Ep 246: MTSS needs a new name - make no bones about it, with Laura Anderson

[Music] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clara Dern, the editor-in-chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. [Music] Pain near the postero-medial tubera is pretty common in running and jumping athletes. What's your diagnostic label for this condition that's often underwhelmingly referred to as shin splints or medial tibial stress syndrome? My guest today is challenging those labels and suggesting a new term, load-induced medial leg pain or limp to better reflect the clinical realities of shin pain. Laura Anderson is a physiotherapist and clinic owner in Jolong, Australia. She's also completing her PhD on leg pain in runners at the Trobe University in Melbourne, Australia. Today, Laura and I explore ways to improve how you diagnose and manage shin pain in athletes, including how you talk with athletes about their condition. We discuss loading, red flags and the role of running retraining. If you treat runners or you're curious about evolving terminology in sports injury rehabilitation, then this episode's definitely for you. Okay, let's get started. Laura Anderson, welcome to J.O.S. PT Insights. Thank you so much, Claire. Thank you very much for having me. It's a pleasure to have you on the podcast, Laura. Today, we're talking about leg pain or shin pain. What some of our listeners might know as medial tibial stress syndrome or MTSS. You argue that the term MTSS is a bit of a problem for how clinicians and athletes communicate about leg pain. And you're suggesting that maybe this load-injuiced medial leg pain term or limp might work a bit better. Tell us why that is, Laura. MTSS has certainly had, I think, its fair share of names over the years. And there's been called lots of different things. And we still hear shin splints is probably the other one that's thrown around a lot. So I think between MTS and shin splints, probably the most common ones. For me, the biggest problem with MTSS is the use of tibial stress in the naming of it. We still don't know what MTSS is or the path that went out of me behind it. And the use of tibial stress in the name certainly implies tibial stress, so tibial bone stress. And I do think this is leading to a decent amount of confusion amongst emerging clinicians and definitely clients in terms of what it actually is. That's less of an issue, perhaps, you know, around that tissue source, but it's the management. So I think then people are confusing the management of MTSS with the management of a tibial bone stress injury. And I think that's something that's definitely worth clarifying. Ellora, you mentioned this lack of clear pathoenatomic or findings or features of MTSS. In that case, how should musculoskeletal rehabilitation clinicians approach diagnosing and managing leg pain? And I guess what might you consider some of the differential diagnoses? I think it's tricky in the sense that it can coexist with other low leg conditions. And we know that there are so many exercise induced leg pain conditions out there. Number one, it's a matter of excluding those. And there is a really good diagnostic flow chart out there that Winters did publish a few years ago that helps. So I think, but what that does highlight is we are in diagnosing MTSS, where often excluding other causes of exercise induced leg pain. So we're excluding our compartments in droims and we're excluding our peripheral nerve entrapments. And then we're landing on this kind of diffuse tenderness exercise induced leg pain that is on your medial leg that is MTSS. So the trick is I think that can and often does exist with other exercise induced leg pain conditions. So it can be tricky in that sense. I think we want to exclude any of your compartments in droims and your peripheral nerve entrapments. But the biggest thing to differentiate MTSS from and I think the thing that is causing the most confusion is differentiating that from a two-wheel bone stress injury. And there is definitely I think a school of thought out there that MTSS is a low grade bone stress injury. But it certainly behaves differently. It presents differently and we manage it differently. So I think we can clinically differentiate it from a two-wheel bone stress injury and I think we should be clinically differentiating it from bone stress injury. In those we're looking at MTSS, which is going to be diffusely tender versus a two-wheel bone stress injury that might be more focal tender. You've got your pain provoking tests which might be jumping or hopping. They may well be positive in both. So it gets tricky. So a lot of it then is the severity of symptoms. Tibial bone stress injury will often be more severe than MTSS. MTSS and a lot of the ones that we certainly see clinically are bilateral. So that's often a bit of a giveaway and that they are on both sides. Symptom duration MTSS, a lot of people have had it for months if not years. So it had it for an incredibly long time. And that isn't at all the same for a bone stress injury that we know will progress and worsen the longevity of someone having it. It tends not to just grumble along for years. It comes on quite acutely and it worsens if they don't modify their activity. We don't see that pattern in MTSS. So a lot of it is that pattern recognition. I think you just really have to take into consideration the whole person. So our tibial bone stress clients we often see are probably not always I must admit but often higher load runners that have our other risk factors present. So they've got elements of low energy availability or red S. They probably do have more significant training load errors if they're at a higher load. So I think factoring in the whole person and the risk factors and not just looking straight at the tibial will also help differentiate those things. As part of an interdisciplinary or at least multi-disciplinary team environment, how regularly or how when do you make the call about. I think we need some imaging here and I guess referring to sports med colleagues to try to complement that differential diagnosis that you're making in the clinic. I suppose you look at clustering some of those findings together. If someone has a vocally tender shin, you're already going to be more suspicious of it than something but it's like MTSS because it's more diffuse. So if it's on one side and it's vocally tender, you're going to be a bit suspicious. There are a lot of evidence out there does suggest we don't necessarily have to jump to imaging for something that we might think is a low grade bone stress injury. But if we're not sure and all we need to kind of confirm that for the client to get them to buy into our management, then maybe imaging is warranted. Certainly think if you're unsure and you need help differentiating. If the person is also often female in a high load sport like endurance running is running a lot and has elements of red S. then my suspicion for bone stress injury, even if it's not textbook on your clinical examinations, would be a lot higher. And I might lean on imaging to help confirm that because I'd be a little bit more wary that it's going to be that even if I didn't think it was behaving like it clinically. Now I want to pick up on the managing side of things because we know that loading and getting the load right you talked about training load errors a little bit earlier getting that load right is key whether we're talking about limp or talking about bone stress injury. How does that optimal loading if you like change when you're managing limp versus when you're managing bone stress injury and what practical tips would you share with our listeners today. I think that's a big one Claire and I think it's a big reason for probably wanting to clarify the name a little bit in that there is a big difference in terms of load management, a TV or bone stress injury versus MTSS. And firstly, I think it's the same in that when we're looking at optimal loading, we're looking for the right amount and progression of load to promote adaptation, minimize risk and return people safely to sport. When we're looking at a typical bone stress injury, we want it to be symptom our load to be symptom driven, but we want symptoms to be zero out of 10. So we want no pain. And that's during after and the day following loading. Whereas with MTSS there's definitely an allowable amount of pain. So it's quite a significant difference when you look at the management we've got zero pain versus some pain. Some evidence suggests a two out of 10 for people with MTSS certainly clinically we see people that are running and running well and running consistently with pain that they report to be up to a full. or out of 10, and it seems to grumble along at that without it having a huge impact on their function. So we know pain's subjective, so I think putting a measure on it can be difficult. So in terms of, I think some tips for clinicians, we certainly need to consider function and pain because if someone's telling you that their pains are two out of 10, but they're walking in with a limp and they can't hop. That's probably, you know, not a two out of 10, whereas if someone's telling you that their pains are nine out of 10, but they can continue to run and run well and progress their running and hop and jump around and well with good function, then, you know, it's, we've got to, I think, factor all of those things in and expecting that person to be a two out of 10 might not be realistic. There's that element when we're talking about essentially pain. Obviously both of them we need to reduce load initially, but in a tibial bone stress injury, there's usually a period of relative rest, like we mentioned before, often they're a little bit more severe, so they might have pain with walking outside of activity. So we need to wait for them to be pain-free with walking and activities of daily living first. Whereas your MTSS guys are often painful with running, they might be a bit sore after, but then they quite quickly don't have pain outside of activity. And if we kind of just, you know, deloaded our MTSS person, waited for them to have no pain and then resumed running, I don't actually think we'd really get anywhere with them. We'd probably just rest them for five days, get them back running again, their symptoms would be there again, and we'd never progress them. And that person would probably just end up deconditioning, which is, you know, just as big a problem. So I think we're then putting load on our MTSS people as we're trying to rehab them, but we need to be aware of the amount of load that we might be applying to them across gym-based things and running and get them definitely when we're managing a condition and we're allowing them to keep running, but we're monitoring their pain and we might be adding gym load in as well. It can be really difficult to balance gym load and running load and not overdo it. So I think we've got to be really careful with that. And another tip I would have is be prescriptive with people's running load if we're allowing them to keep running and that includes pace. A lot of where we see people go wrong is, well, failure to adhere to a running program if you're not really prescriptive with it, which I think everyone will understand, but also the pace side of things, I would encourage everyone to make sure that their easy running pace is actually easy because a lot of the time when you actually go out and witness what they're telling you is an easy running pace and they stop and they're huffing and they're puffing and it takes them two minutes to be able to have a sentence conversation with you. I dare say when they're going out, they're running at a tempo pace and not an easy pace. So you can kind of be pushing things uphill from the beginning if you can't have and determine the basics. - I want to pick up on this idea of running and load and bring in the idea of running retraining. I'm wondering is it worth doing things like trying to change cadence or stride length or duty factor or any of these sorts of running related variables that we hear about in terms of running retraining? Is that worth it in trying to manage MTSS or LIMP? - I don't think I haven't answered to that yet. I think in some runners with MTSS, yes, there may certainly be benefit, but it's certainly not a blanket one size fits all approach. And we know in other load limit conditions and we can, let's take our Tibial bone stress injury, we know that we might reduce our step length and that can reduce our Tibial bending forces, provide if they don't change their foot strike. So we can do similar things like that in MTSS, but I think the biggest consideration to make is whether or not they've actually got the tissue capacity to tolerate the change. So I certainly find clinically if we do look to make those changes. So increasing cadence or reducing step length, yes, they'll alter the person's duty factor as well, but they will often change their foot strike. So most of the time we're looking to shorten their step length and with that, they will most often move from their heel to their more to their mid foot. So what we're actually doing to plan a flexor load is quite tricky, but we're often increasing it. So then we might be implementing a gateway training strategy that's increasing plan a flexor load. We've probably thrown some plan a flexor load into their rehab program and we've already got someone where we're trying to manage their symptoms and keep them running. So being able to determine actually what load we've now put on them and their tissues becomes really tricky, it can be too much at once. So I think you really have to factor in what overall load are you putting on the tissues outside of their running and then with the running cue. So you have to be really mindful of how they've executed the cue that you've given them and have they executed it in the way that you want. So it's not as simple as telling someone to increase their cadence or reduce their step length and think that's enough. You then have to look at what has actually changed in their execution of that and what tissues has it loaded for you to be able to determine if it's safe and if they're going to tolerate it. I don't think it has the short term benefits in managing pain that we might see in some other running related injuries like the telephoto-femoral pain. You mentioned earlier Laura that people don't only have running load, they often have gym load. How, so if we talk about running load and then adding gym load on top of that, how do you think about either quantifying that, keeping control of it, is it simply a matter of going, okay, you're doing this many sets and reps in the gym and I've got some way of matching that up with what you're doing running wise. How do you think about that getting that load balance right and accounting for the whole load picture? With MTSS, we're still, you know, we are still governed by or want to be governed by optimal loading in a sense, which is still symptom driven. So you're primarily tracking and monitoring their symptoms. Certainly if we have someone that comes in with MTSS and we get a really good understanding of what their symptoms are with their running and if we think that they're appropriate, that they're okay, they're not, you know, six, seven, eight, out of 10, but, you know, a grumbly three out of 10, their functions okay and we're happy to keep them running. If we assess them for deficits in the gym and I'll be the first to admit, we're in the privileged position at the clinic where we've got four sticks and we can put numbers on things and we can get good measures of things. So we can instead of just throwing, you know, mud at the wall and seeing what sticks we can target at actual planiflexal load or plyometrics in the way that we want. I think it's a matter of assessing for the deficits that you want to target. And yes, absolutely adding in gym load but with the introduction of that, keep their run load steady. To change one variable and see what happens to it. If we allow them to, you know, progress their running and we're adding in our gym load at the same time, then we can lose control of it really quickly and we don't know what's responsible for what. If their symptoms then kick off, is it because they increase their running or is it because they don't like the exercises we put in, we've just muddied the waters greatly. So I think it's a matter of just add one thing in time and change one thing at a time and monitor their symptoms the whole entire time that we often find that they definitely can tolerate having gym load in targeted at planiflexes and they can have some plyometrics things in and we can make some small progressions in their running and still seeing improvements in their symptoms, but they can tolerate load additions but it's definitely got to be tripped fed in and certainly nice and slow and steady. Any tips on what you found works well for monitoring is that you having to record everything to get athletes to record everything they're doing in their training programs. How do you help keep on track of this? Compliance is definitely, I think, tricky. Gym lasso, we do have a custom up with the clinic that they can record their gym load in and that's certainly, I think, useful. At least then you get an idea of what their actual compliance is. I think sometimes people, depending on what interval you're seeing, then will sometimes think they've been more compliant with something than they have. Running a remains the trickiest, I think, in terms of getting people to adhere, we usually set up a Google sheet. So it's a live document that we share with them and we ask them to kind of input. So we'll put in, they're running in there and we'll ask them to input their pain scores during and after so we can get a gauge of what they are and we can kind of then monitor it and adjust things as we need to. But that isn't to say then that you can check someone's run program and they haven't filled it in and they've gone rogue and you get them back in and they've run three days in a row and they don't know why they're symptoms or worse. So we do the best we can, that at the end of the day, I think they're client also has to take a bit of responsibility for adhering to those things. - Those of us who like to train can relate to the, it's really hard to stop training and to stop running when you, when someone's saying you need to scale your load back. Absolutely. I think if we can emphasise to them that we will absolutely try to make it progressive and we make an effort to understand as a runner or as an athlete what their goals are and what they want to get back to and that we will make it progressive towards those goals then I think they're more likely to stick to it because they're more confident that we understand where they need to get to and I do think tools that allow you to quantify other metrics if you're asking them to adhere so your four sticks and things like that that allow a numbers improvement on something so they can actually see that the work that they're putting in is generating gain. I think is ultimately really important particularly you know we might be asking these guys to commit to a rehab journey that's you know it's months it's not weeks keeping them motivated with those things makes a difference as well. And if we follow this load load trajectory to the other side the overload side what are the indicators for you that are that you might consider red flags for something not being limp and tipping over into bones dress injury what are you watching out for? And we've definitely seen this happen and like I said earlier the trick being that I think both both can occur so you can have someone with MTSS that then can develop a to be a bones dress injury the thing will be that it changes to be vocally tender as opposed to diffusely tender and sometimes you know you have to have you have to be quite specific in getting feedback on that and everyone knows that if you go and poke around the inside of your tibio it's pretty tender you know regardless of whether or not you have MTSS so it's a matter of identifying if there's one spot that is you know acutely tender in their versus the rest of it and you can often tell like the person will winse like it is often a notably tender spot not like a vaguely oh maybe like it definitely can be but they will be able to tell you yes they're that one they can identify a focal spot yeah it's that that's my pain thing yeah it's like that's it you're on a that's horrible you can see it in their facial expression like it's it's definitely changed and you know that that spot wasn't there before so that's definitely a change MTSS you know we don't see night pain it often settles really nicely the day after so I think if they've got pain that's lingering those things again it's an escalation in the severity but also to identify things you do have to have a good understanding of like your client MTSS presentation you have to know how it's behaving you have to know what's typical of it you have to know all of those things to be able to differentiate if it's changed let's wrap up this conversation Laura and talk bigger picture your researcher as well as being in the clinic what change do you hope to see if clinicians and researchers and athletes patients can adopt or choose to adopt limp and drop MTSS I think I'd like decisions when it's dropped first we can do that too but I don't I don't know if that will ever happen perhaps a more pragmatic approach to managing MTSS I think and clear differentiation between MTSS and Tibial bone stress injuries and increasingly I think a lot of this confusion is sitting with our emerging clinicians as they're coming out in their early years we know the MTSS in general unless it's a Tibial bone stress injury and it hasn't been diagnosed but MTSS doesn't progress into a stress fracture and we manage it differently so we do need to be able to differentiate them and not kind of lump them in together is the same condition we know the recurrence rates of MTSS are high and injury recurrence in general with return to run programs if we've stopped an athlete are really higher so we don't want to de-load and de-condition athletes for a long time unnecessarily and I think this is increasingly important now that a lot of people are running for their mental health so that's another consideration to make so to clarify management number one but I think this goes for all conditions as physiotherapists but clear language that conveys what we know or perhaps in this case more so what we don't know is really important and that's for clinicians and researchers and hopefully so we can establish management interventions that we know are safe and work but also for the clients that we work with that have MTSS so they can understand their injury and the rehab journey that we might be asking them to commit to because it is a longer one. Yeah and Laura I think what this conversation is showing me is why yet again it is so important to have clinicians doing research because you ask these important questions that are challenging you in the clinical environment and bring that clinical experience to the research work that you're designing so I want to say thank you for doing that and taking on this challenge of differentiating out what is a tricky presentation that of medial tibial stress syndrome or limp and then the other side of it which is the bone stress injury and thanks for joining me today on JLW's PT in sites. Thanks so much Claire. Thanks for listening to this episode of JOSPT insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice subscribe to JOSPT insights. On Apple podcasts, Spotify, Tune in, Stitcher, Google or your favourite podcast app. If you like JOSPT insights help others find us. Tell your friends and colleagues and rate and review us. 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