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

Phil Newman, Jeremy Witchalls, Gordon Waddington, Roger Adams, Phil Newman, Jeremy Witchalls, Gordon Waddington, Roger Adams

Abstract

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.

Keywords: injury prevention; medial tibial stress syndrome; risk factors; running injuries.

Figures

Figure 1
Figure 1
Traditional differential diagnosis and classification of medial tibial stress syndrome. Note: Concept from Detmer.
Figure 2
Figure 2
Papers selected from initial search to final inclusion.
Figure 3
Figure 3
Risk of bias summary: reviews authors’ judgments about each risk of bias item for each included study. Note: Green = low risk; yellow = unclear risk; red = high risk. Abbreviation: MTSS, Medial tibial stress syndrome.
Figure 4
Figure 4
Forest plot of comparison: risk factors and associations with MTSS and navicular drop. Notes: Green squares = SMD for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; SD, standard deviation; SMD, standard mean difference; IV, inverse variance.
Figure 5
Figure 5
Forest plot of comparison: risk factors and associations with MTSS and navicular drop >10 mm. Notes: Blue squares = RR for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; M-H, Mantel Haenszel test; Nav, navicular; RR, risk ratio.
Figure 6
Figure 6
Forest plot of comparison: risk factors and associations with MTSS and orthotic use. Notes: Blue squares = RR for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; M-H, Mantel Haenszel test; RR, risk ratio.
Figure 7
Figure 7
Forest plot of comparison: risk factors and associations with MTSS and BMI. Notes: Green squares = SMD for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: BMI, body mass index; CI, confidence interval; MTSS, medial tibial stress syndrome; SD, standard deviation; IV, inverse variance; SMD, standard mean difference.
Figure 8
Figure 8
Forest plot of comparison: risk factors and associations with MTSS and years of running experience. Notes: Green squares = SMD for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; SD, standard deviation; SMD, standard mean difference; IV, inverse variance.
Figure 9
Figure 9
Forest plot of comparison: risk factors and associations with MTSS and previous history of MTSS. Notes: Blue squares = RR for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; M-H, Mantel Haenszel test; Hx, previous history of MTSS; RR, risk ratio.
Figure 10
Figure 10
Forest plot of comparison: risk factors and associations with MTSS and female gender. Notes: Blue squares = RR for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; M-H, Mantel Haenszel test; RR, risk ratio.
Figure 11
Figure 11
Forest plot of comparison: risk factors and associations with MTSS and male hip external rotation ROM. Notes: Green squares = SMD for each study, the size of the squares represent relative n. Black diamond = pooled effect of variable. Abbreviations: CI, confidence interval; MTSS, medial tibial stress syndrome; SD, standard deviation; ROM, range of motion; IV, inverse variance; SMD, standard mean difference.
Figure 12
Figure 12
Proposed continuum model of pathogenesis of MTSS. Abbreviations: BMI, body mass index; MTSS, medial tibial stress syndrome.

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