Ian,
Thanks for your reply.
I am familiar with the Beck etal paper, which is one of a number I have
read debunking the myth that Tib Post is responsible for MTSS. Anatomically
it's attachment is remote from the site of symptoms ie tib post attaches to
the LATERAL aspect of the tibia, interosseous membrane and even the medial
border of the fibula, while MTSS is defined most commonly as exercise
induced pain in the mid to lower 1/3 of the MEDIAL tibial border.
Michael and Holder in 1985 were one of the earliest to implicate the
soleus, and more particularly the soleus fascia, which they described as
forming an "impressive, tough attachment" to the medial border of the tibia
extending distally down the tibia. Their dissection study showed the FDL
attaching beneath the soleus, with tib post attaching as described above.
They cited the fact that soleus acts as an invertor (as well as plantar
flexor) due to the obliquity of the STJ axis, the 90 degree rotation of the
achilles as it courses towards the calcaneum (placing the soleus portion
most medially) as factors predisposing soleus and its fascia to injury in
MTSS.
Saxena Bunce and O'Brien (1990) performed cadaveric and amputee dissections
and measured the distance from the medial malleolus to the most distal
attachment of the TP. They found that it attached in the lower 1/3 of the
lower leg in all 10 of their specimens, however did not measure
medial/lateral attachment sites. They reported encountering no soleus
attachment in the lower 1/3 in any of their legs. (This may be due to the
fact that they dissected to the deep fascia initially, thereby removing the
superficial fascia and didn't measure the attachment of the soleus fascia,
only the tib post attachment to the 'medial border, posterior and medial
surfaces' of the tibia in all cases. Their definition of MTSS was
inadequate, also, basically including any form of lower leg pain, not
limiting to medial tibial border pain.
Beck & Osternig seem to have expanded on the above findings by measuring
the med/lateral extent of attachments. They used an n=50, finding that FDL
and soleus attach on the lower 1/2-1/3 medial border of the tibia, with TP
attaching to the lateral surface of the tibia. Anecdotally they describe
the soleus fascia as extending to the medial malleolus in 10% of
preparations they concluded that FDL and soleus have potential to cause
traction on periosteum at site of MTSS symptoms.
It seems to be well recognised in the literature that soleus and FDL are
the culprits most likely to be responsible for periostitis in MTSS. It is
hard to argue with well designed and reported anatomical studies which have
come to light in the last decade.
Another interesting paper I have recently read (Garth WP and Miller ST)
implicates weak intrinsics and mild claw toe deformity in MTSS. They
postulate that this causes FDL overuse and injury at the proximal
attachment, showing correlations between intrinsic weakness and MTSS as
well as loss of MTP flexion and increase in MTP extension range in
symptomatic group compared with controls. Very interesting!
Hope this is of interest. If you want any other references let me know and
I'll send you a more extensive list. Cheers from down under.
Matt
REFS:
Saxena A, O’Brien T and Bunce D (1990) Anatomic dissection of the tibialis
posterior muscle and its correlation to medial tibial stress syndrome. The
Journal of Foot Surgery 29(2)105-108
Michael, R.H. & Holder, L.E. (1985). The Soleus Syndrome. A cause of medial
tibial stress (shin splints). The American Journal Of Sports Medicine 13
(2) 87-94.
Garth WP and Miller ST (1989): Evaluation of claw toe deformity, weakness
of the foot intrinsics , and posteromedial shin pain. The American Journal
of Sports Medicine 17: 821-827.
At 20:04 15/07/98 +1000, you wrote:
>>From: "Mathieson, Ian" <[log in to unmask]>
>>To: Matt McEwan <[log in to unmask]>
>>Subject: RE: Medial Tibial Stress Syndrome
>>Date: Wed, 15 Jul 1998 09:22:00 +0100
>>
>>Matt,
>>
>>
>>I am a Podiatrist in Cardiff, Wales. I have a reference you may be
>>interested in. Recently I have become very interested in the pathology
>>of medial tibial stress syndrome, which is something that I treat an
>>awful lot. A s a Podiatrist, I am looking at foot function mostly. My
>>ideas regarding aetiology are either secondary to excess motion or
>>secondary to limited motion of the rearfoot, but I do look at msucular
>>flexibility and where required I try to deal with this using both
>>stretching and manipulations. Usually I am looking at tibialis
>>posterior, but recently I came across a very interesting article
>>attempting to correlate in-vivo pain sites with in-vitro muscular
>>origins. They found that the site of pain did not actually relate to tib
>>post, but rather, lng flexors and soleus. Reference is:
>>
>> Beck, B, Osternig LR, Medial Tibial Stress Syndrome. The location of
>>muscles in the leg.
>>Journal of Bone & Joint Surgery -American volume July 1994 76-A
>>pp1057-1061
>>
>>In their abstract there is an interesting statement : 'The data support
>>recent reports that the soleus is probably the major contributor to
>>traction-induced MTSS'.
>>
>>You can also get some decent information from
>><http://www.medmedia.com/oa4/78.htm>
>>This will take you into Wheeles textbook of orthopaedics. If this
>>doesn't work you can go through Orthogate - <http://www.orthogate.com
>>
>>Best of Luck
>>
>>
>>Ian Mathieson
>>
>>*************************************************
>>Lecturer in Podiatry
>>Wales Centre for Podiatric Studies
>>University of Wales Institute, Cardiff
>>E-mail: [log in to unmask]
>>Phone: 01222 50 68 64
>>*************************************************
>> ----------
>>From: Matt McEwan
>>To: [log in to unmask]
>>Subject: Medial Tibial Stress Syndrome
>>Date: Tuesday, 14 July, 1998 15:42
>>
>>I am interested in list members experience with surgical management of
>>medial tibial stress syndrome, particularly fasciotomy for relief of
>>tibial
>>periostitis. Ideas re indications for surgical Mx, procedures used,
>>operative findings, postop rehab and success rates, anecdotal or
>>empirical
>>evidence would be greatly appreciated. I am covering this topic as part
>>of
>>my Masters in Sports Physiotherapy and have found very few published
>>papers
>>regarding surgical intervention.
>>I would be interested to hear members ideas re: etiology, differential
>>Dx
>>and treatment of MTSS and exertional compartment syndrome.
>>
>>Thanks in advance
>>
>>Matt McEwan
>>University of Sydney,
>>Australia
>>
>>
>
>
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