title: Treatment of medial tibial stress syndrome: a systematic review.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  The objective of this systematic review was to assess the effectiveness of any intervention in the treatment of MTSS.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: Rehabilitation, Nursing Science and Sports Department, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands, marinuswinters@hotmail.com.
authors: Marinus
authors: M
authors: Winters
authors: Michel
authors: M
authors: Eskes
authors: Adam
authors: A
authors: Weir
authors: Maarten H
authors: MH
authors: Moen
authors: Frank J G
authors: FJ
authors: Backx
authors: Eric W P
authors: EW
authors: Bakker
mesh_terms: D019317:Evidence-Based Medicine / Q000379:methods*; D006801:Humans; D058923:Medial Tibial Stress Syndrome / Q000628:therapy*; D059408:Pain Management / Q000379:methods*; D016896:Treatment Outcome
references: Postgrad Med. 1988 May 15;83(7):43
references: 3368421
references: Ugeskr Laeger. 1994 Dec 5;156(49):7329-31
references: 7801390
references: Epidemiology. 2007 Nov;18(6):805-35
references: 18049195
references: J R Army Med Corps. 2010 Dec;156(4):236-40
references: 21275357
references: Sports Med Arthrosc Rehabil Ther Technol. 2012 Mar 30;4:12
references: 22464032
references: Sports Med. 2009;39(7):523-46
references: 19530750
references: Mil Med. 2006 Jan;171(1):40-4
references: 16532872
references: Anat Rec. 2001 Apr 1;262(4):398-419
references: 11275971
references: Am J Sports Med. 2010 Jan;38(1):125-32
references: 19776340
references: Br J Sports Med. 2012 Mar;46(4):253-7
references: 21393260
references: Health Technol Assess. 2003;7(27):iii-x, 1-173
references: 14499048
references: Am J Phys Med Rehabil. 2001 Jun;80(6):433-8
references: 11399004
references: Am J Sports Med. 2004 Apr-May;32(3):772-80
references: 15090396
references: BMJ. 2010 Mar 23;340:c869
references: 20332511
references: J Orthop Sports Phys Ther. 1986;8(2):77-80
references: 18802244
references: Am J Sports Med. 2003 Jul-Aug;31(4):596-600
references: 12860551
references: J Bone Joint Surg Am. 1974 Dec;56(8):1697-700
references: 4434039
references: J Am Podiatry Assoc. 1976 Jan;66(1):43-5
references: 1244395
references: Am J Sports Med. 2005 Aug;33(8):1241-9
references: 16061959
references: AJR Am J Roentgenol. 2006 Sep;187(3):789-93
references: 16928946
references: Am J Sports Med. 2008 Jun;36(6):1179-89
references: 18490475
references: J Sports Med. 1974 Mar-Apr;2(2):111-7
references: 1186176