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Objective: To assess whether one session of focused ESWT is effective in the treatment of military cadets with MTSS. Design: A randomized, prospective, controlled, single-blind, parallel-group clinical study. Level of evidence: Ib. Setting: Military School of Cadets of the Colombian Army. Methods: Forty-two military cadets with unilateral chronic MTSS were randomly assigned to either one session of focused electromagnetic ESWT (1500 pulses at 0.20 mJ/mm(2)) plus a specific exercise programme (muscle stretching and strengthening exercises) or the exercise programme alone. The primary endpoint was change in asymptomatic running test (RT) duration at four weeks from baseline. Secondary endpoints were changes in the visual analogue scale (VAS) after running and modified Roles and Maudsley (RM) score also at four weeks from baseline. Results: ESWT patients were able to run longer. Mean RT after four weeks was 17 min 33 s (SE: 2.36) compared to 4 min 48 s (SE: 1.03) in the exercise-only group (p = 0.000). Mean VAS after running was 2.17 (SE: 0.44) in the ESWT group versus 4.26 (SE: 0.36) in the exercise-only group (p = 0.001). The ESWT group had a significantly higher RM score, with excellent or good results for 82.6% of patients vs. 36.8% in the exercise-only group (p = 0.002). No significant adverse effects of ESWT were observed. Conclusion: A single application of focused shockwave treatment in combination with a specific exercise programme accelerates clinical and functional recovery in military cadets with MTSS.
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Original Research
Shockwave treatment for medial tibial stress syndrome in military
cadets: A single-blind randomized controlled trial
Santiago Gomez Garcia
a
,
*
,
1
, Silvia Ramon Rona
b
, Martha Claudia Gomez Tinoco
c
,
Mikhail Benet Rodriguez
d
, Diego Mauricio Chaustre Ruiz
e
,
Francia Piedad Cardenas Letrado
f
,
Africa Lopez-Illescas Ruiz
g
, Juan Maria Alarcon Garcia
h
a
Orthopaedic Surgeon and Sports Medicine Physician, Military School of Cadets of the Colombian Army, Calle 80 No. 38-00, Bogot
a, Colombia
b
Director of Physical Medicine and Rehabilitation Department, Hospital Quir
on, Garcia Cugat Foundation CEU-UCH Chair of Medicine and Regenerative,
International University of Catalonia, Plaça d'Alfonso Comín, 5-7, 08023, Barcelona, Spain
c
Psychology Unit of the Academic Vice-Rectory, Military School of Cadets of the Colombian Army, Calle 80 No. 38-00, Bogot
a, Colombia
d
Research Director of the CAFAM University Foundation, Cra. 68 No. 90-88, Bogot
a, Colombia
e
Department of Physical Medicine and Rehabilitation, Central Military Hospital, Transversal 3 No.49-00, Bogot
a, Colombia
f
Physiotherapy Unit, Military School of Cadets of the Colombian Army, Calle 80 No. 38-00, Bogot
a, Colombia
g
Director of Physical Rehabilitation Unit, National Sports Medicine Center, Higher Sports Council, C/ Pintor El Greco S/N, 28040, Madrid, Spain
h
Director of Shockwave Service, Vithas Nuestra Se~
nora de Am
erica Hospital, Madrid, Spain
highlights graphical abstract
Medial tibial stress syndrome (MTSS)
is characterized by pain in the lower
leg, common in athletes and
militaries.
Although MTSS is often mild, it can
evolve to chronicity.
Optimal treatment for MTSS has yet
to be established.
Extracorporeal shockwave treatment
(ESWT) is a tool aimed at alleviating
symptoms and shortening recovery
time in MTSS.
A single focused ESWT combined
with a specic exercise program al-
lows faster recovery in military ca-
dets with MTSS.
article info
Article history:
Received 9 June 2017
Received in revised form
26 July 2017
Accepted 17 August 2017
Available online 5 September 2017
abstract
Medial tibial stress syndrome (MTSS) is a common injury in athletes and soldiers. Several studies have
demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) in athletes with MTSS.
Objective: To assess whether one session of focused ESWT is effective in the treatment of military cadets
with MTSS.
Design: A randomized, prospective, controlled, single-blind, parallel-group clinical study. Level of evi-
dence: Ib.
Setting: Military School of Cadets of the Colombian Army.
*Corresponding author. Calle Amparo L
opez Jean No 8, 5to Izquierda, CP: 15174, Culleredo, A Coru~
na, Spain.
E-mail addresses: sancubacfg@yahoo.es (S. Gomez Garcia), sramon@comb.cat (S. Ramon Rona), nanygomezt@hotmail.com (M.C. Gomez Tinoco), benetmikhail@gmail.com
(M. Benet Rodriguez), diegomchaustrer68@yahoo.com.co (D.M. Chaustre Ruiz), frapcl@hotmail.com (F.P. Cardenas Letrado), lopezillescas@gmail.com (
A. Lopez-Illescas Ruiz),
ondasdechoquealarcon@icloud.com (J.M. Alarcon Garcia).
1
Sports Medicine Physician. Clínica Cenit, C/ Pedro Ferrer, 3 Bajo, 15011, A Coru~
na, Spain.
Contents lists available at ScienceDirect
International Journal of Surgery
journal homepage: www.journal-surgery.net
http://dx.doi.org/10.1016/j.ijsu.2017.08.584
1743-9191/©2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
International Journal of Surgery 46 (2017) 102e109
Keywords:
Medial tibial stress syndrome
Shin splints
Shockwave
Shockwave treatment
Military injuries
Regenerative therapy
Methods: Forty-two military cadets with unilateral chronic MTSS were randomly assigned to either one
session of focused electromagnetic ESWT (1500 pulses at 0.20 mJ/mm
2
) plus a specic exercise pro-
gramme (muscle stretching and strengthening exercises) or the exercise programme alone.
The primary endpoint was change in asymptomatic running test (RT) duration at four weeks from
baseline. Secondary endpoints were changes in the visual analogue scale (VAS) after running and
modied Roles and Maudsley (RM) score also at four weeks from baseline.
Results: ESWT patients were able to run longer. Mean RT after four weeks was 17 min 33 s (SE: 2.36)
compared to 4 min 48 s (SE: 1.03) in the exercise-only group (p ¼0.000). Mean VAS after running was
2.17 (SE: 0.44) in the ESWT group versus 4.26 (SE: 0.36) in the exercise-only group (p ¼0.001). The ESWT
group had a signicantly higher RM score, with excellent or good results for 82.6% of patients vs. 36.8% in
the exercise-only group (p ¼0.002). No signicant adverse effects of ESWT were observed.
Conclusion: A single application of focused shockwave treatment in combination with a specic exercise
programme accelerates clinical and functional recovery in military cadets with MTSS.
©2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Medial tibial stress syndrome (MTSS), also known as shin splints
or tibial periostitis, is characterized by pain in the middle and lower
end of the tibia; the pain is usually elicited by practising sports or
other physical activities [1e3]. The criteria for diagnosis of MTSS
were established by Yates and White [4]. Although the prognosis of
MTSS is usually benign, it can evolve to chronicity and be disabling
[5]. It is a common cause of leg pain in military personnel and
athletes [6,7], with incidences ranging between 4% and 35% in these
populations [8,9]. Basic training can cause tibial periostitis in 4e10%
of recruits after 8e12 weeks [9,10]. In fact, 60e80% of cases are
associated with musculoskeletal overload [11]. Prolonged military
marching and physical activity involving excess training of the
lower limbs contribute to the stress reaction of the bone [12e15],as
conrmed by imaging studies [13,16e21]. This condition has been
considered a precursor stage for stress fracture, which, unlike
MTSS, presents more localized pain that is accentuated on per-
cussion [22] and has a different treatment and prognosis.
According to the theory of bone stress reaction introduced by
Moen et al. [23], oedema in the bone marrow is a sign of bone
remodelling secondary to overload in people subjected to repetitive
strain on the lower limbs. This may cause clinical signs and
symptoms when the load exceeds a certain threshold, due to
microscopic fatigue (microlesions), as explained in the mechano-
stat model [24].
To date, no in-depth studies have been carried out on specic
treatments for MTSS. Several forms of conservative treatment have
been applied in the acute phase, such as relative rest [25e29], anti-
inammatory drugs, analgesics and cryotherapy [9], electrotherapy
[30], laser [31], acupuncture [32,33], orthotics [34,35], foot orthoses
[36], prolotherapy [37], compression [38], corticosteroid injections
[39] and kinesiotaping [40], with varying results. Fasciotomy of the
posterior supercial compartment of the leg has also been per-
formed [41e47], but no preferred therapeutic approach has been
identied yet. The clinical course is generally prolonged despite
treatment, with periods of relapse.
A therapeutic alternative is currently being studied aimed at
reducing pain and shortening recovery time in MTSS, using extra-
corporeal shockwave treatment (ESWT). Two studies from Rompe
[48] and Moen [49] have shown ESWT to be effective for MTSS,
whereas another study from Newman showed no benet[50].
Furthermore, as literature has pointed the efcacy of 3 ESWT
sessions in MTSS, we studied if one ESWT session was effective in
this pathology as well.
The aim of this study was to evaluate the effectiveness of ESWT
in a military population with MTSS.
2. Materials and methods
We performed a single-blind randomized controlled study in 42
military cadets (33 men and 9 women) with MTSS from the Military
School of Cadets of the Colombian Army, between February and
April 2015.
Inclusion criteria were as follows: 1) patients of either sex, aged
over 18 years, diagnosed with MTSS per Yates and White criteria
[4], with pain during exercise in the posterior medial part of the
tibia, and an area of diffuse pain on palpation measuring at least
5 cm; 2) continuous pain that had appeared at least 3 weeks earlier;
3) pain elicited by exercise and occurring during and after exercise;
4) unilateral pain; 5) X-Ray were performed to rule out stress
fracture or other types of fracture.
Exclusion criteria were as follows: 1) patients with current or
prior radiological signs of stress fractures or other types of fracture;
2) local infection or osteomyelitis; 3) tumour in the region; 4)
compartment syndrome; 5) prior surgery on the same leg; 6) prior
use of shockwaves for MTSS; 7) prior or current rheumatic disease;
8) coagulation disorders; 9) pregnancy.
When all the inclusion criteria and none of the exclusion criteria
were met, MTSS patients were enrolled by the orthopaedic surgeon
once informed consent had been obtained. To ensure consistency of
data collection at baseline, a specially designed protocol was used
that included clinical variables, such as the visual analogue scale
(VAS), and functional variables, such as the running test (RT), which
consisted of running on a treadmill at a xed speed (10 km/h). The
RT was stopped if the patient indicated that pain was too severe to
continue or in case of fatigue. Patient satisfaction with the treat-
ment was recorded using the Roles and Maudsley scale (RM).
Clinical assessments were performed at baseline and at a follow-up
4 weeks later by an orthopaedic surgeon blinded to patients'
treatment allocation.
Patients were randomly assigned to receive either a focused
ESWT plus a specic exercise programme (intervention group) or
the exercise programme alone (control group). Random allocation
was performed by the physiotherapist using Epidat 4.0. Allocation
was concealed from the recruiter and participants. The intervention
consisted of a single session of 1500 pulses at an energy ux density
(EFD) of 0.20 mJ/mm
2
and a frequency of 5 Hz generated by an
electromagnetic device (Duolith SD1 T-Top; Storz Medical), per-
formed by a physician specialized in rehabilitation and certied in
the use of shockwaves. ESWT was applied to the most painful
affected region on palpation in the tibia, without anaesthesia, with
S. Gomez Garcia et al. / International Journal of Surgery 46 (2017) 102e109 103
Table 1
Exercise programme for medial tibial stress syndrome patients.
Muscle stretching exercises Calf Stretch With Towel
Standing Calf Stretch
Anterior Compartment Stretch
Muscle strengthening exercises Strengthening Exercises for the Lower Leg muscles with Thera-band
®
:
Resisted Dorsiexion Flexion
Resisted Plantar Flexion
Resisted Inversion
Resisted Eversion
Strengthening Exercises for the Lower Leg:
Heel Raises
Toe Raises: Sitting
Toe Raises: Standing
Strengthening of the stabilizing muscles of the hip and pelvis:
Pelvic bridge
Lateral leg lift extension
Lateral exion leg lift: Clam exercise
Joint mobility exercises Active Range of Motion of the Ankle
Fig. 1. Consort diagram of participants ow through the trial.
Table 2
Description of the patients in the groups at the start of the study.
Variables Patient Group p
ESWT þexercise
(N ¼23)
Exercise
(N ¼19)
Mean SEM Mean SEM
Age 20.04 0.29 19.42 0.35 0.18
Body mass index 24.13 0.56 24.38 0.64 0.78
Number of clinical symptoms at the start 6.96 0.38 7.42 0.30 0.36
Number of overtraining items
a
15.78 2.02 19.11 2.15 0.27
Gender N % N % 0.15
Male 20 86.96 13 68.42
Female 3 13.04 6 31.58
a
Based on the questionnaire of the French Society for Sports Medicine [53]; SEM, standard error of the mean; N, number of patients.
S. Gomez Garcia et al. / International Journal of Surgery 46 (2017) 102e109104
the patient in the supine position and knee extended. Rest and
analgesics were prescribed for 24e48h if necessary. ESWT was
combined with an exercise programme (modied from that used
by Rompe et al. [48]) consisting of 40 min of exercise ve days a
week for four weeks under the supervision of a physiotherapist
(Table 1).
Patients assigned to the control group received the exercise
programme only. In the control group but not in the ESWT group,
cryotherapy was applied to the affected part of the tibia after
completion of the exercises during 10 minuts, in order to avoid its
possible inuence on the biological mechanism of ESWT.
The study design according to the Consort diagram [51] is
shown in Fig. 1.
Sample size calculations were based on normal approximation
Fig. 2. Pain based on visual analogue scale (VAS) at baseline and follow-up in both groups. Graph A shows VAS at rest; and graph B, VAS at the end of running.
S. Gomez Garcia et al. / International Journal of Surgery 46 (2017) 102e109 105
and bilateral contrast with continuity correction. To obtain a sam-
ple size ratio of 1:1 for both treatment groups, criteria were
a
¼0.05,
b
¼0.2, P1 ¼80.5 and P2 ¼65. We obtained a sample size
of 46 patients, i.e. 23 in each group. From this sample, 42 patients
met the inclusion criteria and none of the exclusion criteria.
Statistical analysis was performed using Windows SPSS version
17.0 software. Student's t-test and Chi-square test were used to
compare the two patient groups. Statistical signicance was
established at p 0.05.
The research project was approved by the ethics and research
committee of Hospital Militar Central de Colombia (Ref. 7257/DIGE/
16/09/2014). The study was carried out in line with the Helsinki
Declaration and best clinical practice [52].
3. Results
The initial statistical analysis showed that both patient groups
were homogeneous and therefore comparable (Table 2). There
were no dropouts.
The ESWT group showed a signicantly greater improvement
than the exercise-only group at the end of follow-up, in terms of
pain according VAS at rest (p ¼0.016) and at the end of running
(p ¼0.001) (Fig. 2).
All individuals in the ESWT group who had pain at rest 4 ac-
cording to VAS (16 patients), considered as moderate to high pain
levels [49], were asymptomatic or improved their pain on follow-
up. On the other hand, pain at rest also improved in the control
group. In addition, all patients in the control group suffering pain
before treatment, improved signicantly at follow-up. Further-
more, 69.6% of the intervention group improved pain compared to
10.5% of those treated with exercise alone. (Table 3).
Moreover, patients in the ESWT group were able to run for
17 min 33 s (SE: 2.36) at the end of follow-up, compared to 4 min
48 s (SE: 1.03) in the exercise-only group (p ¼0.000) (Fig. 3). All
patients returned to activity and running in the militar academy at
4 weeks after treatment.
Patient satisfaction with the treatment according to the Roles
and Maudsley scale was excellent (1) or good (2) in 82.6% of
patients in the ESWT group at the end of follow-up, compared to
36.8% of patients in the exercise-only group. The difference was
statistically signicant (p ¼0.002) (Fig. 4).
No complications or signicant adverse effects were observed in
either group.
4. Discussion
Military cadets are regularly subjected to training regimes with
Table 3
Percent reduction of pain for both groups.
Group and variables Before treatment At the end of treatment
Frequency Percentage Frequency Percentage
ESWT þexercise
VAS at rest
High level of pain 16 69,6 0 0,0
Low level of pain 7 30,4 23 100,0
VAS at the end of running
High level of pain 23 100,0 7 30,4
Low level of pain 0 0,0 16 69,6
Exercise
VAS at rest
High level of pain 12 63,2 2 10,5
Low level of pain 7 36,8 17 89,5
VAS at the end of running
High level of pain 19 100,0 17 89,5
Low level of pain 0 0,0 2 10,5
Fig. 3. Running time in minutes in both groups.
S. Gomez Garcia et al. / International Journal of Surgery 46 (2017) 102e109106
intense periods of physical activity, overload of the lower limbs, and
sometimes with insufcient recovery periods, which may lead to
musculoskeletal lesions such as MTSS. Treatment of MTSS using
ESWT has been shown to be effective in athletes [48,49], but its
efcacy in military personnel has not been evaluated to date
(Table 4).
The main result of our study showsthat the use of focused ESWT
plus exercise in military cadets was more effective, as measured by
clinical and functional outcome measures, than exercise alone,
particularly in terms of pain experienced after running, running
time and patient satisfaction with the treatment according to the
Roles and Maudsley scale.
In our study, pain-free running time increased in both groups at
the end of follow-up and was signicantly higher in the ESWT
group. Rompe et al. [48], in a non-randomized retrospective study,
showed pain alleviation in the radial shockwave group compared to
the control group, consisting of rest, cryotherapy and a regime of
therapeutic exercises carried out at home. They also demonstrated
that ESWT was associated with a faster return to sports activities: in
64% of athletes after 4 months of treatment and 85.1% after 15
months, compared to 46.80% of controls after 15 months.
In our study, patients in the ESWT group were able to run
without pain for 17 min 33 s at one month after treatment, much
longer than the 4 min 49 s in the exercise-only group.
Similarly, Moen et al. [49], in a non-randomized, non-blinded
observational study in MTSS, showed that 5 sessions of focused
ESWT signicantly shortened recovery time to 59.7 days, compared
to 91.6 days for the patients in the control group.
We used the same device as Moen et al. [49] and Newman et al.
[50] to generate focused electromagnetic ESWT to treat MTSS, as
well as the same type of functional evaluation, the running test.
This test was chosen because running is one of the essential
training activities of military cadets.
Surprisingly, Newman et al. [50], in a randomized, double-blind
Fig. 4. Excellent or good results according Roles and Maudsley scale on last follow-up in both groups.
Table 4
Evidence on shockwaves in medial tibial stress syndrome.
Author
(year)
Type of Study
(No. of Patients)
Device No. of
Pulses
EFD Frequency
(Hz)
No. of
Sessions
Main Results
Rompe et al.
(2010)
[48]
Retrospective cohort, in athletes
N¼94
Radial 2000 2.5 bar 8 3 Recovery level:
Completely recovered or much improved: ESWT 76% vs. Control 37%.
Moen et al.
(2012)
[49]
Prospective observational, non-
randomized, in athletes
N¼42
Focused 1000
e1500
0.10
e0.30
a
2.5 5 Time to full recovery:
ESWT 59.7 days vs. Control 91.6 days.
Newman
et al.
(2017)
[50]
Prospective RCT, in athletes
N¼28
Focused 1000
e1500
0.10
e0.30
a
e5 - No signicant differences between groups during muscle pressure,
during running.
- No differences in running pain-limited distance.
- Self-perception of change GROC: no signicant difference between
groups.
Gomez et al.
(2017)
[58]
Prospective RCT, in military
personnel
N¼42
Focused 1500 0.20
a
5 1 - Lower pain (VAS) after running in ESWT þexercise programme of 2.17
vs. 4.26 in the exercise programme group.
- Faster running time in ESWT þexercise programme of 17.33 min vs.
4.49 in the exercise programme group.
- Excellent or good results in 86.2% in ESWT þexercise programme
compared to 36.8% in exercise programme group.
a
mJ/mm
2
; EFD, energy ux density; ESWT, extracorporeal shockwave treatment; RCT, randomized clinical trial; GROC, Global Rating of Change score.
S. Gomez Garcia et al. / International Journal of Surgery 46 (2017) 102e109 107
study in patients with MTSS treated with an electromagnetic de-
vice, found no signicant differences between the treatment group
and the control group in terms of pain at rest, on muscle palpation,
while running or in pain-free running distance. These results are
different to our results and there are several possible causes for
this: 1) no complementary investigations were performed in MTSS
patients to rule out other conditions, such as stress fracture, which
require different treatment and longer recovery times; 2) the small
sample size of 28 patients initially and 24 at the nal follow-up; 3)
non-adherence to ISMST standard [54], given that EFD was
increased from 0.1 to 0.3 mJ/mm
2
in each session, instead of a
specic therapeutic energy level; treatment was performed every
two weeks, instead of weekly; 4) the shamdose consisted of 1000
pulses of 0.01 mJ/mm
2
in each session, which may have had a
positive therapeutic effect. These circumstances may explain why
there were no differences in the ESWT group compared to the sham
group.
Standard electromagnetic ESWT parameters recommended are
1200e1500 pulses, EFD ¼0.18e0.25 mJ/mm2 and 3 or 4 treatment
sessions [55]. In our case, our ESWT protocol consisted of 1500
pulses, EFD 0.20 mJ/mm2 in a single session. Cadets with MTSS
were able to resume their activity in a safe and effective manner
within the shortest time possible. Other pathologies, such as
plantar fasciitis, have been treated with one session of electro-
magnetic ESWT with favorable results [56,57]. Unlike other studies,
we showed that a single session of focused shockwaves produced
excellent or good results in 82.6% of patients one month after
treatment [58]. In contrast, in the studies by Rompe et al. [48],
Moen et al. [49] and Newman et al. [50],(Table 4). MTSS patients
required, respectively, 3, 5 and 5 ESWT sessions. Shorter recovery
time is important in military personnel with MTSS, so that they can
return to their functional activities quickly. On the other hand,
compliance with the training exercise programme was conrmed
at the end of the study by all patients in both groups.
Another important aspect associated with this condition is the
body mass index. Unlike the study by Plisky [59], our study shows
no signicant differences in this variable, probably due to the fact
that, in military training, the intense aerobic physical exercise
required by the cadets makes them more likely to be in good
physical condition and not overweight or obese. This observation
supports the hypothesis that the condition is due to repeated
overloading of the cadets' leg bones during the period of military
training, not to excess weight.
MTSS tends to become chronic and may lead to a stress fracture
of the tibia [5,22], which could end a patient's military career due to
the long time to functional recovery. A cost study would presum-
ably show that a single session of focused electromagnetic shock-
waves is more efcient in improving symptoms and reducing the
time to functional recovery than multiple physiotherapy sessions.
We therefore believe that focused shockwaves in MTSS are safe,
effective and efcient, shortening the time required to achieve
functional recovery compared to conventional therapies.
We must consider that the current study included military
personnel of both sexes and there were no age group differences.
Therefore, the ndings of this study could be generalized to the
population of military cadets and patients with MTSS as well.
Limitations of our study are small sample size and short follow-
up. Further research is required to establish long-term ESWT cost-
effective interventions in MTSS patients for a safer and faster
functional recovery to their previous activities.
5. Conclusion
A single application of focused extracorporeal shockwave
treatment in combination with a specic exercise programme
accelerates clinical and functional recovery in military cadets with
MTSS, with a success rate of 82.6% at 4 weeks.
Conicts of interest
Nothing to declare.
Funding
The authors have not received external funding for this study.
Storz Medical AG, lent the device Duolith SD1 T-Top for the study
period. No other potential conicts of interest relevant to this
article were reported.
Ethical approval
The research project was approved by the ethics and research
committee of Hospital Militar Central de Colombia (Ref. 7257/DIGE/
16/09/2014). The study was carried out in line with the principles of
the Helsinki Declaration and best clinical practice.
Unique identifying number (UIN)
researchregistry2377.
Author contribution
Santiago G
omez García: coordination, design of the study, data
collection, interpretation of data, writing the article, tables, nal
revision.
Silvia Ram
on Rona: writing, gures, tables, nal revision.
Martha Claudia G
omez Tinoco: data collection, writing, nal
revision.
Mikhail Benet Rodriguez: design of the study, statistical anal-
ysis, interpretation of data.
Diego Mauricio Chaustre Ruiz: data collection, revision.
Francia Piedad C
ardenas Letrado: data collection, revision.
Africa L
opez-Illescas Ruiz: nal revision and correction.
Juan María Alarc
on García: nal revision and correction.
Guarantor
Santiago G
omez García.
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... Both RCTs (Garcia 2017;Newman, 2017) assessed pain, but at different moments in time. Garcia (2011) used VAS andNewman (2017) used NRS. ...
... Garcia (2011) used VAS andNewman (2017) used NRS. Garcia (2017) measured pain before and after treatment, with the patient resting, or running. At rest, in the ESWT-group pain decreased from 3.78 (SE: 0.338) to 0.56 (SE: 0.206) at four weeks, whereas in the control-group pain decreased from 4.05 (SE: 0.408) to 1.47 (SE: 0.309) at four weeks (between-group analysis p=0.016). ...
... Both RCTs (Garcia 2017, Newman 2017) assessed function. Garcia (2011) measured the duration of running at 10km/h and Newman (2017) the distance of running until pain reached a specific level (4 on a scale of 0-10). ...
... The mean age was 26.51 yr, with similar mean ages of 26.82 yr and 26.16 yr for the intervention group and the control group, respectively. The participants' mean body mass index (BMI) in Gomez Garcia et al. 31 Pain History: The pain was induced by exercise and lasted for a few hours or days after exercise. The pain was located on the posteromedial border of the tibia. ...
... 4 The shortest time from the onset of MTSS injury reported in studies was two months, 32 and the maximum time spent from the onset of injury was 30 mo. 32 The mean duration of symptoms was 16.36 mo, which were 19.92 mo for the intervention group and 12.56 mo for the control group. 27,32,33 Gomez Garcia et al. 31 did not provide data on the duration of symptoms. ...
... In the study by Gomez Garcia et al., 31 42 participants with unilateral chronic MTSS were randomly divided into intervention and control groups. The intervention group received a single session fESWT with 1500 pulses at 0.20 mJ/mm 2 and a specific exercise program that is provided in the Table 2. ...
Article
This systematic review evaluates the available evidence for extracorporeal shockwave therapy (ESWT) use in the treatment of medial tibial stress syndrome (MTSS). PubMed, EMBASE, Scopus, ISI Web of Science, and Cochrane Central Register of Controlled Trials (Cochrane CENTRAL) database searches were performed without a time limit in August 2021. Two independent researchers performed the search, screening, and final eligibility of the articles. Data were extracted using a customized spreadsheet, which included detailed information on patient characteristics, interventions, and outcomes. The methodological quality of the included studies was independently assessed by two reviewers using the Physiotherapy Evidence Database scale (PEDro). Three studies were identified that compared 23, 12, and 22 participants in the intervention group with 19, 12, and 20 participants in the control group, respectively. The mean age of participants in these studies was 26.51 yr, and the mean duration of symptoms in the two studies that reported this was 16.36 mo. All studies used focus shockwave therapy. Extracorporeal shockwaves reduced pain and time to recovery and increased patient satisfaction. No study reported adverse effects. Based on the limited studies, ESWT may reduce pain and shorten recovery duration in MTSS. Further randomized clinical trials with sham control may substantiate these findings in other patient populations. Level II.
... It is most commonly seen in runners, ballet dancer, run on uneven surfaces improper shoes sole all these factors provoke the symptoms. The anterior and posterior aspects of the tibia are the most typically affected (Garcia, 2017). Medial side is most commonly involved than lateral side sometime anterolateral side also shows the symptoms and both of the side also shows same symptoms Leg pain and stiffness, as well as overuse of the foot flexors. ...
... In ESWT, a small tensile wave element is represented by one main positive pressure wave that has a frequency range of several kHz to 10 MHz or more. The focal area of ESWT is the position in which the shock wave is focused during treatment, which is reached by 80% of the maximum amount of emitted energy (Gomez- Garcia et al., 2017). The energy in this focal area is defined as the energy density per shock, and the unit area is recorded in joules. ...
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This study was conducted to investigate the therapeutic effects of three electrotherapy intervention methods on abnormally elevated muscle tone and reduced functional activities, such as walking, in stroke patients with central nervous system (CNS) injuries. A total of 32 subjects diagnosed with stroke were randomized into three experimental groups: Experimental Group 1 received extracorporeal shock wave therapy (ESWT); Experimental Group 2 received functional electrical stimulation (FES); and Experimental Group 3 received transcutaneous electrical nerve stimulation (TENS). MyotonPRO was used to measure abnormal muscle tone in stroke patients, and the timed up and go test (TUG) was employed to evaluate their functional activity by measuring their gait speed before and after the interventions. All three therapeutic interventions were applied to the triceps brachii, wrist extensors, quadriceps femoris, and tibialis anterior muscles three times a week for six weeks. In this study, decreased muscle tone of the triceps brachii and the wrist and increased gait speed were observed in Experimental Group 1, and decreased muscle tone of the tibialis anterior muscle and increased gait speed were observed in Experimental Group 2.
... The risk of getting the MTSS is particularly high in the military members of the first year of service, who also include the cadets from HMEI [11]. It has been determined that the course of primary military training can lead to periostitis of the tibia in 10% of cadets and 60-80% of all injury cases are associated with musculoskeletal overuse [19]. ...
Article
Full-text available
Aim: The purpose of the study was to substantiate the relevance of the introduction of physiotherapy for prevention and rehabilitation for medial tibial stress syndrome in cadets by analyzing of their injuries experience. Materials and Methods: 256 cadets took part in the retrospective study. The study was conducted in a survey form. The specially prepared questionnaire included questions about injuries and pain syndromes with an emphasis in the manifestation of symptoms of medial tibial stress syndrome. Results: 59.5% of respondents reported on the occurrence of injuries and pain syndromes during training in higher military educational institutions. The first year was pointed out as the most traumatic by the cadets of all year of studying. Out of all respondents 62% of the first year cadets, 37.8% of the second years, and 32.2% of the third years pointed the first year as the most traumatic. 83.2% of respondents indicated having an experience of injuries and pain syndromes in the lower limbs during training. It was found that 13.6% of injuries and pain syndromes in cadets occur in the lower limbs; among them 62.1% have the localization of pain on the medial surface. Conclusions: The highest number of injuries and pain syndromes in cadets occurs in the first year of studying. The most common are injuries and pain syndromes of the lower limbs, a third part of which are the injuries of the tibiae area. More than half of all injuries and pain syndromes of the lower limbs are localized on the medial surface, which means the risk of development of MTSS. The obtained results determine the relevance of research on the development and analysis of the effectiveness of using physiotherapy interventions to prevent and treat the MTSS in cadets
... [4][5][6][7][8][9] Beyond the acute phase, therapies include splinting, bracing, crutches, shockwave, and physiotherapy with proprioceptive training. 6,7,10 Surgery is reserved for recalcitrant cases and may include posterior fasciotomy, procedures to address the tibial bone surface, and tibial nailing for stress fractures. 11 The role of steroids for treatment of MTSS has been described in the literature, though with a limited examination into effective-ness, safety profile, and adverse effects. ...
Article
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.
... In another study, conducted to assess whether a focused ESWT session was effective in the treatment of military students with chronic shin splint, the control, and treatment groups were both performed the same exercises. According to this study, single-session focused ESWT therapy has been shown to accelerate clinical and functional recovery when combined with a specific exercise program 15 . Similar to our study, they used an exercise program for both groups and both groups showed improvement. ...
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Aim: To determine the infectious danger of medical waste from patients with COVID-19, by examining them for the presence of coronavirus SARS-CoV-2. Materials and Methods: Regulatory – legal acts, foreign editions, results of the laboratory researches that we received served as materials for carrying out research. While researching such methods were used: descriptive, bibliographic, analytical, epidemiological, laboratory diagnostics, statistical. Results: The study confirmed the presence of RNA of the coronavirus SARS-CoV-2 in 5 selected samples from protective masks of patients with COVID-19 (8.9%) by polymerase chain reaction (PCR). SARS-CoV-2 coronavirus was not detected in samples taken from medical masks. Separate studies of wastewater from the infectious disease hospital of Ostroh General Hospital and from the city sewer network for the presence of coronavirus SARS-Cov-2 were conducted. SARS-CoV-2 coronavirus was not detected in the selected samples by PCR. Conclusions: The results of the study confirm the infectious potential of medical waste, mostly wrong treatment.
Article
Objectives: We aimed to explore, which muscle stiffness changes may be related to medial tibial stress syndrome (MTSS) and the correlation between the medial tibial periosteal thickness and lower leg muscle stiffness. Methods: This study included 63 subjects distributed into 3 groups: the symptomless group, the MTSS group, and the control group. The lower leg muscle stiffness of the tibialis anterior (TA), extensor digitorum longus (EDL), peroneus longus (PL), soleus (SOL), lateral gastrocnemius (LG), medial gastrocnemius (MG), tibialis posterior (TP), and flexor digitorum longus (FDL) in the 3 groups was obtained by two-dimensional shear wave elastography. Differences in the muscle stiffness and medial tibial periosteal thickness in the 3 groups were determined by one-way analysis of variance (ANOVA) and least significant difference tests. The relationships between the periosteal thickness and the muscle stiffness were assessed using Pearson correlations. Results: The shear wave velocity (SWV) of all lower leg muscles except the EDL was higher in the symptomless and MTSS groups than in the control group (TA, P = .001; PL, P = .006; SOL, P < .001; LG, P < .001; MG, P < .001; TP, P < .001; FDL, P = .013; and ANOVA). A significant difference was found in the SWV of the SOL, TP, and FDL between the control and symptomless groups (P = .041, P < .001, and P = .013, respectively). Moreover, the medial tibial periosteum was thickened after running training, and its thickness was positively correlated with muscle stiffness. Conclusion: The medial tibia periosteal thickness is positively correlated with the lower leg muscles stiffness. Changes in SOL, TP, and FDL stiffness may be related to the occurrence of MTSS.
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Objectives: Up to 35% of runners develop medial tibial stress syndrome (MTSS) which often results in lengthy disruption to training and sometimes affects daily activities. There is currently no high quality evidence to support any particular intervention for MTSS. This study aims to investigate the effect of shockwave therapy for MTSS. Design: A randomized, sham-controlled, pilot trial in a university-based health clinic including 28 active adults with MTSS. Methods: Intervention included standard dose shockwave therapy for the experimental group versus sham dose for the control group, delivered during Week 1-3, 5 and 9. Main outcome measures were pain measured during bone and muscle pressure as well as during running using a numerical rating scale (0-10) and running was measured as pain-limited distance (m), at Week 1 (baseline) and Week 10 (post-intervention). Self-perception of change was measured using the Global Rating of Change Scale (-7 to +7) at Week 10 (post-intervention). Results: Pain (palpation) was reduced in the experimental group by 1.1 out of 10.0 (95% CI -2.3 to 0.0) less than the control group. There were no other statistically significant differences between the groups. Conclusions: Standard dose shockwave therapy is not more effective than sham dose at improving pain or running distance in MTSS. However, the sham dose may have had a clinical effect. Further investigation including a no intervention control is warranted to evaluate the effect of shockwave therapy in the management of MTSS.
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Medial stress tibial syndrome (MTSS) has been and remains one of the most common pathologic conditions of the lower extremity. The results of conventional therapies for this condition have been inconsistent. Local corticosteroid injection has been shown to have favourable effects in treating musculoskeletal disorders. The effect of local multipunctual injections of a corticosteroid combined with an anaesthetic was studied in 47 patients (29 male and 18 female subjects, with an average age of 23.8 years) with MTSS. Direct consultation and examination was used to assess outcome. Patients were evaluated once a week after first injection for the first 4 weeks, and 3 months after treatment as well. Level of symptoms-free activity was recorded for each patient. The outcomes of the multipunctual injections were determined by comparing preintervention and posintervention level of symptoms-free activity and ability of the athletes to return to presymptom levels of exercise. The results suggest that the treatment reduces the recovery time and improves functional outcomes.
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To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients. Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.
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In brief Tibial stress fractures often occur in Patients who participate in running and jumping sports. With rest, most stress fractures heal without incident, though midshaft fractures are more resistant to healing. Bone scans are usually required to confirm the diagnosis. Relative rest, strength training, proper footwear, and treating underlying risk factors are the mainstays of treatment. A new treatment option is a pneumatic brace that the patient can wear when he or she returns to play. Physicians should be prepared to counsel competitive athletes about the risks of returning to play too soon.
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Forty athletes, ages 18-45 with tibial stress syndrome (shin splints), were analysed using subjective questioning based on a ten point Likert-type pain scale that was used to assess pain level. The scale ranged from None (1) to Distressing (5) to Unbearable (10). The athletes were divided into three treatment groups: Sports Medicine (N=17), Acupuncture (N=12) and a combination group of Sports Medicine and Acupuncture (N=11). The treating practitioners were certified and student athletic trainers at University of California, San Diego RIMAC Athletic Training Center along with acupuncture interns supervised by the author from Pacific College of Oriental Medicine, San Diego. The study took place over a 3 week period, with each participant filling out an initial questionnaire (Intake) prior to the first week of treatment. Follow-up questionnaires were utilised at the beginning of each week of treatment for the remaining 2 weeks (Follow-up 1 and Follow-up 2). Participants answered questions concerning intensity and duration of pain during and between activities, in addition to dosages taken of anti-inflammatory medications (NSAID). Participants in all groups received a minimum of 2 treatments per week. The three treatment groups were compared to each other: Sports Medicine (S), Acupuncture (A) and Acupuncture and Sports Medicine combination (AS). All athletes reported an increase in effectiveness of treatment from Intake to Follow-up 2, regardless of the treatment group they were in. Athletes in the A and AS Groups received the most pain relief, were least hindered by pain during sporting and non-sporting activities, and felt overall that the treatments were more effective than those reporting in the S Group. The perception of pain, pain relief, and effectiveness was not significantly improved for athletes in the S Group. Athletes taking anti-inflammatory medications in the AS and A Treatment Groups took significantly fewer doses during the course of the study than athletes in the S Group.
Article
Context Medial tibial stress syndrome (MTSS) is an overuse injury occurring among the physically active. Linked to increased strain on the medial tendons of the ankle, studies emphasize controlling medial foot loading in the management of this condition. Kinesio taping (KT) has gained popularity for treating musculoskeletal pathologies; however, its effect on MTSS remains uninvestigated. This study aimed to determine if healthy participants and patients with current or previous history of MTSS differ in the rate of loading, and if KT affects plantar pressures in these participants. Methods Twenty healthy participants and 20 participants with current or previous history of MTSS were recruited and walked across a plantar pressure mat prior to KT application, immediately after application, and after 24-hours of continued use. Time-to-peak force was measured in 6 foot areas and compared across groups and conditions. Results ANOVA revealed a significant interaction between group, condition, and foot area (F=1.990, p=0.033).MTSS participants presented with lower medial midfoot time-to-peak force before tape application (95%CI: 0.014 to 0.160%, p=0.021) that significantly increased following tape application (p<0.05). Conclusions These results suggest that KT decreases the rate of medial loading in MTSS patients. Future research might assess mechanisms by which this effect is achieved.
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L'expression la plus évidente du syndrome de surentraînement associe des signes fonctionnels et psychocomportementaux qui accompagnent une baisse de performance alors que l'entraînement est poursuivi, voire accru. Afin de préciser ce type de manifestation clinique peu spécifique, on utilise souvent des questionnaires et des échelles psychocomportementales. Dans cette perspective, le groupe de travail propose un questionnaire adapté à ce syndrome. À partir des signes habituellement décrits, il doit permettre de dégager leur fréquence respective. À terme, il servira de base pour l'élaboration d'une échelle diagnostique spécifique du surentraînement.