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Evaluation of Conditioning and Predisposition to Medial Tibial Stress Syndrome


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Evaluation of Conditioning and Predisposition to Medial Tibial Stress Syndrome

  1. 1. 1 Evaluation of Conditioning and Predisposition to Medial Tibial Stress Syndrome (MTSS) in College Athletes Krista L. Capelli, LAT, ATC; Thomas F. West, PhD, LAT, ATC *California University of Pennsylvania, California, PA Objective: The primary purpose of this study is to determine whether athletes suffering from MTSS have a greater participation in flexibility, plyometric, balance, cardiorespiratory, resistance, and/or speed, agility, and quickness (SAQ) training than those without MTSS. Subjects: The subjects for this study consisted of Division II and III student athletes at NCAA colleges/universities. The study looked at both male and female athletes from a number of college sports teams. Measurements:We assessed athletes’ perceived diagnosis of symptoms related to MTSS using a diagnosis survey titled "The Medial Tibial Stress Syndrome Score: A New Patient-reported Outcome Measure” by Marius Winters13 as well as their frequency, duration and intensity of training by design of the researcher’s own questionnaire. The Rate of Perceived Exertion (RPE) Scale was used to measure level of intensity. Results: 69 completed surveys were submitted for data analyses. We found that 9 (13%) were considered having signs of MTSS while 60 (87%) showed no signs of MTSS. The average intensity of plyometric training as well as the duration of cardiovascular training for athletes with MTSS was significantly greater than athletes without MTSS. There was no huge difference of means between groups in any other form of training. Conclusions: Athletes with MTSS showed no significant difference in training than those without MTSS. Females were found to be at a higher risk for symptoms associated with MTSS than males. Key Words: MTSS, athletic training ______________________________________________ Introduction Many athletes suffer a number of lower extremity overuse injuries. Medial tibial stress syndrome (MTSS), more commonly referred to as “shin splints” is one of the most common lower leg injuries. Some studies show that MTSS accounts for 6% to 16% of all running injuries. Research has also shown that MTSS is responsible for as much as 50% of all lower leg injuries reported in select populations1-3 . The exact cause for MTSS is inconsistent within the research and varies based on athlete and sport. Much of the research found MTSS is associated with repetitive activity on hard surfaces, forceful and excessive foot pronation, rapid increases in training, improper shoe wear, inadequate calcium intake, muscle imbalances between genders, navicular drop, foot length, history and BMI1-6 . It is important that athletic trainers recognize the signs and symptoms as well as predisposing risks of MTSS to prevent further and more serious injuries like stress fractures from occurring. If an athlete should suffer from stress fractures, it could result in a greater loss of time through periods of immobilization, rehabilitation, and overall return to play. Although there have been many methods to prevent and treat for MTSS, research is still limited 1, 2, 7 . According to the review of the literature, the athlete should be advised to use nonsteroidal
  2. 2. 2 anti-inflammatory drugs (NSAIDS) for pain and crutches to keep the athlete non-weight bearing or partial weight bearing. Although surgery has been shown to relieve symptoms associated with MTSS, conservative treatment has been seen to be the better option. Treatment may include modalities such as ultrasound, electrical stimulation, cryotherapy and other forms such as orthotics, arch taping, and shoe modifications8 . A rehabilitation plan may include non-aggravating activities for flexibility, strength, and cardiovascular fitness, as well as modified training routines with low- impact exercises8 . Other methods of treatment like bisphosphonates to inhibit bone reabsorption and interfere with the action of osteoclasts, pneumatic leg braces, and extracorporeal shockwave therapy (ESWT) to reduce symptoms of MTSS require further research9-12 . The purpose of this study is to determine whether athletes suffering from MTSS have a greater participation in flexibility, plyometric, balance, resistance, and/or speed/agility/quickness (SAQ) training than those without MTSS. It is important to understand the different components of training in order to determine which specific form of training causes a greater risk of MTSS. Once the participation of training has been identified, the next step is to determine a prevention strategy. If athletic trainers can limit or change some aspects of training, the overall care of the athletes suffering from MTSS may improve. Additionally, it may also be beneficial to learn the effects of pre-existing injuries in athletes playing at the colligate level as well as differences in incidence rate between genders and sports. METHODS Subjects The subjects for this study were Division II and III college student athletes at NCAA colleges/universities. The study consisted of both male and female athletes from all collegiate sports (swimming, volleyball, baseball, softball, soccer, football, track and field, cross-country, lacrosse, wrestling, tennis, field hockey, ice hockey, and basketball). Instrumentation The survey consisted of approximately 19 questions including demographic information, sport, and most recently completed competitive season and the availability of the strength and conditioning coach at the athlete’s school. We also collected the athlete’s signs and symptoms for MTSS, and their participation in flexibility, plyometric, balance, cardiorespiratory, resistance, and SAQ training. If the athlete reported under the age of 17, the survey was complete and was not used for the study. For the second portion of the study, we included a validated MTSS scoring system using a study by Marinus Winters et. al13 . All athletes were asked to choose complaints of a specific shin followed by point valued questions based on level of pain with sporting activities, pain with walking, and pain during rest. Also, we explored their frequency (days), intensity (BORG Rating of Perceived Exertion) and duration of training (minutes) looking at specific training categories. Preliminary Research A panel of experts reviewed the survey before any research was conducted. The panel members consisted of 10 certified athletic trainers who added to the content validity of the survey. A draft of the cover letter explaining the design and the experts’ responsibilities were sent out via email in this study. Members were also given the researcher’s problem statement and a copy of the “Shin Splints and Training” survey. Members reviewed the survey instrument and added to the content validity by adding any recommendations for improvement. After reviewing the survey, the panel members provided critiques and changes. The necessary changes were made to the survey based on critiques by the panel of experts. Procedures The study was approved by the Institutional Review Board (IRB) at California University of Pennsylvania before beginning any data collection or distribution of surveys. The athletic directors of the selected colleges were
  3. 3. 3 contacted via email. The athletic directors were asked for written or electronic approval to allow the researcher to distribute surveys to coaches who in turn would send the cover letter and link to the survey to student athletes. The participants for this study were then notified of the questionnaire through the students’ e-mail account. The cover letter explained the purpose of the study to each potential participant. Surveys were collected for a 2-week period following distribution and were deactivated after that time. This timeframe was to allow adequate time for both the subjects to complete the survey and the researcher to collect adequate data. After one week, a reminder was sent to coaches asking them to remind athletes. All data was kept confidential and organized into a spreadsheet for analysis. Null Hypothesis Student athletes having MTSS will show greater frequency and intensity of participation in flexibility, plyometric, balance, resistance, cardiorespiratory and/or SAQ training than those without MTSS. Data Analysis All data was analyzed with SPSS 22.0 analysis software. The research hypothesis was analyzed using an independent sample T- test with a p≤ .05. RESULTS Descriptive Analyses Of the 104 student-athletes who responded to the questionnaire, 69 returned completed surveys for data analyses. From this sample, 30 (43.5%) were male and 39 (56.5%) were female between the ages of 18-23. 31 (44.9%)of those athletes play a Division II sport and 38 (55.1%) are Division III athletes. Winters et al.13 categorizes MTSS athletes with smallest detectable change at a score 4.80 out of a total score of 10. Due to limited responses, the score required for athletes to be considered for MTSS was 3 out of 10. We found that 9 (13%) were considered having signs of MTSS while 60 (87%) showed no signs of MTSS. Of the 9 participants who were diagnosed with having MTSS, 3 were male (33.3%) and 6 were female (66.7%). Athletes with MTSS participated more in track and field (5), soccer (1) tennis (2) and field hockey (1). From the 5 athletes that participated in track and field, 3 of those athletes also participated in cross- country. Athletes with MTSS utilized their strength and conditioning coach either 3-4 days per week or not at all where athletes without MTSS would also work 3-4 days per week (44.3%) or not at all (31.1%). Table 1: Means (Standard Deviation) of Frequency, Duration and Intensity MTSS Frequency Duration Intensity Flexibility Yes 3.56 (1.509) 4.11 (1.965) 6.11 (3.919) No 2.97 (1.785) 3.05 (2.213) 5.83 (4.009) Plyometric Yes 3.22 (2.167) 3.89 (3.296) 9.00 (3.905) No 3.82 (2.119) 2.60 (2.330) 6.97 (4.042) Balance Yes 3.44 (2.455) 2.78 (2.906) 5.67 (4.031) No 3.87 (2.198) 2.07 (1.745) 7.12 (4.166) Cardiorespiratory Yes 3.22 (1.787) 7.00 (3.428) 6.22 (3.153) No 3.40 (1.709) 5.80 (3.896) 6.17 (3.335) Resistance Yes 3.67 (1.936) 3.44 (3.167) 7.33 (4.444) No 3.45 (1.926) 4.10 (3.150) 6.77 (3.837) SAQ Yes 3.00 (1.871) 6.00 (2.872) 6.67 (3.742) No 2.90 (1.526) 5.57 (3.387) 6.17 (3.263)
  4. 4. 4 Discussion Table 1 illustrates the means and standard deviation for frequency, duration, and intensity of all components of training for this study of athletes with and without MTSS. The mean intensity of plyometric training for athletes with MTSS (m= 9.00) is significantly greater than athletes without MTSS (m= 6.97). There was no statistical difference of means between groups in any other form of training. The table also shows the mean duration of cardiorespiratory for athletes with MTSS (m= 7.00) is higher than those without MTSS (m= 5.80) and more than any other duration of training. An independent-samples t-test was calculated comparing the mean score of the frequency, duration, and intensity of flexibility, plyometric, balance, resistance, cardiorespiratory, and SAQ training in participants with and without MTSS. The data showed no significant difference between the groups. Table 2 illustrates significance, t value, and p-value for all components of training. If the significance was larger than .05, the variances were considered equal. The p-value for duration (p=.148) and intensity (.162) of plyometric training presented as the lowest values. MTSS Treatment The researchers also investigated the frequency of treatments for athletes with MTSS. The study found that all 9 participants use some form of cryotherapy (ice, cold whirlpool, etc.). In regards to other types of treatment the following percentages were utilized: tape (33.3%), orthotics (11.1%), heat (66.7%), ultrasound (22.2%), electrical stimulation (55.6%), and massage (44.4%). However, only 5 found cryotherapy to be a successful treatment while other successful uses for treatment included heat, electrical stimulation, and massage. We asked participants to include any other form of successful treatments. These methods included: pressure release techniques, manual therapy (Graston, scrapping), acupuncture, and shockwave therapy. Conclusions Though the sample size was small, the data found that females are more at risk to having signs and symptoms related to MTSS. The research has found that no specific form of training causes signs and symptoms associated with MTSS. There is not enough evidence in this study to show whether plyometric training is the true cause for MTSS. The need for further research would have to be implicated. Limitations The limitation of this study was the insignificant number of participants due to student-athlete compliance and the minimal selection of NCAA schools chosen for this study. The participants were only considered for data analysis if all necessary questions were answered. If the athlete missed more than one question, they were excluded from the study. The researchers had no information Table 2: Significance, t value, and p- value for Frequency, Duration, and Intensity for all Components of Training Levene’s Test for Equality of Variances t-test for Equality of Means Sig. t Sig. (2- tailed) Flexibility Frequency Duration Intensity .441 .941 .663 .939 1.359 .194 .351 .179 .846 Plyometric Frequency Duration Intensity .503 .066 .200 -.783 1.462 1.413 .437 .148 .162 Balance Frequency Duration Intensity .406 .169 .145 -.530 1.035 -.977 .598 .304 .332 Resistance Frequency Duration Intensity .652 .393 .277 .315 -.582 .405 .754 .563 .687 Cardiorespiratory Frequency Duration Intensity .838 .390 .460 -.289 .873 .047 .773 .386 .963 SAQ Frequency Duration Intensity .331 .363 .682 .178 .364 .421 .859 .717 .675 *Equal variances assumed *p-value≤ .05
  5. 5. 5 on any previous or current injuries to the lower leg. Another limitation was compliance of coaches to distribute surveys to their teams. Acknowledgements I would like to acknowledge Dr. Thomas West for his initial contribution for this study, and Dr. Shelly DiCesaro for her final contribution. I would also like to thank the graduate athletic training students for their role in the preliminary study. This study was conducted as the first author’s master’s thesis. References 1. Craig, D.I. "Medial Tibial Stress Syndrome: Evidence-Based Prevention." Journal of Athletic Training 43.3 (2008): 316-318. 2. Thacker, S.B. et al. “The Prevention of Shin Splints in Sports: A Systematic Review of Literature.” Medicine and Science in Sports and Exercise 34.1 (2002): 32–40. 3. Yates, B., and White, S. “The Incidence and Risk Factors in the Development of Medial Tibial Stress Syndrome Among Naval Recruits.” The American Journal of Sports Medicine 32.3 (2004): 772– 780. 4. Miller, M.D., Hart J.A., and MacKnight, O.M. Essential Orthopaedics. 1st ed. Saunders, (2010). 5. Bennett, J.E. et al. “Factors Contributing to the Development of Medial Tibial Stress Syndrome in High School Runners.” Journal of Orthopaedic and Sports Physical Therapy 31.9 (2001): 504–510. 6. Plisky, M.S. et al. “Medial Tibial Stress Syndrome in High School Cross- Country Runners: Incidence and Risk Factors.” Journal of Orthopaedic and Sports Physical Therapy 37.2 (2015): 40–49. 7. Barnes, R.P., Behnke, R.S., Gushiewicz, K.M., Holmes, C.F., and Starkey, C. Athletic Training and Sports Medicine. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons, (1991). 8. Galbraith, M.R., and Lavallee, M.E. “Medial Tibial Stress Syndrome: Conservative Treatment Options.” Current Reviews In Musculoskeletal Medicine 2.3 (2009): 127–133. 9. Moen, M.H. et al. “Shockwave Treatment for Medial Tibial Stress Syndrome in Athletes; A Prospective Controlled Study.” Journal of Sports Medicine (2011): 1–5. 10. Higgins, M. “Rehabilitation of the Foot and Ankle Complex.” Therapeutic Exercise: From Theory to Practice. F.A. Davis Company, (2011): 289–348. 11. Moen, M.H., Bongers, T., Bakker E.W.P., et al. “The Additional Value of a Pneumatic Leg Brace in the Treatment of Recruits with Medial Tibial Stress Syndrome; A Randomized Study.” Journal of the Royal Army Medical Corps 156.4 (2010): 236–240. 12. Moen, M. H., Ratnayake, A., Weir, A., Suraweera, H. J., and Backx, F. J. G. The Treatment of Medial Tibial Stress Syndrome with Bisphosphanates. Sport & Geneeskunde, 44.1 (2011): 22-25. 13. Winters, M., Moen MH, Zimmermann WO, Lindeboom R, Weir A, Backx F, and Bakker E. "The Medial Tibial Stress Syndrome Score: A New Patient- reported Outcome Measure." British Journal of Sports Medicine Br J Sports Med (2015).
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