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Treatment of Medial Tibial Stress Syndrome: A Systematic Review



Medial tibial stress syndrome (MTSS) is a common exercise-induced leg injury among athletes and military personnel. Several treatment options have been described in the literature, but it remains unclear which treatment is most effective.


The objective of this systematic review was to assess the effectiveness of any intervention in the treatment of MTSS.

Study Selection

Published or non-published studies, reporting randomized or non-randomized controlled trials of any treatment in subjects with MTSS were eligible for inclusion. Treatments were assessed for effects on pain, time to recovery or global perceived effect.

Data Sources

Computerized bibliographic databases (MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro and SPORTDiscus) and trial registries were searched for relevant reports, from their inception to 1 June 2012. Grey literature was searched for additional relevant reports.

Study Appraisal

The Cochrane Risk of Bias Tool was used to appraise study quality of randomized clinical trials (RCTs) whereas the Newcastle Ottawa Scale was used to appraise non-randomized trials. The ‘levels of evidence’, according to the Oxford Centre for Evidence-Based Medicine, addressed the impact of the assessed trials. Two reviewers independently performed the search for articles, study selection, data extraction and appraised methodological quality.


Eleven trials were included in this systematic review. All RCTs revealed a high risk of bias (Level 3 of evidence). Both non-randomized clinical trials were found to be of poor quality (Level 4 of evidence). RCTs, studying the effect of a lower leg brace versus no lower leg brace, and iontophoresis versus phonophoresis, were pooled using a fixed-effects model. No significant differences were found for lower leg braces (standardized mean difference [SMD] −0.06; 95 % CI −0.44 to 0.32, p = 0.76), or iontophoresis (SMD 0.09; 95 % CI −0.50 to 0.68, p = 0.76). Iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking and extracorporeal shockwave therapy (ESWT) could be effective in treating MTSS when compared with control (Level 3 to 4 of evidence). Low-energy laser treatment, stretching and strengthening exercises, sports compression stockings, lower leg braces and pulsed electromagnetic fields have not been proven to be effective in treating MTSS (level 3 of evidence).


None of the studies are sufficiently free from methodological bias to recommend any of the treatments investigated. Of those examined, ESWT appears to have the most promise.

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We thank Faridi van Etten – Jamaludin of the Academic Medical Centre, Amsterdam, for developing a bibliographic database search strategy, and Steve McMahon for his help to retrieve two relevant studies. We also thank Karl Bert Fields and Nicholas Piantanida for providing the manuscript of their unpublished study, and Marieke Brinkman and co-authors for providing us with their submitted manuscript.

Authors’ contributions

Marinus Winters came up with the idea for this study, he performed the study search and selection, data extraction, quality assessment and wrote the manuscript.

Michel Eskes performed the study search and selection, data extraction and quality assessment.

Adam Weir and Maarten H. Moen both co-wrote the protocol and provided feedback on the manuscript.

Frank J.G. Backx provided feedback and assisted in managing the study.

Eric W.P. Bakker co-wrote the manuscript, assisted in methodological aspects and managed the study.

Conflict of interest

None reported.

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Correspondence to Marinus Winters.

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Winters, M., Eskes, M., Weir, A. et al. Treatment of Medial Tibial Stress Syndrome: A Systematic Review. Sports Med 43, 1315–1333 (2013).

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  • Military Population
  • Athletic Population
  • Pulse Electromagnetic Field
  • Medial Tibial Stress Syndrome
  • Chronic Exertional Compartment Syndrome