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Shockwave treatment for medial tibial stress syndrome in athletes; A prospective controlled study

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Objective The purpose of this study was to describe the results of two treatment regimens for medial tibial stress syndrome (MTSS); a graded running programme and the same running programme with additional shockwave therapy (extracorporeal shockwave therapy; ESWT). Design A prospective observational controlled trial. Setting Two different sports medicine departments. Participants 42 athletes with MTSS were included. Intervention Patients from one hospital were treated with a graded running programme, while patients from the other hospital were treated with the same graded running programme and focused ESWT (five sessions in 9 weeks). Main Outcome Measures Time to full recovery (the endpoint was being able to run 18 min consecutively without pain at a fixed intensity). Results The time to full recovery was significantly faster in the ESWT group compared with the patients who only performed a graded running programme, respectively 59.7±25.8 and 91.6±43.0 days (p=0.008). Conclusions This prospective observational study showed that MTSS patients may benefit from ESWT in addition to a graded running programme. ESWT as an additional treatment warrants further investigation in a prospective controlled trial with the addition of randomisation and double blinding.
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Original article
Moen MH, Rayer S, Schipper M, et al. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081992 1 of 5
Accepted 3 February 2011
A B S T R A C T
O b j e c t i v e The purpose of this study was to describe
the results of two treatment regimens for medial tibial
stress syndrome (MTSS); a graded running programme
and the same running programme with additional
shockwave therapy (extracorporeal shockwave therapy;
ESWT).
D e s i g n A prospective obser vational controlled trial.
S e t t i n g Two different sports medicine departments.
P a r t i c i p a n t s 42 athletes with MTSS were included.
I n t e r v e n t i o n Patients from one hospital were treated
with a graded running programme, while patients from
the other hospital were treated with the same graded
running programme and focused ESW T (fi ve sessions in
9 weeks).
Main Outcome Measures Time to full recover y (the
endpoint was being able to run 18 min consecutively
without pain at a fi xed intensity).
R e s u l t s The time to full recovery was signifi cantly
faster in the ESWT group compared with the patients
who only performed a graded running programme,
respectively 59.7±25.8 and 91.6±43.0 days (p=0.008).
C o n c l u s i o n s This prospective observational study
showed that MTSS patients may benefi t from ESWT in
addition to a graded running programme. ESWT as an
additional treatment warrants fur ther investigation in a
prospective controlled trial with the addition of randomi-
sation and double blinding.
Medi al t ibial str ess sy ndr ome (MTSS) is one of the
most common complaints of t he lower leg in the
athletic population.
1
Incidences between 4% and
35% have been reported in both military and ath-
letic studies.
2
4
Different aetiological mechanisms
have been proposed for MTSS. For years MTSS
was thought to be caused by traction-induced
periostitis.
5
7
Another aetiological theory is that
overloaded bone remodelling causes MTSS.
8
9
Recent studies showed that with overloaded
remodelling the cortex appears osteopaenic on
CT scans and that dual energy x-ray absorpti-
ometry scans reveal decreased bone densit y.
10
11
When MTSS symptoms subside the bone density
returns to normal values,
12
suggesting that MTSS
is related to mechanical overloading of the bone.
In the treatment of MTSS a therapy in which
bone cells are upregulated would possibly
enhance bone density and t hus decrease symp-
toms. Studies that tried to enhance the number of
bone cells in the treatment of stress fractures and
the non-union of fractures provided evidence for
the plausibility of this theory.
13
14
In those studies
extracorporeal shockwave therapy (ESWT) was
used to stimulate the bone.
At the time of planning the study no studies had
been published on the use of ESW T in MTSS. As
some idea of ef fect size is necessary to perform an
adequate power analysis for the proper planning
of a randomised controlled trial it was decided to
perform a prospective obser vational controlled
study that could be simply realised in the local
area. In two regional hospitals the treatment pro-
tocol used was different and this situation lent
itself to performing this observational study. The
effect on time to full recovery after ESWT and a
graded runn ing programme was compared with
a group of MTSS patients who performed only a
running programme. The aim of this study was
to describe the results of two different treatment
regimens on MTSS; one group was rehabilitated
with a running programme, whereas the other
group was rehabilitated with the same running
programme in combination with ESW T.
M E T H O D S
S u b j e c t s
Patients were included in two separate sports
medicine departments of large general district
hospitals by one sports medicine specialist. For
inclusion in the study the Yates and White
4
crite-
ria from 2004 were used.
Pain history
The pain was induced by exercise and could last for
hours or days after exercise. Pain was located on
the posteromedial border of the tibia. T here was no
history of paraesthesia or other symptoms indica-
tive of other causes of exercise-induced leg pain.
L o c a t i o n
The patients identifi ed pain along the posterome-
dial border of the tibia. The site had to be spread
over a min imum of 5 cm.
P a l p a t i o n
Palpation of the posteromedial border of the tibia
produced discomfort that was diffuse in nature
and confi ned to the posteromedial border of the
tibia.
Symptoms had to be present for at least 21 days
for patients to be included.
Exclusion criteria
Patients were excluded if there was a past history
of a tibial fracture and when ESWT had been used
previously for MTSS symptoms.
P r o c e d u r e
Patients were included in two different sports
medicine clinics by the same investigator. In
1 Rehabilitation and Sports
Medicine Depar tment,
University Medical Center
Utrecht, Utrecht, The
Netherlands
2 Department of Physical
Therapy, Rayer Health Care
Physical Therapy, Zoetermeer,
The Netherlands
3 Department of Sports
Medicine, Medical Center
Haaglanden, Leidschendam,
The Netherlands
Correspondence to
Dr M H Moen, Rehabilitation
and Sports Medicine
Department, University
Medical Center U trecht,
Heidelberglaan 100, 3508 CX
Utrecht, The Netherlands;
m . m o e n @ u m c u t r e c h t . n l
Shockwave treatment for medial tibial stress
syndrome in athletes; a prospective controlled study
M H M o e n , 1 S R a y e r , 2 M S c h i p p e r , 2 S S c h m i k l i , 1 A W e i r , 3 J L T o l , 3 F J G Backx 1
BJSM Online First, published on March 9, 2011 as 10.1136/bjsm.2010.081992
Copyright Article author (or their employer) 2011. Produced by BMJ Publishing Group Ltd under licence.
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one clinic, patients were advised to start ESWT in combi-
nation with a running programme. In the other clinic, as
therapy, patients were advised to perform the same running
programme.
At inclusion, various baseline parameters were measured:
sex, weight, height, body mass index, kind of sport in
which the patient is involved, centimetres of pain on pal-
pation of the posteromedial border of the tibia, side of the
sy mptoms a nd nu mber of days with symptoms (see table 1 ).
The study was performed in compliance with the Helsinki
Declaration.
15
Running test
Before starting treatment, all patients performed a running
test. The test consisted of running on a treadmill at a fi xed
speed while wearing run ning shoes. Before the test, the
patient was shown a visual analogue scale (VAS, 1–10). It was
explained that a score of 4 on the analogue scale was associ-
ated with symptoms and pain that started to become annoy-
ing. With the onset of such leg symptoms by pointing at the
4 on the analogue scale, the running test would be stopped.
The test started at 7.5 km/h for 2 min. After this initial phase
of warming up, the distance was registered that could be run
at 10 km/h until a 4 on the VAS scale was indicated by the
patient. The distance ran at 7.5 km/h was subtracted from
the total metres run and was called ‘metres run on a treadmill
without pain’.
T r e a t m e n t
The treatment consisted of focused ESWT in combination
with a graded running programme or a running programme
only (see table 2 ).
Running programme
All patients performed a graded runn ing programme as part
of the treatment.
16
The programme consisted of six phases. In
the rst t wo phases the patient ran on a treadmill while in the
following phases the patient ran outdoors. A starting point
in the running programme was established using the results
from the running test. If ‘metres run on a treadmill without
pain’ was between 0 and 400 m, the patient was told to start
the running programme in phase 1. If 401– 800 m could be
run, the patient started in phase 2. With 801–1200 m, the
patient started in phase 3. If 1201–1600 m could be run, the
patient started in phase 4. At 1600 m or more, patients started
with phase 5. The running programme was not started if the
patient experienced pain during walking. In that case, t he
patient was advised to avoid symptoms by reducing loading
of the leg. Only after two consecutive days without pain dur-
ing walking, were they allowed to start the programme in
the rst phase. The programme was performed three times
per week. Instructions were given not to run on consecutive
days.
A new phase of the running programme could be com-
menced if the previous one could be fi nished without a pain
score of 4 or higher on the 1–10 VAS pain scale. A lso, if
pain (4 or more on the VAS scale) was experienced imme-
diately after the session of the running programme or 1
day after the session, the next phase was not commenced.
In that case, the next run ning session started in the same
phase with 2 min less to run. When phase 6 was fi nished,
we advised patients gradually to start their own sport. They
were instructed to practise sport and to adjust the intensity
and duration to keep their pain score at 4 or lower on the
1–10 VAS pain scale.
ESWT and running programme
In addition to the running programme, one group of patients
was treated with focused ESW T. All treatments were per-
formed by one of the authors (SR) without local anaesthesia. A
focuse d ESW T device (D uolith SD1; Storz M edical, Tä gerwi len,
Switzerland) was used in all patients. Five treatment sessions
were scheduled in the weeks 1, 2, 3, 5 and 9 after inclusion.
At the fi rst session, 1000 shocks were administered with an
energy fl ux density of 0.10 mJ/mm
2
with the patient supine
and the knees fl exed at 30°. The treatment frequency was 2.5
shocks per second. Before each treatment session, contact fl uid
was applied over the length of the posteromedial tibia. At the
start of the fi rst session, the part of the tibia that was painful
on palpation was treated with the ESW T device and also high-
lighted with a waterproof marker. The zone t hat was high-
lighted with the marker was also treated in the consecutive
sessions. At the second session (in the second week of treat-
ment), 1500 shocks were applied with an energy ux density
of 0.15 mJ/mm
2
and 2.5 shocks per second. The third session
took place in the third week of treatment; 1500 shocks were
applied with an energy ux of 0.20 mJ/mm
2
and 2.5 shocks
per second. At the fourth session (in week 5 of the treatment),
again 150 0 shocks were applied with an energy fl ux density of
0.25 mJ/mm
2
and 2.5 shocks per second. The last session was
in week 9 of the treatment. In this session, 1500 shocks were
applied with an energy ux density of 0.30 mJ/mm
2
and 2.5
shocks per second.
The treatment was performed along the painful area on
the posteromedial border of the tibia. No restrictions after
the treatment sessions were given. The running programme
started in the week of the fi rst treatment with ESWT.
Table 1 Baseline values for the treatment groups
Running programme
(N=20)
Running programme +
focused ESW T (N=22) p Value
Sex (% male) 35 73 0.029
Weight (kg) 68.5 (SD 8.6) 74.2 (SD 10.1) NS
Length (cm) 175.1 (SD 6.5) 178.5 (SD 10.3) NS
Body ma ss index (kg/ length in cm
2 ) 22.2 (SD 1.9) 23.2 (SD 2.2) NS
Age (year s) 22.7 (SD 7.2) 30.0 (SD 12.5) 0.027
Days with symp toms 189.3 (SD 339.8) 629.2 (SD 761.1) 0.022
Centimetres palpa tion pain on tibia 11.7 (SD 4.5) 11.3 (SD 6.4) NS
Metres run on t readmill without p ain 744.8 (SD 417.1) 1329.6 (SD 562.9) 0.001
ESWT, extrac orporeal shockwave ther apy; NS, not signifi cantly different (p>0.05).
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Outcome measure
The number of days from inclusion to completion of phase 6
of the running schedule (full recovery) was used as the pri-
mary outcome measure. When a patient did not fully recover
according to the graded runn ing programme, the Likert scale
was used to assess the status of the patient.
17
Scores varied on
a sca le from 1 t o 6 : 1, completely recovered; 2, much i mproved;
3, somewhat improved; 4, same; 5, worse; and 6, much worse.
Statistical analysis
After blinded, double, data entr y, all analyses were carried
out using SPSS version 17.0. To compare data between groups
and explore for possible confounding factors, χ
2
analysis and
analysis of variance (ANOVA) were used. Variables with a sig-
nifi cant difference between treatment groups using univariate
ANOVA or χ
2
analysis were considered as potential confound-
ers. Their univariate relation with the outcome parameter,
‘days to full recovery’ was expressed by the (corrected) amount
of variance explained using univariate ANOVA in the case of
ordinal or nominal confounders, or by means of univariate
regression analysis in the case of scale confounders.
All confounders were tested together in a multivariate
ANOVA, with scale confounders as covariate and nominal or
ordinal confounders as a random factor. All confounders were
also tested in interacting with the treatment status. Statistical
signi cance was set at p≤0.05.
R E S U L T S
In total, 42 athletes were included in the study. The athletes
participated most frequently in recreational running (19.1%)
and soccer (13.2%). Other sports that at hletes practised were
eld hockey, tennis, basketball, athletics and dancing. The
baseline characteristics of the athletes are shown in table 1 .
One patient in the running programme group and t wo
patients in the running programme with focused ESWT did
not fi nish the last phase of the running programme due to
persisting symptoms. The patient in the running programme
group scored a 3 on the Likert scale (somewhat improved) on
quitting the study. In the running programme with ESWT
group two patients scored 4 on the Likert scale (same) on
quitting the study. In total, 39 athletes nished the running
programme.
Time to recovery
In the group of the running programme with ESWT the dura-
tion to full recovery was 59.7 (SD 25.8) days. In the group with
the running programme only, the duration was 91.6 (SD 43.0)
days. The means were signifi cantly different between the
groups (p=0.008), with treatment explaining 17.5% of the
total variance in the number of days to full recovery.
Multivariate risk factor analysis
Some baseline characteristics were different between the
treatment groups: sex (p=0.029), age (p=0.027), days with
symptoms (p=0.022) and metres run on a treadmill without
pain (p=0.001).
Apart from sex (p=0.039), no confounder could explain
a signifi cant percentage of the variance (corrected R
2
) in the
number of days to full recovery: age, less than 1%; days with
symptoms, less than 1%; metres run on a treadmill without
pain, 3%. Women needed more days to complete phase 6 than
men: 88.8 days (SD 38.4 days) versus 63.6 days (SD 35.1 days).
With treatment used as fi xed factor in a multivariate ANOVA
on the number of days to full recovery, none of potential con-
founders mentioned above in uenced the outcome parameter
‘number of days to full recover y’. The use of ESWT was the
only variable that explained the difference between the two
groups.
DISCUSSION
This prospective observational controlled study described the
time to full recovery for two different treatment protocols.
The protocol in which ESWT was added to the running pro-
gramme showed a signifi cantly quicker recovery. This study is
limited as it was observational and no randomisation or blind-
ing was used. There are signi cant differences in the baseline
characteristics between the groups, although on analysis these
did not sign ifi cantly affect the outcome. These results provide
support for the hypothesis that the treatment of MTSS with a
running programme combined with ESWT may be faster than
treatment with a running programme alone.
The results of this study are in keeping with a recently pub-
lished retrospective trial by Rompe et al ,
18
who studied the
effect of ESWT on MTSS retrospectively. The authors com-
pared this treatment with a control group that performed a
home training programme. They found that the group receiv-
ing ESWT did recover faster, and more patients recovered than
the control group. No studies were found that investigated
ESWT for MTSS prospectively.
Other prospective studies on the treatment of MTSS could
not fi nd a signifi cant difference comparing different treatment
options. Three randomised controlled trials were performed
in which the following interventions were investigated: ice
massage with ice massage and aspirin, ice massage and fenylb-
utazone; ice massage and heel-cord stretching and a walking
cast; active laser and placebo laser and a leg orthosis.
2
19
20
It
Table 2 Running programme
Running phase Surface Minutes Total (min) Speed/intensity
1 Treadmil l 2 2 2 2 2 2 2 2 16 2 = running at 10 km/h, 2 = walki ng at 6 km /h
2 Treadmil l 2 2 2 2 2 2 2 2 16 2 = running at 12 km/ h, 2 = walk ing at 6 k m/h
3Concrete3 2 3 2 3 2 3 2 20 Intensity 1–2 (*)
3 = running, 2 = walking
4Concrete3 2 3 2 3 2 3 2 20 Intensity 2– 3 (*)
3 = running, 2 = walking
5 Concrete Continu ous running 16 Inten sity 1–2 (*)
6Concrete Continuous running 18 Intensity 2–3 (*)
*Inten sity 1, ru nning speed: lig ht jogging; Intensity 2, ru nning speed: jog ging while able t o speak ; Inte nsit y 3, running speed:
jogging while speaking becomes dif fi cult.
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should be noted that the studies mentioned had serious meth-
odological shortcomings such as small numbers or the lack of
blinding.
ESWT was only used for MTSS in one retrospective study
by Rompe et al .
18
The ESWT device used in that study was
radial. One group was treated with ESW T, while the other
group received a home exercise programme (calf stretches,
heel raises and toe raises). As a primary outcome measure they
used a six-point Likert to assess recovery (1, completely recov-
ered; 6, much worse). They found that after 1, 4 and 15 months
the group that was treated with ESW T had signi cantly better
L ik er t s co re s ( p< 0. 00 1). Ro mp e et al
18
did not str uctural ly report
the time to return to sport. They stated that time to return
to sport ranged from 6 weeks to 6 months. After 15 months,
85.1% of the athletes treated with ESW T had returned to their
preinjury sport, while 46.8% of the athletes in the exercise
group had returned to their preinjury sport.
This study did not measure time to return to sport, so a
comparison with the study by Rompe et al
18
is diffi cult. The
primary outcome measure in the current study was days to
complete a running programme (termed full recovery). This
was used to have an outcome measure that was the same for
all athletes, regardless of the type of sport and level of sport.
The time to full recovery in the running programme with
ESWT group was 59.7 (SD 25.8) days. Rompe et al
18
reported
that only 64% of their athletes with MTSS treated with ESWT
were completely recovered or much improved after 4 months.
The difference in outcome may be explained by the differ-
ing outcome measures. In the present study the patients had
to complete a running programme, whereas in the study by
Rompe et al
18
the patients had to have made a full return to
sport, which, for most athletes, would possibly involve more
tibial loading than the running programme. The difference
between the studies may also possibly be due to t he fact that
the present study used a focused ESW T instead of the radial
ESWT used by Rompe et al .
18
One study was found that com-
pared radial and focused shockwave while treating bone.
21
Differences in microcrack density and microcrack length were
found. What these differences mean for clinical practice is not
clear. The difference in outcome between our study and the
study by Rompe et al
18
could also be explained by the fact that
our study added a running programme to the ESWT. Waldorff
et al
22
showed a signifi cant decrease in microdamage in tibiae
over time following weightbearing or intermittent weight-
bearing compared with limb suspension.
Fina lly, baseline c haracter istics for age a nd duration of sym p-
toms were not the same between this study and the study by
Rompe et al .
18
This could also have in uenced the outcome.
However, Moen et al
23
showed that days with symptoms (and
metres run on a treadmill without pain) were not prognostic
factors to predict time to full recovery.
Several recent studies investigated the impact and conse-
quences of ESWT on cortical bone.
13
14
24
27
Those studies
showed an increase in osteoblast activity and an increase in
bone matrix deposition in vitro.
26
28
Promising clinical results
of ESWT on bone healing were found in studies involving
humans.
13
14
24
25
In this study, at baseline, several baseline characteristics
were different between the groups, so these were considered
possible confounding factors (age, days with symptoms and
metres run without pain on a treadmill and sex). Univariate
ANOVA with sex as a random showed only a weak relation-
ship with days to fu ll recovery. This could have possibly in u-
enced the results in this study, because more men were present
in the running programme with ESWT group. However, after
multivariate ANOVA and χ
2
analysis, no signifi cant relation-
ship was found between these parameters and days to full
recovery.
This study has several limitations. First, although the study
had a prospective design, it was not a randomised study. This
explains the difference in baseline characteristics. With a ran-
domised study the chance of unequal distributions of these
characteristics would be lower. The prospective observational
design of this study was chosen because of the limited avail-
abilit y of focused shockwave devices and the fact that the
pre-existing protocols were well suited to this observational
design to assess the possible effect size for future study plan-
ning. Also, the control group did not have contact with a phys-
ical therapist, whereas the patients in the treatment group
did. This could have infl uenced the time to complete the run-
ning programme. The physical therapists who performed the
ESWT were instructed to advise the patients as little as pos-
sible. However, the treatment in itself could have led to a pla-
cebo effect. In the future blinding would help eliminate this
shortcoming.
Another limitation of the study is its relatively small num-
ber of participants. However, even with the limited numbers
of participating athletes a signi cant difference between the
two treatment groups was found. This allows for a good esti-
mation of effect size of the treatment, which can now serve
to perform a good power analysis for designing a randomised,
blinded trial.
C O N C L U S I O N
T he t im e t o f ul l r ec ove r y i n a th le tes w it h MTSS w it h a ru nn in g
programme and focused ESWT was signifi cantly (p=0.008)
faster in the running programme and ESWT group (59.7
days (SD 25.8) and 91.6 days (SD 43.0), respectively). These
results from this study provide a base for further research of
the treatment of MTSS with ESWT combined with a running
programme for the treatment for MTSS in a prospective, ran-
domised, blinded study.
Acknowledgements The authors would like to thank Eric Bakker, from the
Depar tment of Clinical Epidemiology, Biostatistics and Bioinformatics, for his
contributions to the ar ticle.
Competing interests N o n e .
Patient consent Obtained.
What is already known on this topic
A retrospective study was conducted before on the treat-
ment of MTSS with shockwave.
This study showed that shockwave was a good possible
treatment option for MTSS.
What this study adds
This study prospectively investigated the effect of shock-
wave on MTSS and showed promising results.
This is the fi rst prospective study on MTSS that was able
to fi nd a signi cant difference on primary outcome mea-
sures between two treatment groups.
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Ethics approval This stud y was conducted with the approval of the Medical
Ethical Committee South West Holland.
Provenance and peer review Not commissioned; externally peer reviewed.
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doi: 10.1136/bjsm.2010.081992
published online March 9, 2011Br J Sports Med
M H Moen, S Rayer, M Schipper, et al.
controlled study
syndrome in athletes; a prospective
Shockwave treatment for medial tibial stress
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... 26 Studies have shown that the combination of ESWT and a graded running program reduces the duration of MTSS symptoms compared with the control group. 27 Moen et al. 17 hypothesized that an increase in bone density, and thus symptom relief, may be possible by a therapy in which bone cells are unregulated. ESWT is a treatment modality that can induce bone-cell stimulation. ...
... In the study by Moen et al., 27 22 athletes with MTSS from one hospital received fESWT plus a graded running program, and 20 athletes with MTSS from the other hospital received a graded running program alone. The shockwave protocol was similar with Newman et al., 32 and a total dose of 1450 mJ/ mm 2 was delivered during five sessions (Table 4). ...
... The shockwave protocol was similar with Newman et al., 32 and a total dose of 1450 mJ/ mm 2 was delivered during five sessions (Table 4). 27,32 The graded running program consisted of six stages. In the first two stages, patients ran on a treadmill, while in later stages, the patients ran outdoors. ...
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.
... A shockwave is a type of transient pressure fluctuation generated by electromagnetic, electrohydraulic, or piezoelectric devices (7). As an effective and safe treatment, extracorporeal shockwave therapy (ESWT) is widely used in urinary disease and musculoskeletal disorders (8)(9)(10). The main biological mechanism of ESWT includes wound healing, tissue regeneration, bone remodeling, angiogenesis, and anti-inflammation (11). ...
Article
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Objective To evaluate the efficacy and safety of extracorporeal shockwave therapy (ESWT) for postherpetic neuralgia. Design Randomized single-blind clinical study. Patients Patients with postherpetic neuralgia. Methods Patients were randomly divided into the control group and the ESWT group. The control group received conventional treatment while the ESWT group received conventional treatment and ESWT. The primary outcome is pain degree as assessed by the numeric rating scale (NRS), and secondary outcomes include brief pain inventory (BPI), Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Pittsburgh Sleep Quality Index (PSQI). Data were collected at baseline and at weeks 1, 4, and 12. Linear mixed-effects models were applied to repeated measurement data. Results The scores on the NRS, BPI, SAS, SDS, and PSQI decreased over time in both groups. The NRS and SDS scores of the ESWT group were statistically lower than the control group. There was no time × group interaction in the mixed model analysis. Baseline age was correlated with NRS scores and BPI scores, and invasive treatment was related to PSQI scores, with no interaction effect for baseline confounders observed. No adverse events were observed during the process of this trial. Conclusion Extracorporeal shockwave therapy combined with conventional treatment could relieve pain and improve the psychological state in patients with postherpetic neuralgia without serious adverse effects.
... Moen et al. 10 Os estudos foram, no geral, de baixa qualidade metodológica. Rompe et al. 8 avaliaram pacientes que concordaram em se submeter a sessões pagas de TOC (U$ 200,00), enquanto que os que não concordaram receberam tratamento domiciliar com orientações, o que pode ser um viés de seleção e viés de confundimento. ...
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A síndrome do estresse tibial medial é uma lesão comum devido a sobrecarga mecânica, principalmente em atletas, devido a inflamação local e estresse ósseo. A terapia de ondas de choque (TOC) vem sendo utilizada como tratamento para esta patologia por seus efeitos analgésicos e anti-inflamatórios. Objetivo: Avaliar a eficácia da TOC no tratamento analgésico da síndrome do estresse tibial medial e medidas de funcionalidade. Métodos: Foi realizada uma revisão da literatura, sendo incluídos estudos clínicos em humanos. Resultados: 3 artigos preencheram os critérios de inclusão, incluindo 166 pacientes. Os trabalhos trouxeram uma ampla variedade de intervenções, tipos de aparelhos, frequência e energia utilizada, além de diferenças nas quantidades de sessões e tipos de ondas de choque utilizado no tratamento. Conclusão: Ainda não há evidências consistentes quanto ao uso da TOC no tratamento conservador da síndrome do estresse tibial medial, com estudos pequenos, de qualidade metodológica baixa. Os estudos inclusos no trabalho não relataram efeitos colaterais significativos.
... 8 Studies examining measurement methods in individuals with EILP in the literature are mostly evaluated with Visual Analog Scale (VAS), numerical scoring systems, and questionnaires with Likert scale. 9,10 One of the most critical advantages of diseasespecific evaluations is its ability to be more sensitive to targeted patient population changes. 11 The EILP questionnaire, which evaluates leg pain depending on the clinic's activity, is a crucial questionnaire that evaluates the pain level between the activity and moderate sports activities. ...
Article
Context: Exercise-induced leg pain is a chronic condition that generally arises in elite and recreational athletes' lower quarter of the legs. Objectives: The study aimed to translate and culturally adapt the exercise-induced leg pain questionnaire into Turkish (T-EILP) and evaluate its reliability and validity. Design: A cross-sectional study. Methods: Established guidelines were preferred for translation and adaptation. T-EILP was filled twice with a one-week interval. In the first assessment, patients were also evaluated with Short Form-36 (SF-36) and Visual Analog Scale (VAS), both for pre-exercise and post-exercise. Test-retest reliability and internal consistency of the T-EILP were measured with the Intraclass correlation coefficient (ICC) and Cronbach's α coefficient, respectively. The construct validity was demonstrated with the Pearson correlation coefficient (r). Also, the minimum detectable change (MDC95) and Standard error of measurement (SEM95) were calculated. Results: A total of 121 participants (23.03.59 years) were included in the study. The test-retest reliability was excellent and internal consistency was acceptable (ICC=0.821, alpha=0.808). T-EILP was highly correlated with the physical function subscore of the SF-36 (r=0.509, p<0.01). There was a moderate correlation between T-EILP with the bodily pain subscore of the SF-36 and VAS (post-exercise) (r1=0.436, r2=-0.355 p<0.01). SEM95 and MDC95 were 3.54 and 9.81, respectively. Conclusion: T-EILP is a reliable and valid tool in Turkish speaking participants. MDC95 of the T-EILP provides an essential reference for monitoring exercise-induced leg pain.
... Extracorporeal shockwave therapy (ESWT) combined with a graded running program has been shown to decrease symptom duration compared to a graded running program alone. [57,58] Moen et al. conducted a study on 42 runners with MTSS using a focused ESWT device over regions painful to palpation. Five treatment sessions were performed over 9 weeks. ...
Article
Full-text available
Purpose of Review To present a synthesis of recent literature regarding the risk factors and management for MTSS. Recent Findings Risk factors include female sex, prior history of MTSS, less running experience, female athlete triad/RED-S, higher BMI, smoking, and biomechanical abnormalities. Management includes activity modification, gait retraining, orthotics, medications, and, very rarely, surgery. Summary MTSS is an overuse injury commonly seen in runners. The pathophysiology remains disputed, and diagnosis is often determined from clinical presentation alone. For unclear reasons, women are at increased risk for development of MTSS. Other risk factors include increased BMI, prior history of MTSS, less running experience, smoking, presence of at least one component of the female athlete triad/RED-S, and biomechanical abnormalities. Treatment often includes cessation of high-impact activity, gait retraining, neuromuscular training, and orthotics. In rare circumstances, surgery may be considered. Identifying risk factors is important for prevention and individualized management.
... There is evidence confirming analgesic effectiveness of similar interventions in physically active populations, for example with ESWT [37,38]. Hides et al. confirmed the effectiveness of stability training for the lumbosacral spine in athletes [39]. ...
Article
Full-text available
Background The unique repetitive nature of ballet dancing, which often involves transgressing endurance limits of anatomical structures, makes dancers prone to injury. The following systematic review aims to assess the effectiveness of physiotherapy interventions in the treatment of injuries in ballet dancers. Methods The review was performed in line with the PRISMA statement on preferred reporting items for systematic reviews and meta-analyses. Six electronic databases (PubMed, Ovid Embase, Cochrane, Medline, PEDro, Google Scholar) were queried. The study populations comprised active ballet dancers and/or ballet school attendees with acute and chronic injuries and those with persistent pain. There were no restrictions regarding age, sex, ethnicity or nationality. The Modified McMaster Critical Review Form for quantitative studies was used to assess the methodological quality of the studies reviewed in accordance with the relevant guidelines. Results Out of the total of 687 articles subjected to the review, 10 met the inclusion criteria. Diverse physiotherapeutic interventions were described and effectiveness was assessed using different parameters and measurements. Overall, the results indicate that physiotherapy interventions in ballet dancers exert a positive effect on a number of indices, including pain, ROM and functional status. Conclusions Due to the small amount of evidence confirming the effectiveness of physiotherapeutic interventions in ballet dancers after injuries and methodological uncertainties, it is recommended to improve the quality of prospective studies.
... Moen et al. prospectively compared an exercise running program to F-SWT plus exercise program. 61 Participants in the F-SWT group received five treatment sessions over 9 weeks, with graded increase of total EFD. Time to recovery was significantly faster in the F-SWT group. ...
Article
Introduction Extracorporeal shockwave therapy (ESWT) has a wide variety of clinical applications ranging from urology to orthopedics. Extracorporeal shockwave therapy is of particular interest to military medicine in the treatment of diverse musculoskeletal injuries, including recalcitrant tendinopathy. Much of the evidence for ESWT is from studies in the civilian population, including athletes. A few investigations have been conducted within military personnel. Musculoskeletal conditions within military personnel may contribute to pain and physical limitations. Optimal functional outcomes could be achieved through ESWT. The purpose of this narrative review is to summarize the current evidence on the efficacy of ESWT the in management of lower extremity musculoskeletal injuries in the military. Further, we explore the relative efficacy of ESWT compared to regenerative medicine procedures, including studies with treatment using platelet-rich plasma. Materials and Methods A literature review was performed in April 2020 to identify studies evaluating the use of ESWT for lower extremity conditions commonly observed in military personnel, including plantar fasciitis, Achilles tendinopathy, patellar tendinopathy, medial tibial stress syndrome, and knee arthritis. The literature search was completed by two researchers independently, using PubMed and Embase databases and same search terms. Disagreements were adjudicated by a senior author. Due to the paucity of relevant search results, the search term parameters were expanded to incorporate active participants. Results Two studies evaluated the use of ESWT in a military population for lower extremity injuries. This included a randomized control trial in active military with medial tibial stress syndrome and an unblinded retrospective study for the chronic plantar fasciitis condition. Both studies in the military had favorable outcomes in the use of ESWT compared to other treatment arms. The remaining studies predominantly included athletes. Although heterogeneity on the quality of the studies may prevent meta-analysis and limit the generalization of the findings, the majority of studies demonstrated an improvement in pain and return to activity using ESWT. Two studies using platelet-rich plasma as a treatment arm identified similar short-term outcomes compared to ESWT for Achilles tendinopathy and patellar tendinopathy. Conclusion Our findings suggest that ESWT is a safe and well-tolerated intervention with positive outcomes for lower extremity conditions commonly seen in the military. The few studies comparing ESWT to PRP suggest regenerative benefits similar to orthobiologics in the shorter term. More robust quality designed research may enable the evaluation of ESWT efficacy within the military population. In summary, the use of ESWT may provide pain reduction and improved function in active populations with lower extremity musculoskeletal injuries. Further research in the military is needed to evaluate shockwave efficacy in order to advance musculoskeletal care and improve outcomes.
... 4,8 Assuming MTSS represents bony overload, temporary cessation of loading activities followed by gradual re-loading is essential in management. 1 Extracorporeal shockwave therapy in combination with a home-training program resulted in a shortened time to full recovery. 9,10 The role of surgery for MTSS is debated and not discussed in recent literature. However, surgery may be considered in patients with disabling and recalcitrant complaints although treatment outcome of earlier cohort studies was suboptimal. ...
Article
Full-text available
Purpose To compare outcome following continuation of conservative interventions with surgery in patients with chronic recalcitrant Medial Tibial Stress Syndrome (MTSS). Methods Patients with chronic leg pain underwent physical examination and an intracompartmental muscle pressure (ICP) in a tertiary referral center. MTSS was diagnosed by a suggestive history and physical examination and normal ICP of the deep posterior compartment. Patients were offered continuation of conservative treatment or surgery. Patient characteristics, symptom scores (Verbal Rating Scale, range 1‐5) and sports participation before and at least one year later were collected using questionnaires. Success was defined as a good or excellent outcome. Results A total of 883 patients underwent an ICP between January 2013 and March 2019. Sixty‐five patients were diagnosed with MTSS and fulfilled inclusion criteria (surgery n=19, conservative n=46). At intake, gender, age and level of sports participation were comparable, but symptom duration was significantly longer in the surgical group (40±24 versus 25±21 months; P<0.02). At follow up, surgical treatment reduced intensity of tightness more effectively, both in rest (surgical ‐1.0±0.2 versus conservative ‐0.3±0.2; p=0.04) and during exercise (surgical ‐1.0±0.3 versus conservative ‐0.3±0.2; p=0.04). Total symptom scores during exercise dropped more following surgery (surgery ‐23±19 versus conservative ‐11±18; p=0.02), and more surgically treated patients returned to physical activity (surgical 74% versus conservative 65%; p=0.04). Success rates were similar (surgical 47% versus conservative 28%; p=0.16). Conclusion Some patients with chronic recalcitrant MTSS may benefit from surgical treatment. Future studies should focus on identifying patient factors legitimizing surgery.
Article
Full-text available
To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits. In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures. In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 +/- 27.7 (mean +/- SD) vs Non-Brace 57.9 +/- 26.2 (mean +/- SD, p = 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 +/- 1.1 (mean +/- SD) on a 1-10 scale for the brace group and 7.1 +/- 0.7 (mean +/- SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 +/- 1.3 (mean +/- SD) on a 1-10 scale. No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.
Article
Full-text available
The objective of the study was to examine the risk factors and prognostic indicators for medial tibial stress syndrome (MTSS). In total, 35 subjects were included in the study. For the risk factor analysis, the following parameters were investigated: hip internal and external ranges of motion, knee flexion and extension, dorsal and plantar ankle flexion, hallux flexion and extension, subtalar eversion and inversion, maximal calf girth, lean calf girth, standing foot angle and navicular drop test. After multivariate regression decreased hip internal range of motion, increased ankle plantar flexion and positive navicular drop were associated with MTSS. A higher body mass index was associated with a longer duration to full recovery. For other prognostic indicators, no relationship was found.
Article
Medial tibial stress syndrome (MTSS) is one of the most common leg injuries in athletes and soldiers. The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. The name given to this condition refers to pain on the posteromedial tibial border during exercise, with pain on palpation of the tibia over a length of at least 5 cm. Histological studies fail to provide evidence that MTSS is caused by periostitis as a result of traction. It is caused by bony resorption that outpaces bone formation of the tibial cortex. Evidence for this overloaded adaptation of the cortex is found in several studies describing MTSS findings on bone scan, magnetic resonance imaging (MRI), high-resolution computed tomography (CT) scan and dual energy x-ray absorptiometry. The diagnosis is made based on physical examination, although only one study has been conducted on this subject. Additional imaging such as bone, CT and MRI scans has been well studied but is of limited value. The prevalence of abnormal findings in asymptomatic subjects means that results should be interpreted with caution. Excessive pronation of the foot while standing and female sex were found to be intrinsic risk factors in multiple prospective studies. Other intrinsic risk factors found in single prospective studies are higher body mass index, greater internal and external ranges of hip motion, and calf girth. Previous history of MTSS was shown to be an extrinsic risk factor. The treatment of MTSS has been examined in three randomized controlled studies. In these studies rest is equal to any intervention. The use of neoprene or semi-rigid orthotics may help prevent MTSS, as evidenced by two large prospective studies.
Article
Objectives-To determine whether bone microcracks are altered after application of focused and radial extracorporeal shock wave therapy (ESWT) to the equine distal limb. Study Design-An ex vivo experimental model. Sample Population-A contralateral limb specimen was obtained from 11 Thoroughbred racehorses with a unilateral catastrophic injury. Distal limb specimens were also obtained from 5 non-racing horses. Methods-Three separate skin-covered bone segments were obtained from the mid-diaphysis of the metacarpus (MC3) or metatarsus (MT3). Focused (9,000 shockwaves, 0.15mJ/mm(2), 4 Hz) and radial (9,000 shockwaves, 0.175 mJ/mm(2), 4 Hz) ESWT treatments were randomized to the proximal and distal segments and the middle segment was used as a treatment control for pre-existing microcracks. After treatment, bone specimens were bulk-stained with basic fuchsin and microcracks were quantified in transverse calcified bone sections. Results-ESWT had small but significant effects on microcracks. Microcrack density (Cr.Dn) and microcrack surface density (Cr.S.Dn) were increased after focused ESWT, whereas Cr.Le was increased after radial ESWT. In racing Thoroughbreds, Cr.Le increased with increased number of races undertaken. Cr.Dn and Cr.S.Dn were not significantly influenced by the number of races undertaken. Conclusion-ESWT has small but significant effects on bone microcracking ex vivo. Clinical Relevance-These preliminary data suggest that ESWT has the potential to increase bone microcracking in equine distal limb bone in vivo. Such effects may be more pronounced in Thoroughbreds that are actively being raced, because in vivo microcracking increases with increased number of races undertaken. (C) Copyright 2004 by The American College of Veterinary Surgeons.
Article
In the last 30 years, few advances have been made in the management of tibial stress injuries such as tibial stress fracture and medial tibial stress syndrome (MTSS). Tibial overuse injuries are a recognised complication of the chronic, intensive, weight-bearing training commonly practised by athletic and military populations. Generally, the most effective treatment is considered to be rest, often for prolonged periods. This is a course of action that will significantly disrupt an active lifestyle, and sometimes end activity-related careers entirely. There is now considerable knowledge of the nature of tibial stress injuries, such that presently accepted management practices can be critically evaluated and supplemented. Most recent investigations suggest that tibial stress injuries are a consequence of the repetitive tibial strain imposed by loading during chronic weight-bearing activity. Evidence is presented in this article for an association between repeated tibial bending and stress injury as a function of: (i) strain-related modelling (in the case of MTSS), and (ii) a strain-related positive feedback mechanism of remodelling (in the case of stress fracture). Factors that influence the bending response of the tibia to loading are reviewed. Finally, a guide for injury prevention and management based on research observations is presented.
Article
The project conceived in 1929 by Gardner Murphy and the writer aimed first to present a wide array of problems having to do with five major "attitude areas"--international relations, race relations, economic conflict, political conflict, and religion. The kind of questionnaire material falls into four classes: yes-no, multiple choice, propositions to be responded to by degrees of approval, and a series of brief newspaper narratives to be approved or disapproved in various degrees. The monograph aims to describe a technique rather than to give results. The appendix, covering ten pages, shows the method of constructing an attitude scale. A bibliography is also given.
Article
The current "gold standard" for treatment of chronic fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal is intramedullary screw fixation. Complications with this procedure, however, are not uncommon. Shock wave therapy can be an effective treatment for fracture nonunions. The purpose of this study was to evaluate the safety and efficacy of shock wave therapy as a treatment of these nonunions. Twenty-three patients with a fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal received high-energy shock wave therapy (2000 to 4000 shocks; energy flux density per pulse, 0.35 mJ/mm(2)), and twenty other patients with the same type of fracture nonunion were treated with intramedullary screw fixation. The numbers of fractures that were healed at three and six months after treatment in each group were determined, and treatment complications were recorded. Twenty of the twenty-three nonunions in the shock wave group and eighteen of the twenty nonunions in the screw fixation group were healed at three months after treatment. One of the three nonunions that had not healed by three months in the shock wave group was healed by six months. There was one complication in the shock wave group (post-treatment petechiae) and eleven complications in the screw-fixation group (one refracture, one case of cellulitis, and nine cases of symptomatic hardware). Both intramedullary screw fixation and shock wave therapy are effective treatments for fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal. Screw fixation is more often associated with complications that frequently result in additional surgery.
Article
Delayed and nonunion of the tibia are not uncommon in orthopaedic practice. Multiple methods of treatment have been developed with variable results. The objective of this study was to define disease-specific and treatment-related factors of prognostic significance in patients undergoing shock wave therapy for tibia nonunion. Retrospective analysis. One hundred ninety-two patients treated with extracorporeal shock wave therapy (ESWT) at a single referral trauma center, AUVA-Trauma Center Meidling, a large single-referral trauma center located in Vienna, Austria, in an attempt to determine the feasibility and factors associated with the use of ESWT in the treatment for tibia nonunion. ESWT coupled with posttreatment immobilization, external fixation, or ESWT alone. Fracture healing, overall healing percent, and factors associated with ESWT success or failure. At the time of last follow up, 138 of 172 (80.2%) patients have demonstrated complete fracture healing. Mean time from first shock wave therapy to complete healing of the tibia nonunion was 4.8+/-4.0 months. Number of orthopaedic operations (P=0.003), shock wave treatments (P=0.002), and pulses delivered (P=0.04) were significantly associated with complete bone healing. Patients requiring multiple (more than one) shock wave treatments versus a single treatment had a significantly lower likelihood of fracture healing (P=0.003). This may be attributable to the finding that a significantly greater proportion of patients with multiple rather than single ESWT treatments had three or more prior orthopaedic procedures (more than one ESWT, 63.9% versus one ESWT, 23.5%; P<0.001). ESWT is a feasible treatment modality for tibia nonunion.