CRD summary

This review concluded that the existing evidence for the treatment of medial tibial stress syndrome was of insufficient methodological quality to recommend any specific treatment. The authors recommended further research into extracorporeal shockwave therapy. The review was clearly reported and its conclusions appear to be reliable.

Authors' objectives

To assess the effectiveness of conservative and surgical treatment for medial tibial stress syndrome.

Searching

Two reviewers independently searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, CINAHL, PEDro, and SPORTDiscus, without language and publication restrictions, up to June, 2012. Search terms were reported. Trial registries, conference proceedings and reference lists were searched for relevant studies.

Study selection

Randomised or non-randomised controlled trials, evaluating any treatment for patients with medial tibial stress syndrome, against any comparator, were eligible for inclusion. Trials had to report time to recovery, global perceived effect, or pain as outcomes.

The included trials evaluated the effects of iontophoresis, phonophoresis, ice massage, ultrasound, low-energy laser treatment, periosteal pecking (needling), stretching and strengthening exercises, sports compression stockings, lower leg braces, extracorporeal shockwave therapy, and pulsed electromagnetic field therapy. Where reported, the trials were conducted in military or athletic populations.

Two reviewers independently selected trials for inclusion, with disagreements resolved by consensus.

Assessment of study quality

Two reviewers independently assessed the quality of randomised controlled trials (RCTs), using the Cochrane Risk of Bias tool. Trials were considered to be at low risk if all five domains were met, at moderate risk if one or two domains were not met, and at high risk if three or more domains were not met. Non-randomised trials were rated as good, moderate, or low quality, using a modified version of the Newcastle-Ottowa scale. Disagreements were resolved by consensus or by consulting a third reviewer.

Data extraction

Two reviewers independently extracted trial characteristics, with disagreements resolved by consensus. Where appropriate, continuous outcomes were extracted as standardised mean differences, with 95% confidence intervals.

Methods of synthesis

Heterogeneity was assessed using Ι². Trial data were combined in a fixed-effect meta-analysis, if the trials were considered to be clinically and statistically homogeneous. Otherwise, trial data were presented in a narrative synthesis, with consideration of subgroup analyses and meta-regression to explore the sources of heterogeneity. Publication bias was assessed using a funnel plot.

Results of the review

Eleven trials were included in the review. No trials investigated surgery. Nine were RCTs (399 participants) and two were non-randomised controlled trials (120 participants). All the RCTs were rated as having a high risk of bias, and all non-randomised trials were rated as being of poor quality. There was no evidence of publication bias.

No benefit was observed in the RCTs comparing lower leg braces with control (SMD -0.06, 95% CI -0.44 to 0.32; three RCTs; Ι²=0), and comparing iontophoresis with phonophoresis (SMD 0.09, 95% CI -0.50 to 0.68; two RCTs; Ι²=0).

The lower quality non-randomised evidence reported some positive findings for iontophoresis, phonophoresis, ice massage, ultrasound, periosteal pecking, and extracorporeal shockwave therapy relative to no treatment.

There were no positive results for low-energy laser treatment, stretching and strengthening exercises, sports compression stockings, lower leg braces, and pulsed electromagnetic field therapy.

Authors' conclusions

None of the trials were sufficiently free from methodological bias to recommend any specific treatment, but extracorporeal shockwave therapy seemed to show the most promise.

CRD commentary

This review clearly reported efforts to identify all the relevant controlled evidence on the treatment of medial tibial stress syndrome. Attempts were made to minimise the errors and bias in the selection, assessment and data extraction procedures. The authors thoroughly assessed the methodological quality of the included trials, using appropriate methods.

Their conclusion that the available trials were of inadequate quality to recommend any specific treatment appears to be reliable.

Implications of the review for practice and research

Practice: The authors stated that rehabilitation focusing on bone recovery seemed to be most appropriate for medial tibial stress syndrome. Several days of non-weight bearing should be considered, before weight bearing was gradually increased, until full function was achieved.

Research: The authors stated that research was needed to understand the underlying histology and etiology that contributed to medial tibial stress syndrome. The effects of weight bearing should be assessed, and a good quality RCT evaluating extracorporeal shockwave therapy was warranted.

Funding

No funding received.

Bibliographic details

Winters M, Eskes M, Weir A, Moen MH, Backx FJ, Bakker EW. Treatment of medial tibial stress syndrome: a systematic review. Sports Medicine 2013; 43(12): 1315-1333. [PubMed: 23979968]

Indexing Status

Subject indexing assigned by CRD

MeSH

Humans; Medial Tibial Stress Syndrome; Physical Therapy Modalities

AccessionNumber

12013050946

Database entry date

21/11/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.