and no adverse events. While this case may suggest a therapeutic role for steroids in the treatment of MTSS from blunt trauma, it also highlights the need for additional studies to elucidate the safety profile and therapeutic efficacy of steroid injections.

A Comprehensive Summary of Systematic Reviews on Sports Injury Prevention Strategies

Background

A large volume of systematic reviews and meta-analyses has been published on the effectiveness of sports injury prevention programs.

Purpose

To provide a qualitative summary of published systematic reviews and meta-analyses that have examined the effectiveness of sports injury prevention programs on reducing musculoskeletal injuries.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched the PubMed, CINAHL, EMBASE, and the Cochrane databases for systematic reviews and meta-analyses that evaluated the effectiveness of sports injury prevention programs. We excluded published abstracts, narrative reviews, articles not published in English, commentaries, studies that described sports injury prevention strategies but did not assess their effectiveness, studies that did not assess musculoskeletal injuries, and studies that did not assess sports-related injuries. The most relevant results were extracted and summarized. Levels of evidence were determined per the Oxford Centre for Evidence-Based Medicine, and methodological quality was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews, revised version).

Results

A total of 507 articles were retrieved, and 129 were included. Articles pertaining to all injuries were divided into 9 topics: sports and exercise in general (n = 20), soccer (n = 13), ice hockey (n = 1), dance (n = 1), volleyball (n = 1), basketball (n = 1), tackle collision sports (n = 1), climbing (n = 1), and youth athletes (n = 4). Articles on injuries by anatomic site were divided into 11 topics: general knee (n = 8), anterior cruciate ligament (n = 34), ankle (n = 14), hamstring (n = 11), lower extremity (n = 10), foot (n = 6), groin (n = 2), shoulder (n = 1), wrist (n = 2), and elbow (n = 1). Of the 129 studies, 45.7% were ranked as evidence level 1, and 55.0% were evidence level 2. Based on the AMSTAR-2, 58.9% of the reviews reported a priori review methods, 96.1% performed a comprehensive literature search, 47.3% thoroughly described excluded articles, 79.1% assessed risk of bias for individual studies, 48.8% reported a valid method for statistical combination of data (ie, meta-analysis), 45.0% examined the effect of risk of bias on pooled study results, and 19.4% examined the risk for publication bias.

Conclusion

This comprehensive review provides sports medicine providers with a single source of the most up-to-date publications in the literature on sports injury prevention.

Conceptualisation of a region-based group of musculoskeletal pain conditions as 'tibial loading pain' and systematic review of effects of load-modifying interventions

OBJECTIVES

Conceptualisation of a clinically-relevant group of conditions as a region-based, load-related musculoskeletal pain condition ('tibial loading pain') to enable identification of evidence of treatment effect from load-modifying interventions.

DESIGN

Systematic review and evidence synthesis based on a developed and justified theoretical position.

METHODS

Musculoskeletal pain localised to the tibial (shin) region and consistent with clinical presentations of an exercise/activity-related onset mechanism, was conceptualised as a group of conditions ('tibial loading pain') that could be reasoned to respond to load modifying interventions. Five databases were searched for randomized controlled studies investigating any load-modifying intervention for pain in the anterior-anteromedial lower leg (shin). Study quality was evaluated (Risk of Bias Tool Version 2) and level of certainty for the findings assessed.

RESULTS

Six studies reporting seven comparisons were included. Interventions included braces, anti-pronation taping, compression stocking and a stretch + strengthening programme. All included studies were assessed as having unclear or high risk of bias. The review found no evidence of beneficial effect from any of the load-modifying interventions on symptoms, physical performance or biomechanical measures, apart from a possible benefit of anti-pronation 'kinesio' taping. There was very low certainty evidence that kinesio taping improves pain and pain-free hopping distance after one week. The braces were associated with minor adverse effects and problems with acceptability.

CONCLUSIONS

None of the treatments investigated by the included studies can be recommended. Conceptualisation of the problem as regional, primarily loading-related pain rather than as multiple distinct pathoanatomically-based conditions, and clearer load-modifying hypotheses for interventions are recommended.

Injury Occurrence and Return to Dance in Professional Ballet: Prospective Analysis of Specific Correlates

Professional ballet is a highly challenging art, but studies have rarely examined factors associated with injury status in ballet professionals. This study aimed to prospectively examine gender-specific correlates of injury occurrence and time-off from injury in professional ballet dancers over a one-year period. The participants were 99 professional ballet dancers (41 males and 58 females). Variables included: (i) predictors: sociodemographic data (age, educational status), ballet-related factors (i.e., experience in ballet, ballet status), cigarette smoking, alcohol drinking, and consumption of illicit drugs; and (ii) outcomes: injury occurrence and time-off from injury. Participants were questioned on predictors at the beginning of the season, while data on outcomes were collected continuously once per month over the study period. Dancers reported total of 196 injuries (1.9 injuries (95% CI: 1.6–2.3) per dancer in average), corresponding to 1.4 injuries per 1000 dance-hours (95% CI: 1.1–1.7). In females, cigarette smoking was a predictor of injury occurrence in females (OR: 4.33, 95% CI: 1.05–17.85). Alcohol drinking was a risk factor for absence from dance in females (OR: 1.29, 95% CI: 1.01–4.21) and males (OR: 1.21, 95% CI: 1.05–3.41). Less experienced dancers were more absent from dance as a result of injury than their more experienced peers (Mann-Whitney Z: 2.02, p < 0.04). Ballet dancers and their managers should be aware of the findings of this study to make informed decisions on their behavior (dancers) or to initiate specific programs aimed at the prevention of substance use and misuse in this profession (managers).

Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.

Risk Factors Associated With Musculoskeletal Injury: A Prospective Study of British Infantry Recruits

Background:

Musculoskeletal Injury (MSKI), a common problem in both military and physically active civilian populations, has been suggested to result from both extrinsic and intrinsic factors.

Objective:

To investigate prospectively whether gait biomechanics, aerobic fitness levels and smoking status as well as entry military selection test variables can be used to predict MSKI development during recruit training.

Methods:

British infantry male recruits (n = 562) were selected for the study. Plantar pressure variables, smoking habit, aerobic fitness as measured by a 1.5 mile run time and initial military selection test (combination of fitness, Trainability score) were collected prior to commencement of infantry recruit training. Injury data were collected during the 26 week training period.

Results:

Incidence rate of MSKI over a 26 week training period was 41.28% (95 % CI: 37.28 - 45.40%). The injured group had a higher medial plantar pressure (p < 0.03), shorter time to peak heel rotation (p < 0.02), current smoking status (p < 0.001) and a slower 1.5 mile run time (p < 0.03). In contrast, there were no significant differences (p > 0.23) in lateral heel pressure, age, weight, height, BMI and military selection test. A logistic regression model predicted MSKI significantly (p= 0.03) with an accuracy of 34.50% of all MSK injury and 76.70% of the non-injured group with an overall accuracy of 69.50%.

Conclusion:

The logistic regression model combining the three risk factors was capable of predicting 34.5% of all MSKI. A specific biomechanical profile, slow 1.5 mile run time and current smoking status were identified as predictors of subsequent MSKI development. The proposed model could include evaluation of other potential risk factors and if validated then further enhance the specificity, sensitivity and applicability.

Do shock absorbing insoles in recruits undertaking high levels of physical activity reduce lower limb injury? A randomized controlled trial

Objectives

To assess the benefits, if any, of the use of shock absorbing insoles in reducing lower limb injury among Air Force recruits, and to assess the differences, if any, in the efficacy of two commonly available shock absorbing insoles.

Design

Randomized controlled trial. Setting: RAF Halton, UK. Site of all basic training for RAF personnel. Participants: 1205 recruits participating in basic training between 17 September 2003 and 7 April 2004. Interventions: Participants were randomized to receive either standard issue Saran non-shock absorbing insoles, or shock absorbing Sorbothane or Poron insoles, on a 1:1:1 basis.

Main Outcome Measures

The primary outcome measure was withdrawal from training for lower limb injury. The two primary comparisons were shock absorbing insole versus non-shock absorbing insole, and Sorbothane versus Poron (comparison of different shock absorbing insoles). Secondary outcomes were medical withdrawals for reasons other than those qualifying for the primary outcome measure.

Results

When comparing the non-shock absorbing insole to the shock absorbing insoles 72/401 participants (18.0%) allocated to Saran insoles were removed from training because of a qualifying lower limb injury, compared with 149/ 804 (18.5%) allocated to the shock absorbing insole (Sorbothane or Poron), odds ratio 1.04 (95% CI 0.75 to 1.44; P=0.87). When comparing the two shock absorbing insole 73/ 421 participants (17.3%) randomized to Sorbothane were removed from training because of a qualifying lower limb injury, compared with 76/383 for Poron (19.8%), odds ratio 0.85 (95% CI 0.58 to 1.23; P=0.37).

Conclusions

Similar rates of lower limb injuries were observed for all insoles (shock absorbing and non-shock absorbing) in the trial. The trial provides no support for a change in policy to the use of shock absorbing insoles for military recruits.

Short-term effects of sports taping on navicular height, navicular drop and peak plantar pressure in healthy elite athletes: A within-subject comparison

Medial tibial stress syndrome (MTSS) is one of the most common exercise-induced leg pain. The navicular drop (ND) was identified as a risk factor for MTSS. This study aimed to evaluate the short-term effects of sports taping applied to the supporting lower leg during sitting, standing, walking, and jogging to restrict the ND in healthy elite athletes.Twenty-four healthy elite athletes without a history of exercise-induced pain or injuries in the lower limbs participated in this study (median age: 21.00 years; 1st--3rd quartiles; 19.25-22.00). The 4 taping conditions were used: rigid taping (RT), kinesiology taping (KT), placebo taping (PT), and non-taping (NT). The order of taping techniques was randomly assigned. Normalized navicular height (NH), ND, and normalized ND evaluated using 3-dimensional motion analysis, and normalized peak plantar pressure (PP) were compared in 4 taping conditions during sitting, standing, walking, and jogging.During sitting, the normalized NH of RT is higher than that of NT, KT, and PT (χ = 17.30, P = .001), while during jogging, the normalized NH of RT is higher than that of NT and PT (χ = 10.55, P = .014). The normalized peak PP of NT is higher than that of PT (χ = 8.871, P = .031) in the lateral midfoot region.This study showed the RT technique maintained NH during sitting and jogging, and the RT technique could be an effective preventive and treatment strategy for MTSS.

Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review

Reference/Citation: Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 2015;49(6):362-369.

CLINICAL QUESTION

What factors put physically active individuals at risk to develop medial tibial stress syndrome (MTSS)?

DATA SOURCES

The authors performed a literature search of CINAHL, the Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE from each database's inception to July 2013. The following key words were used together or in combination: armed forces, athlete, conditioning, disorder predictor, exercise, medial tibial stress syndrome, militaries, MTSS, military, military personnel, physically active, predictor, recruit, risk, risk characteristic, risk factor, run, shin pain, shin splints, and vulnerability factor.

STUDY SELECTION

Studies were included in this systematic review based on the following criteria: original research that (1) investigated risk factors associated with MTSS, (2) compared physically active individuals with and without MTSS, (3) was printed in English, and (4) was accessible in full text in peer-reviewed journals.

DATA EXTRACTION

Two authors independently screened titles or abstracts (or both) of studies to identify inclusion criteria and quality. If the article met the inclusion criteria, the authors extracted demographic information, study design and duration, participant selection, MTSS diagnosis, investigated risk factors, mean difference, clinical importance, effect size, odds ratio, and any other data deemed relevant. After the data extraction was complete, the authors compared findings for accuracy and completeness. When the mean and standard deviation of a particular risk factor were reported 3 or more times, that risk factor was included in the meta-analysis. In addition, the methodologic quality was assessed with an adapted checklist developed by previous researchers. The checklist contained 5 categories: study objective, study population, outcome measurements, assessment of the outcome, and analysis and data presentation. Any disagreement between the authors was discussed and resolved by consensus.

MAIN RESULTS

A total of 165 papers were initially identified, and 21 original research studies were included in this systematic review. More than 100 risk factors were identified in the 21 studies. Continuous data were reported 3 or more times for risk factors of body mass index (BMI), navicular drop, ankle plantar-flexion range of motion (ROM), ankle-dorsiflexion ROM, ankle-eversion ROM, ankle-inversion ROM, quadriceps angle, hip internal-rotation ROM, and hip external-rotation ROM. As compared with the control group, significant risk factors for developing MTSS identified in the literature were (1) greater BMI (mean difference [MD] = 0.79, 95% confidence interval [CI] = 0.38, 1.20; P < .001), (2) greater navicular drop (MD = 1.9 mm, 95% CI = 0.54, 1.84 mm; P < .001), (3) greater ankle plantar-flexion ROM (MD = 5.94°, 95% CI = 3.65°, 8.24°; P < .001), and (4) greater hip external-rotation ROM (MD = 3.95°, 95% CI = 1.78°, 6.13°; P < .001). Ankle-dorsiflexion ROM (MD = -0.01°, 95% CI = -0.96, 0.93; P = .98), ankle-eversion ROM (MD = 1.17°, 95% CI = -0.02, 2.36; P = .06), ankle-inversion ROM (MD = 0.98°, 95% CI = -3.11°, 5.07°; P = .64), quadriceps angle (MD = -0.22°, 95% CI = -0.95°, 0.50°; P = .54), and hip internal-rotation ROM (MD = 0.18°, 95% CI = -5.37°, 5.73°; P = .95), were not different between individuals with MTSS and controls.

CONCLUSIONS

The primary factors that appeared to put a physically active individual at risk for MTSS were increased BMI, increased navicular drop, greater ankle plantar-flexion ROM, and greater hip external-rotation ROM. These primary risk factors can guide health care professionals in the prevention and treatment of MTSS.

Forefoot flexibility and medial tibial stress syndrome

PURPOSE

To investigate the association between medial tibial stress syndrome (MTSS) and morphology and flexibility of the foot arches.

METHODS

131 feet from 74 healthy subjects and 31 feet from 27 patients with MTSS were classified as normal feet (n=78 in 40 subjects), flat feet (n=53 in 34 subjects), or MTSS feet (n=31 in 27 patients). The medial longitudinal arch (MLA) ratio and the transverse arch length (TAL) were measured in both rearfoot and forefoot loading positions. The difference between the 2 positions indicated the flexibility of the MLA (diff-MLA ratio) and the transverse arch (diff- TAL).

RESULTS

The MLA ratio was higher in normal feet than MTSS feet or flat feet (15.1% vs. 12.8% vs. 12.3%, p<0.001). The diff-TAL was lower in MTSS feet than normal feet or flat feet (0.4% vs. 0.8% vs. 0.9%, p<0.001]). The 3 groups were comparable in terms of the diff-MLA ratio and the TAL. Respectively for the MLA ratio and the diff-TAL, the cut-off value was 11.9% and 0.61% based on the Youden index. The sensitivity, specificity, and odds ratio of the cut-off value were 0.4, 0.9, and 4.8 for the MLA ratio, and 0.6, 0.7, and 9.8 for the diff-TAL, respectively.

CONCLUSION

Decreased flexibility of the transverse arch and decreased MLA ratio are risk factors for MTSS. In contrast, the flexibility of the MLA and the height of the transverse arch were not risk factors for MTSS.

The relationship between shin splints with anthropometric characteristics and some indicators of body composition

BACKGROUND

Medial tibial stress syndrome (MTSS), commonly known as "shin splints," is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes. The aim of this study was to study the relationship between Shin splints, anthropometric characteristics and some indicators of body composition.

METHODS

In this descriptive-comparative study, 35 students of physical education were evaluated in two groups: Shin Splints group ([N.=17], mean [±SD] height and weight, 161.52±5.32 and 56.85±9.30 respectively) and healthy group ([N.=18], mean [±SD] height and weight, 162.75±3.85 and 54.73±6.36 respectively). Anthropometric and body composition characteristic of both groups were studied under identical conditions. Independent t-test was performed in order to analyze the data.

RESULTS

No significant differences were found in anthropometric parameters (thigh length, leg length, foot length and leg circumference) body composition (the amount of minerals and body fat percentage) between the healthy group and the Shin Splints group (P>0.05).

CONCLUSIONS

According to the results of this study, anthropometric characteristics and body composition indicators may not be regarded as a risk factor for shin splints.

The injured runner

Running is often recommended by physicians to maintain a healthy lifestyle. As more individuals participate in running-related activities, clinicians must be increasingly aware of common injuries. Training errors leading to overuse are the most common underlying factors in most running-related injuries. Clinicians need to keep in mind that the presenting injury is frequently the result of an inability to compensate for a primary dysfunction at another site. Although imaging may be helpful in differentiating among diagnoses with similar clinical presentations, a detailed history and physical examination are essential in making a correct diagnosis.

Functional Popliteal Artery Entrapment Syndrome: Poorly Understood and Frequently Missed? A Review of Clinical Features, Appropriate Investigations, and Treatment Options

Functional popliteal artery entrapment syndrome (PAES) is an important and possibly underrecognized cause of exertional leg pain (ELP). As it is poorly understood, it is at risk of misdiagnosis and mismanagement. The features indicative of PAES are outlined, as it can share features with other causes of ELP. Investigating functional PAES is also fraught with potential problems and if it is performed incorrectly, it can result in false negative and false positive findings. A review of the current vascular investigations is provided, highlighting some of the limitations standard tests have in determining functional PAES. Once a clinical suspicion for PAES is satisfied, it is necessary to further distinguish the subcategories of anatomical and functional entrapment and the group of asymptomatic occluders. When definitive entrapment is confirmed, it is important to identify the level of entrapment so that precise intervention can be performed. Treatment strategies for functional PAES are discussed, including the possibility of a new, less invasive intervention of guided Botulinum toxin injection at the level of entrapment as an alternative to vascular surgery.

Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis

Background

Medial tibial stress syndrome (MTSS) affects 5%–35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners.

Methods

Medical research databases were searched for relevant literature, using the terms “MTSS AND prevention OR risk OR prediction OR incidence”.

Results

A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI), ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29–1.04, P<0.001); prior use of orthotics (risk ratio [RR] 2.31, 95% CI 1.56–3.43, P<0.001); fewer years of running experience (SMD −0.74, 95% CI −1.26 to −0.23, P=0.005); female gender (RR 1.71, 95% CI 1.15–2.54, P=0.008); previous history of MTSS (RR 3.74, 95% CI 1.17–11.91, P=0.03); increased body mass index (SMD 0.24, 95% CI 0.08–0.41, P=0.003); navicular drop (SMD 0.26, 95% CI 0.02–0.50, P=0.03); and navicular drop >10 mm (RR 1.99, 95% CI 1.00–3.96, P=0.05).

Conclusion

Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed. These data can inform both screening and countermeasures for the prevention of MTSS in runners.

Risk factors for self-reported exercise-related leg pain in high school cross-country athletes

CONTEXT

Prevention of exercise-related leg pain (ERLP) has not been successful because ERLP risk factors are not well known.

OBJECTIVE

To determine the percentage of high school cross-country (XC) athletes who reported a history of ERLP in their running careers, to identify the percentage of athletes who reported an occurrence of ERLP during 1 XC season, and to investigate the association of selected factors (age, high school year, years of high school running, sex, ERLP history, body mass index [BMI], foot type, and training distance) and the occurrence of ERLP.

DESIGN

Prospective cohort study.

SETTING

Six local high schools.

PATIENTS OR OTHER PARTICIPANTS

One hundred twenty-five high school XC athletes (62 females, 63 males).

MAIN OUTCOME MEASURE(S)

All athletes completed an initial ERLP questionnaire, and foot type was visually assessed. After the season, athletes were asked to complete a Web-based questionnaire regarding the seasonal occurrence of ERLP. Statistical analyses of differences (t tests) and associations (chi(2), relative risk) were conducted.

RESULTS

A total of 103 of the 125 athletes (82.4%) reported a history of ERLP, with 81 athletes reporting ERLP occurrence within the month preceding completion of the initial questionnaire. Bilateral medial leg pain was the most common ERLP presentation. More than half of the athletes (58.4%) with an ERLP history reported that the pain had interfered with XC participation. Ninety-three athletes responded to the postseason questionnaire, and 45 (48.0%) reported ERLP seasonal occurrence. Most athletes (97.8%) who experienced the seasonal occurrence of ERLP had a history of ERLP. No associations were noted between ERLP history or seasonal occurrence and age, high school year, years of high school running, sex, BMI, foot type, or training distance.

CONCLUSIONS

Both a history of ERLP and the seasonal occurrence of ERLP were common among these XC athletes. The only risk factor identified for ERLP season occurrence was ERLP history.

Prevention of physical training-related injuries recommendations for the military and other active populations based on expedited systematic reviews

BACKGROUND

The Military Training Task Force of the Defense Safety Oversight Council chartered a Joint Services Physical Training Injury Prevention Working Group to: (1) establish the evidence base for making recommendations to prevent injuries; (2) prioritize the recommendations for prevention programs and policies; and (3) substantiate the need for further research and evaluation on interventions and programs likely to reduce physical training-related injuries.

EVIDENCE ACQUISITION

A work group was formed to identify, evaluate, and assess the level of scientific evidence for various physical training-related injury prevention strategies through an expedited systematic review process. Of 40 physical training-related injury prevention strategies identified, education, leader support, and surveillance were determined to be essential elements of a successful injury prevention program and not independent interventions. As a result of the expedited systematic reviews, one more essential element (research) was added for a total of four. Six strategies were not reviewed. The remaining 31 interventions were categorized into three levels representing the strength of recommendation: (1) recommended; (2) not recommended; and (3) insufficient evidence to recommend or not recommend.

EVIDENCE SYNTHESIS

Education, leadership support, injury surveillance, and research were determined to be critical components of any successful injury prevention program. Six interventions (i.e., prevent overtraining, agility-like training, mouthguards, semirigid ankle braces, nutrient replacement, and synthetic socks) had strong enough evidence to become working group recommendations for implementation in the military services. Two interventions (i.e., back braces and pre-exercise administration of anti-inflammatory medication) were not recommended due to evidence of ineffectiveness or harm, 23 lacked sufficient scientific evidence to support recommendations for all military services at this time, and six were not evaluated.

CONCLUSIONS

Six interventions should be implemented in all four military services immediately to reduce physical training-related injuries. Two strategies should be discouraged by all leaders at all levels. Of particular note, 23 popular physical training-related injury prevention strategies need further scientific investigation, review, and group consensus before they can be recommended to the military services or similar civilian populations. The expedited systematic process of evaluating interventions enabled the working group to build consensus around those injury prevention strategies that had enough scientific evidence to support a recommendation.

Low-energy extracorporeal shock wave therapy as a treatment for medial tibial stress syndrome

BACKGROUND

Medial tibial stress syndrome (MTSS) is a pain syndrome along the tibial origin of the tibialis posterior or soleus muscle. Extracorporeal shock wave therapy (SWT) is effective in numerous types of insertional pain syndromes.

HYPOTHESIS

Shock wave therapy is an effective treatment for chronic MTSS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Forty-seven consecutive subjects with chronic recalcitrant MTSS underwent a standardized home training program, and received repetitive low-energy radial SWT (2000 shocks; 2.5 bars of pressure, which is equal to 0.1 mJ/mm(2); total energy flux density, 200 mJ/mm(2); no local anesthesia) (treatment group). Forty-seven subjects with chronic recalcitrant MTSS were not treated with SWT, but underwent a standardized home training program only (control group). Evaluation was by change in numeric rating scale. Degree of recovery was measured on a 6-point Likert scale (subjects with a rating of completely recovered or much improved were rated as treatment success).

RESULTS

One month, 4 months, and 15 months from baseline, success rates for the control and treatment groups according to the Likert scale were 13% and 30% (P < .001), 30% and 64% (P < .001), and 37% and 76% (P < .001), respectively. One month, 4 months, and 15 months from baseline, the mean numeric rating scale for the control and treatment groups were 7.3 and 5.8 (P < .001), 6.9 and 3.8 (P < .001), and 5.3 and 2.7 (P < .001), respectively. At 15 months from baseline, 40 of the 47 subjects in the treatment group had been able to return to their preferred sport at their preinjury level, as had 22 of the 47 control subjects.

CONCLUSION

Radial SWT as applied was an effective treatment for MTSS.

Medial tibial stress syndrome: conservative treatment options

Medial tibial stress syndrome (MTSS), commonly known as “shin splints,” is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes (Willems T, Med Sci Sports Exerc 39(2):330–339, 2007; Korkola M, Amendola A, Phys Sportsmed 29(6):35–50, 2001; Hreljac A, Med Sci Sports Exerc 36(5):845–849, 2004). Although often not serious, it can be quite disabling and progress to more serious complications if not treated properly. Often, the cause of MTSS is multi-factorial and involves training errors and various biomechanical abnormalities. Few advances have been made in the treatment of MTSS over the last few decades. Current treatment options are mostly based on expert opinion and clinical experience. The purpose of this article is to review published literature regarding conservative treatment options for MTSS and provide recommendations for sports medicine clinicians for improved treatment and patient outcomes.

The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes

Objective

To determine the relationship between lower extremity alignment and MTSS amongst non-professional athletes

Design

In a prospective Study, sixty six subjects were evaluated. Bilateral navicular drop test, Q angle, Achilles angle, tibial angle, intermalleolar and intercondylar distance were measured. In addition, runner's height, body mass, history of previous running injury, running experience was recorded. Runners were followed for 17 weeks to determine occurrence of MTSS.

Results

The overall injury rate for MTSS was 19.7%. The MTSS injury rate in girls (22%) was not significantly different from the rate in boys (14.3%). Most MTSS injuries were induced after 60 hours of exercise, which did not differ between boys and girls. There was a significant difference in right and left navicular drop (ND) in athletes with MTSS. MTSS had no significant correlation with other variables including Quadriceps, Tibia and Achilles angles, intercondylar and intermaleolar lengths and lower extremity lengths.

Limitation

All measurements performed in this study were uniplanar and static. The small sample size deemed our main limitation. The accurate assessment of participants with previous history of anterior leg pain for MTSS was another limitation.

Conclusion

Although a significant relationship between navicular drop and MTSS was found in this study; there was not any significant relationship between lower extremity alignment and MTSS in our sample study.

Development and evaluation of a tool for the assessment of footwear characteristics

BACKGROUND

Footwear characteristics have been linked to falls in older adults and children, and the development of many musculoskeletal conditions. Due to the relationship between footwear and pathology, health professionals have a responsibility to consider footwear characteristics in the etiology and treatment of various patient presentations. In order for health professionals and researchers to accurately and efficiently critique an individual's footwear, a valid and reliable footwear assessment tool is required. The aim of this study was to develop a simple, efficient, and reliable footwear assessment tool potentially suitable for use in a range of patient populations.

METHODS

Consideration of previously published tools, other footwear related literature, and clinical considerations of three therapists were used to assist in the development of the tool. The tool was developed to cover fit, general features, general structure, motion control properties, cushioning, and wear patterns. A total of 15 participants (who provided two pairs of shoes each) were recruited, and assessment using the scale was completed on two separate occasions (separated by 1 - 3 weeks) by a physiotherapist and a podiatrist on each participant's dominant foot. Intra-rater and inter-rater reliability were evaluated using intra-class correlation coefficients (ICCs) (model 2, 1) and the 95% limits of agreement (95% LOAs) for continuous items, and percentage agreement and kappa (kappa) statistics for categorical items.

RESULTS

All categorical items demonstrated high percentage agreement statistic for intra-rater (83 - 100%) and inter-rater (83 - 100%) comparisons. With the exception of last shape and objective measures used to categorise the adequacy of length, excellent intra-rater (ICC = 0.91 - 1.00) and inter-rater reliability (ICC = 0.90 - 1.00) was indicated for continuous items in the tool, including the motion control properties scale (0.91 - 0.95).

CONCLUSION

A comprehensive footwear assessment tool with good face validity has been developed to assist future research and clinical footwear assessment. Generally good reliability amongst all items indicates that the tool can be used with confidence in research and clinical settings. Further research is now required to determine the clinical validity of each item in various patient populations.

Cochrane reviews used more rigorous methods than non-Cochrane reviews: survey of systematic reviews in physiotherapy

OBJECTIVE

To describe the quality and methods of systematic reviews of physiotherapy interventions, compare Cochrane and non-Cochrane reviews, and establish the interrater reliability of the Overview Quality Assessment Questionnaire (OQAQ) quality assessment tool.

STUDY DESIGN AND SETTING

A survey of 200 published systematic reviews was done. Two independent raters assessed the search strategy, assessment of trial quality, outcomes, pooling, conclusions, and overall quality (OQAQ). The study was carried out in the University research center.

RESULTS

In these reviews, the five most common databases searched were MEDLINE, EMBASE, Cochrane Library, CINAHL, and Cochrane Review Group Registers. The Cochrane allocation concealment system and Jadad Scale were most frequently used to assess trial quality. Cochrane reviews searched more databases and were more likely to assess trial quality, report dichotomous outcomes for individual trials, and conduct a meta-analysis than non-Cochrane reviews. Non-Cochrane reviews were more likely to conclude that there was a beneficial effect of treatment. Cochrane reviews were of higher quality than non-Cochrane reviews. There has been an increase in the quality of systematic reviews over time. The OQAQ has fair to good interrater reliability.

CONCLUSION

The quality of systematic reviews in physiotherapy is improving, and the use of Cochrane Collaboration procedures appears to improve the methods and quality.

Medial tibial stress syndrome: evidence-based prevention

REFERENCE

Thacker SB, Gilchrist J, Stroup DF, Kimsey CD. The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc. 2002;34(1):32-40.

CLINICAL QUESTION

Among physically active individuals, which medial tibial stress syndrome (MTSS) prevention methods are most effective to decrease injury rates?

DATA SOURCES

Studies were identified by searching MEDLINE (1966-2000), Current Contents (1996-2000), Biomedical Collection (1993-1999), and Dissertation Abstracts. Reference lists of identified studies were searched manually until no further studies were identified. Experts in the field were contacted, including first authors of randomized controlled trials addressing prevention of MTSS. The Cochrane Collaboration (early stage of Cochrane Database of Systematic Reviews) was contacted.

STUDY SELECTION

Inclusion criteria included randomized controlled trials or clinical trials comparing different MTSS prevention methods with control groups. Excluded were studies that did not provide primary research data or that addressed treatment and rehabilitation rather than prevention of incident MTSS.

DATA EXTRACTION

A total of 199 citations were identified. Of these, 4 studies compared prevention methods for MTSS. Three reviewers independently scored the 4 studies. Reviewers were blinded to the authors' names and affiliations but not the results. Each study was evaluated independently for methodologic quality using a 100-point checklist. Final scores were averages of the 3 reviewers' scores.

MAIN RESULTS

Prevention methods studied were shock-absorbent insoles, foam heel pads, Achilles tendon stretching, footwear, and graduated running programs. No statistically significant results were noted for any of the prevention methods. Median quality scores ranged from 29 to 47, revealing flaws in design, control for bias, and statistical methods.

CONCLUSIONS

No current evidence supports any single prevention method for MTSS. The most promising outcomes support the use of shock-absorbing insoles. Well-designed and controlled trials are critically needed to decrease the incidence of this common injury.

Effect of cushioned insoles on impact forces during running

BACKGROUND

The use of cushioned or shock-absorbing insoles has been suggested as a mechanism to reduce the impact forces associated with running, thereby protecting against overuse injuries. The purpose of this study was to determine whether the use of cushioned insoles reduced impact forces during running in healthy subjects.

METHODS

Sixteen recreational runners (9 females and 7 males) ran at a self-selected pace for five trials with and without the use of cushioned insoles. During each trial, ground reaction forces, tibial accelerations, lower-extremity kinematics, and subject-perceived comfort were recorded. All variables were tested with the level of statistical significance set at alpha = .05.

RESULTS

The use of cushioned insoles resulted in significant reductions in mean vertical ground reaction force peak impact (6.8%) and ground reaction force loading rate (8.3%), as well as peak tibial acceleration (15.8%). Spectral analysis of the tibial acceleration data in the frequency range associated with impact accelerations (12-25 Hz) revealed no change in the predominant frequency or the power of the predominant frequency. The knee flexion angle at initial contact and perceived comfort were similar for the two conditions.

CONCLUSIONS

This study demonstrates the effectiveness of one type of cushioned insole in reducing peak impact force and tibial acceleration at initial foot-ground contact during running. The impact reduction observed was independent of knee kinematic adjustments or changes in perceived comfort. Further study is required to determine whether the reduction in loading that accompanied the use of the cushioned insoles can affect the incidence of running-related injuries.

Mouthguards in Sport Activities

Three systematic reviews were conducted on: (i) the history of mouthguard use in sports; (ii) mouthguard material and construction; and (iii) the effectiveness of mouthguards in preventing orofacial injuries and concussions. Retrieval databases and bibliographies were explored to find studies using specific key words for each topic. The first recorded use of mouthguards was by boxers, and in the 1920s professional boxing became the first sport to require mouthguards. Advocacy by the American Dental Association led to the mandating of mouthguards for US high school football in the 1962 season. Currently, the US National Collegiate Athletic Association requires mouthguards for four sports (ice hockey, lacrosse, field hockey and football). However, the American Dental Association recommends the use of mouthguards in 29 sports/exercise activities. Mouthguard properties measured in various studies included shock-absorbing capability, hardness, stiffness (indicative of protective capability), tensile strength, tear strength (indicative of durability) and water absorption. Materials used for mouthguards included: (i) polyvinylacetate-polyethylene or ethylene vinyl acetate (EVA) copolymer; (ii) polyvinylchloride; (iii) latex rubber; (iv) acrylic resin; and (v) polyurethane. Latex rubber was a popular material used in early mouthguards but it has lower shock absorbency, lower hardness and less tear and tensile strength than EVA or polyurethane. Among the more modern materials, none seems to stand out as superior to another since the characteristics of all the modern materials can be manipulated to provide a range of favourable characteristics. Impact studies have shown that compared with no mouthguard, mouthguards composed of many types of materials reduce the number of fractured teeth and head acceleration. In mouthguard design, consideration must be given to the nature of the collision (hard or soft objects) and characteristics of the mouth (e.g. brittle incisors, more rugged occusal surfaces of molars, soft gingiva). Laminates with different shock absorbing and stress distributing (stiffness) capability may be one way to accommodate these factors.Studies comparing mouthguard users with nonusers have examined different sports, employed a variety of study designs and used widely-varying injury case definitions. Prior to the 1980s, most studies exhibited relatively low methodological quality. Despite these issues, meta-analyses indicated that the risk of an orofacial sports injury was 1.6-1.9 times higher when a mouthguard was not worn. However, the evidence that mouthguards protect against concussion was inconsistent, and no conclusion regarding the effectiveness of mouthguards in preventing concussion can be drawn at present. Mouthguards should continue to be used in sport activities where there is significant risk of orofacial injury.

Do shock absorbing insoles in recruits undertaking high levels of physical activity reduce lower limb injury? A randomized controlled trial

OBJECTIVES

To assess the benefits, if any, of the use of shock absorbing insoles in reducing lower limb injury among Air Force recruits, and to assess the differences, if any, in the efficacy of two commonly available shock absorbing insoles.

DESIGN

Randomized controlled trial.

SETTING

RAF Halton, UK. Site of all basic training for RAF personnel.

PARTICIPANTS

1205 recruits participating in basic training between 17 September 2003 and 7 April 2004.

INTERVENTIONS

Participants were randomized to receive either standard issue Saran non-shock absorbing insoles, or shock absorbing Sorbothane or Poron insoles, on a 1:1:1 basis.

MAIN OUTCOME MEASURES

The primary outcome measure was withdrawal from training for lower limb injury. The two primary comparisons were shock absorbing insole versus non-shock absorbing insole, and Sorbothane versus Poron (comparison of different shock absorbing insoles). Secondary outcomes were medical withdrawals for reasons other than those qualifying for the primary outcome measure.

RESULTS

When comparing the non-shock absorbing insole to the shock absorbing insoles 72/401 participants (18.0%) allocated to Saran insoles were removed from training because of a qualifying lower limb injury, compared with 149/804 (18.5%) allocated to the shock absorbing insole (Sorbothane or Poron), odds ratio 1.04 (95% CI 0.75 to 1.44; P=0.87). When comparing the two shock absorbing insole 73/421 participants (17.3%) randomized to Sorbothane were removed from training because of a qualifying lower limb injury, compared with 76/383 for Poron (19.8%), odds ratio 0.85 (95% CI 0.58 to 1.23; P=0.37).

CONCLUSIONS

Similar rates of lower limb injuries were observed for all insoles (shock absorbing and non-shock absorbing) in the trial. The trial provides no support for a change in policy to the use of shock absorbing insoles for military recruits.

A prospective study of gait related risk factors for exercise-related lower leg pain

The purpose of this study was to determine prospectively gait related risk factors for exercise-related lower leg pain (ERLLP) in 400 physical education students. Static lower leg alignment was determined, and 3D gait kinematics combined with plantar pressure profiles were collected. After this evaluation, all sports injuries were registered by the same sports physician during the duration of the study. Forty six subjects developed ERLLP and 29 of them developed bilateral symptoms thus giving 75 symptomatic lower legs. Bilateral lower legs of 167 subjects who developed no injuries in the lower extremities served as controls. Cox regression analysis revealed that subjects who developed ERLLP had an altered running pattern before the injury compared to the controls and included (1) a significantly more central heel-strike, (2) a significantly increased pronation, accompanied with more pressure underneath the medial side of the foot, and (3) a significantly more lateral roll-off. These findings suggest that altered biomechanics play a role in the genesis of ERLLP and thus should be considered in prevention and rehabilitation.

Shin splints: painful to have and to treat

When people overuse their legs they develop an uncomfortable awareness of these limbs manifested as a dull burning or aching. The cause is often clear to the person with the problem as a result of the often obvious relationship to overdoing an exercise or activity and the pain. "Shin splints" is the lay term; physicians use the term medial tibial stress syndrome. The pathophysiology that leads to this pain is unclear, although there are a number of competing theories. Differential diagnosis includes stress fractures and compartment syndromes. Bone tumors or lipomas can also cause similar pain to shin splints. Diagnosis can be made by history alone in a majority of cases, but if the diagnosis is unclear, an X-ray and magnetic resonance imaging should be considered. Treatment is still mostly supportive and symptom related. Rest is the most important aspect of treatment. Locally applied cold and anti-inflammatory medication have also been felt to be beneficial.

Risk factors associated with exertional medial tibial pain: a 12 month prospective clinical study

OBJECTIVE

To investigate in a military setting the potential role of intrinsic biomechanical and anthropometric risk factors for, and the incidence of, exertional medial tibial pain (EMTP).

METHODS

A prospective clinical outcome study in a cohort of 122 men and 36 women at the Australian Defence Force Academy. Each cadet underwent measurements of seven intrinsic variables: hip range of motion, leg length discrepancy, lean calf girth, maximum ankle dorsiflexion range, foot type, rear foot alignment, and tibial alignment. Test-retest reliability was undertaken on each variable. A physician recorded any cadet presenting with diagnostic criteria of EMTP. Records were analysed at 12 months for EMTP presentation and for military fitness test results.

RESULTS

23 cadets (12 men, 11 women) met the criteria for EMTP after 12 months, with a cross gender (F/M) odds ratio of 3.1. In men, both internal and external range of hip motion was greater in those with EMTP: left internal (12 degrees, p = 0.000), right internal (8 degrees, p = 0.014), left external (8 degrees, p = 0.042), right external (9 degrees, p = 0.026). Lean calf girth was lower by 4.2% for the right leg (p = 0.040) but by only 2.9% for the left leg (p = 0.141). No intrinsic risk factor was associated with EMTP in women. EMTP was the major cause for non-completion of the run component of the ADFA fitness test in both men and women.

CONCLUSIONS

Greater internal and external hip range of motion and lower lean calf girth were associated with EMTP in male military cadets. Women had high rates of injury, although no intrinsic factor was identified. Reasons for this sex difference need to be identified.

Relative motions of the tibia, talus, and calcaneus during the stance phase of gait: a cadaver study

The motions of the tibia, talus, and calcaneus during walking were analyzed three-dimensionally using a dynamic cadaver model that recreates the stance phase of walking. Rigid marker clusters were attached to each of the three bones, and the rotations of the talus and calcaneus with respect to the tibia and the calcaneus with respect to the talus were analyzed for eight right cadaver feet. The talus rotated primarily in plantarflexion/dorsiflexion about the talocrural joint, with an average range of 18 degrees +/- 4.7 degrees. The calcaneus began in inversion and internal rotation with respect to the tibia, moved into the neutral position at 28% of the stance phase and rotated primarily in plantarflexion from that point onward. Rotation of the calcaneus with respect to the talus at the subtalar joint occurred about all three axes, with approximately 5 degrees of relative dorsiflexion and 7 degrees of relative internal rotation. After 25% of stance, the talus and calcaneus moved together as one body into plantarflexion, providing a rigid lever as toe-off was approached.

The impact of stretching on sports injury risk: a systematic review of the literature

PURPOSE

We conducted a systematic review to assess the evidence for the effectiveness of stretching as a tool to prevent injuries in sports and to make recommendations for research and prevention.

METHODS

Without language limitations, we searched electronic data bases, including MEDLINE (1966-2002), Current Contents (1997-2002), Biomedical Collection (1993-1999), the Cochrane Library, and SPORTDiscus, and then identified citations from papers retrieved and contacted experts in the field. Meta-analysis was limited to randomized trials or cohort studies for interventions that included stretching. Studies were excluded that lacked controls, in which stretching could not be assessed independently, or where studies did not include subjects in sporting or fitness activities. All articles were screened initially by one author. Six of 361 identified articles compared stretching with other methods to prevent injury. Data were abstracted by one author and then reviewed independently by three others. Data quality was assessed independently by three authors using a previously standardized instrument, and reviewers met to reconcile substantive differences in interpretation. We calculated weighted pooled odds ratios based on an intention-to-treat analysis as well as subgroup analyses by quality score and study design.

RESULTS

Stretching was not significantly associated with a reduction in total injuries (OR = 0.93, CI 0.78-1.11) and similar findings were seen in the subgroup analyses.

CONCLUSION

There is not sufficient evidence to endorse or discontinue routine stretching before or after exercise to prevent injury among competitive or recreational athletes. Further research, especially well-conducted randomized controlled trials, is urgently needed to determine the proper role of stretching in sports.