hi and welcome to Physio tutor podcast episode 63 with Tom goom also known as the running physio. Tom is a physiotherapist from the UK specialized in lower limp rehab and of course running. He started his popular website running dphys phys. comom 12 years ago and is very active on social media where you might have seen some of his infographics or blogs. He has written for different high-profile running magazines and published in the Journal of orthopedic and sports physical therapy about proximal hamstring tenoperiosteal. [Music] a couple of question questions from our social media audience for Tom as well. So we have lots to talk about. Let's start. First question, Tom is could you please give us a brief definition of mtss and maybe its pathophysiology. So is it a bone injury is it the an irritation of the periost what is it yeah so current thinking really sees it as a a bone stress injury so and and the kind of name gives you the clue that medial tibial stress syndrome so we

think that that medial part of the tibia is reacting to excessive load, and then we're seeing the development of symptoms. Now, there's a few different um ideas around um, you know, causes of pain. Some work by um Winters at all sums are up, uh, quite nicely, saying that it's essentially unrepaired micro damage accumulation. So, it's like the bone can't quite adapt to the load of the sport, and we start to see a reaction, uh, instead. Uh, like most areas, the correlation between MRI findings and symptoms is a bit blurry, uh, but sometimes you may see features like periostal inflammation or bone marrow edema as part of this, um, although sometimes you won't. You will sometimes see an MRI that looks clear and and still have someone with pain, okay, and what would be risk factors to develop mtss? Yeah, so there's been quite a few studies and and reviews looking at this, but generally in in um, in running injuries, and particularly ones like this, there's not a huge amount of high-quality prospective data, but the ones

that seem to come out relatively consistently um would be things like um higher BMI. So um we might see that being a risk factor, increased navicular drop, so slightly more pronated, uh foot type. Um it's also more common in females, um compared to to males. Um there are other factors that might might be a play like increased um weekly running distance, um gluteal weakness has been found to be a factor, um in females. So it's a bit of a mixed bag really, um in terms of risk factors, uh but I think if essentially if you're loading the bone more than it can adapt to, then that's probably what's going to end, you know, create this situation and lead to this injury, yeah, probably the good Al too fast, too soon, too much, exactly, yeah, that's so often to blame, is is it, yeah, um, and if we look at the typical patient with mtss, like what would be the the typical characteristics in terms of age, sex, hobbies, and so on, you already mentioned female, uh, as being female as a

risk factor, yeah. So, the typical patient I see would tend to be a younger female runner. So, sometimes I will see adolescents and, you know, people in that kind of age category or female runners in their 20s and early 30s with this. You do get it in more Masters athletes as well, but the typical presentation would probably be, for me at least, a younger female runner. That's the kind of classic, very common in military recruits and things as well, but particularly runners seem to struggle with it. Okay. And we already touched a little bit on it. Are there any specific training errors that athletes should avoid? Yes. So, when we think about bone stress, it is likely to increase with training intensity. So, if people suddenly increase the speed, the pace of their running or their training in general, that is likely to increase the stress on the bone and it's going to be less able to adapt to that. But also training volume's got to be a factor as well.

is any big changes in your training either doing too much or too quickly the other things to think about is we we think the calf muscles actually put a lot of stress on the tibia um during the running gate so anything that increases the demands on the Cal muscles during running may increase the stress on the tibia too so things like uphill running um Can potentially because the increase the demands on the calf actually leaning to more stress on the tibia also switching to Barefoot or Minimalist Shoes because they increase the demands on the calf may be a factor to but in shell it's don't change too much really that's how best to avoid uh these types of injuries yeah clear you you already kind of answered my follow-up question which is uh can you elaborate on specific Footwear to prevent uh or to manage mtss so you said flat flat foot wear would be or like the natural shoes would be a risk factor kind of uh what else yeah so I think it does depend on what your what your body's used to so um

I'm not suggesting that minimalist style shoes or barefoot running is an issue in itself, but the problem is so often is change. So if you always run in a very supportive shoe with a high heel to toe drop, and suddenly you decide you want to go something more minimalist, then yes, that could lead to some issues, potentially in the shin, commonly actually around the calf and achilles. There isn't actually a lot of evidence that Footwear will prevent Shin pain. There is one study, I believe Williams at to suggested that a motion control shoe may help to reduce exercise indued leg pain, but that's not consistent finding across the other studies as well. So I'd say the shoes is probably a smaller piece of the puzzle, and I probably get people to focus more on their training and Recovery, and make sure that they're on top of that if they want to prevent these types of injuries. Do we have any data or studies on forefoot running?

because you said like the more uh stress there is on a calf, the more risk we have to to to develop it. Yeah, so I've not in the research I've read, I've not found 4-foot running to be a risk factor that they've identified. Now that may be because it's not been studied um or not covered in a particular um, you know, systematic reviews and stuff that I'm aware of. But there is some some recent work that would suggest that that's likely to incre increase the stress on the tibia um, but again I think it's about change. There's a real Trend at the moment for people to be advised to switch to for foot um, and if you're if you're not habitually a four foot Runner, that is going to change the stresses, so maybe less stress on the knee potentially but probably more stress on the car Achilles and potentially the the tibia. Yeah, I was just about to say if they don't get Achilles tenin opathy, then they might end up with mtss that's

it but but so often, it's going to be individual-based, and that's why it's always very difficult to generalize with these things. So, if you look, for example, think about two different runners. So, you've got a rearfoot striker, um, but they're really overstriding, and they've got a low step rate. You might actually think there's going to be more stress on the shin for that runner versus a forefoot runner who has a higher step rate and isn't overstriding. So, it really does depend on the individual. And, as we said, the other factors, um, you know, things like body mass, muscle strength, recovery, they're all going to play a part in individual risk, I would say. Yeah, okay. Uh, if we move on and and and we look at or we go towards diagnosis and, uh, specifically red flags, what are the red flags that we need to rule out in this case if someone presents with shin pain? Yeah. So, the biggest one here, um, and you know, it's a key point.

for people to take away listening in is anterior tibial stress fractures are known to be a high-risk stress fracture, and they will present with shag now typically. It's more pinpoint so um mtss is usually quite spread out. It's more pinpoint, and it's more anterior um so if someone's saying to you they've got pinpoint bony anterior shiman that's aggravated by impact and weight bearing that should be waving a flag for you to think okay this could well be a high-risk uh injury here um and we we do recommend um an urgent x-ray to all at a true fracture but really what we want is an urgent MRI in those cases um because they're often managed non-weight bearing for a period of time yeah okay so to summarize it's it's more one specific location if it's a Str stress fracture compared to mtss and it's more anterior than anterior medial or medial yes that's right so you know typical medor tibial stress syndrome.

symptoms are postoral tibia there. When you palpate the tibia, there's usually an area of tenderness of at least 5 cm, so it's spread out along that posterior medial tibia. Now it's not true for every bone, but it does seem in the tibia that the stress fractures are more focal, so you have more pinpoint tenderness. If there's pinpoint tenderness in the posteromedial tibia, that could be a stress in that part of the tibia, which is considered generally to be low risk. So we're still going to meas, you know, carefully manage it, but it's the anterior uh issues that really do need, uh, very careful, uh, investigation and management, okay? And what about compartment syndrome as something to rule out? Yeah, so you know, chronic exertional compartment syndrome, um, that tends to present with anterolateral Shi symptoms that are around, um, tibialis anterior. So it has a different pain location and behavior than medial tibial stress in most cases. So typically what

people will say is that it's it's in that kind of muscular region symptoms build up with continued running and and settle quite quickly afterwards with rest um most bone stress injuries will be aggravated by impact whereas those more compartment syndrome type presentations are aggravated by repeated use of that muscle so that might help you with your testing um you also wouldn't expect bony tenderness in a true chronic exertional compartment syndrome presentation so they do look they do look and present differently although as we know real life stuff real clinical stuff when we see people you can have both you can have mixed presentation so we've got to bear that in mind yeah it's never exactly like in a in a textbook no never it's always slightly different but it's I think it's about looking at the overall picture really and and that's why we got to use our judgment okay and uh we we already talked about some clinical signs and symptoms of mtss what else would I be looking for in my diagnostic process so

yeah I think as I said that the palpation um of of over you know 5 cm or over is going to be a factor um pain that worsens with impact and settles with rest is a Factor. Sometimes there's going to be pain with prolonged weight bearing so sometimes it can just be longer walks or if people are um you know clocking up higher steps per day will will aggravate it as well. Um you might sometimes have some swelling over that region in uh in more irritable cases but because it's a bone stress reaction you're not likely to bring on symptoms with most of your kind of basic resisted tests um so it helps you to kind of narrow it down towards your um you know your bone stress injury your medior tibial stress syndrome. Okay and and if we move on to to your assessment process uh I mean you you you probably have a suspicion of mtss uh but what else do you assess. You already said uh we have a couple of risk factors like Glu strength. Uh how does your assessment

process look like what are you looking for in a in a patient what what do you want to know yeah so um I mean a big believer in history being really really important for for our patients so you want to get a good history in terms of their training and how that's changed so you can identify the potential causes. You also want to try and explore what their current tolerance of activity is that's really really important um so if we can identify amount of their sport that they can do without pain for example so we we want to explore around that a little bit. We know too that with bone stress injuries bone health is is influenced by a lot of General Health factors particularly diet and energy availability um sleep potentially stress so we we really want to get a good overall history a good idea of this this um athlete as a person um and then when we're going into our physical tests um the things I would tend to to look at here um I like a brief overview of alignment um and I think you

think potentially a slightly more pronated foot type as a factor. So we're going to have a look at those things, but I'm not going to overplay them to the runner. I don't want to find fault for them, you know. I'm looking for solutions, really. But I would look at that. I would look at strength in what in the shock absorbers. So, you know, in running, we know, for example, the quads, the calf, glute, me. They're all very much involved in managing the loading phase of running. Um, so I we definitely want to be assessing those in most runners, usually the hamstrings too. Um, then I will tend to look at range. So things like ankle flexibility to see if there's any loss on that side. Um, movement control like balance and single leg dip, those types of things. So we get that nice overview. We got alignment, we've got strength, we got control, we got flexibility. And then the final, well, one of the final pieces in of the puzzle once we've done palpation and diagnostic.

testing is impact testing now. Bone stress injuries are, as I said, aggravated by impact, so I will start with light impact, like jogging on the spot for a minute, and see if there's any pain. And if that's not painful, we might then go on to more challenging impact, like jumping, bounding, or potentially hopping, because it helps us to work out the diagnosis and also their current tolerance of load, okay? And going back to your muscle testing, like, for example, for the calf complex, how would that look like? Do you do one-legged calf raises and then or is it more strength like maximal strength testing, or is it more endurance testing? How would that look like in practice? Yeah, so that can vary, um, runner to runner, but I think a good place to start for people is often your reps to fatigue tests. So a calf raise typically on the edge of the step, single leg, and seeing how many reps they're doing with body weight till they reach fatigue. Um, a lot of people

actually do find that quite challenging, and it gives us the opportunity to compare left versus right. I would say technically for most, it's probably not a true strength test. It's probably a mix of strength and endurance. So, it may be that if they're doing well with that, we would want to load that test up a bit more and maybe look at 10 rep max testing or even heavier six rep max testing to get a truer reflection of calf strength. And it's a similar process with the quads. You can do a single leg rise test as a reps to fatigue, but I might choose to get them on a seated knee extension or leg press potentially as well and look at heavier load testing with that. Glute med is a bit more difficult. Personally, I think with glute med, if you've got a handheld dynamometer, I think that's probably one of the better ways to test it. So, test it isometrically to see how it compares, you know, left versus right and where

you'd expect them to be. Before we dive back into the episode, I've got something to share with you. Picture this: you're wrapping up a day packed with patient sessions, and you're again behind on your patient documentation. Sounds familiar, right? But what if there was a way to make this necessary evil a breeze? That's where Lindy Doai comes into play, an AI scribe that's revolutionizing the way we in physiotherapy or chiropractic practice handle our documentation. Lindy Doai isn't just any tool; it's a bespoke solution designed with our unique needs in mind. This AI scribe listens in on your patient interaction, transcribing them in real time. But don't worry, it's fully compliant with HIPAA and PIPA, ensuring your patient data is safe and secure. But what's even more interesting, Lindy AI can customize the output to your specific needs, from patient homework notes to new patient consultation notes, SOAP notes, and even referral letters. It can even transcribe and return patient notes in 13 different languages.

including French, Spanish, Dutch, and German, among others. Lindy delivers comprehensive, instantly ready patient notes that seamlessly integrate with your EMR, be it Jane, WebPT, or any other system you're using. The feedback from users has been great, with many saying it's like having a documentation miracle at their fingertips. Plus, Lindy is offering a free trial week, allowing you to create unlimited patient notes and truly experience the difference it can make. Check out the link in the show notes or video description to sign up for your free trial. And do you use any parameter that you would like to see in a patient, like, for example, 25 C phrases or single leg C phrases, and similar for the hamstrings or the quads? Yeah, so I do use some parameters, but I really think of them as very much kind of ballpark figures. If you look at the research, saying in calf raises from Herbert Losier Tool, there's a huge variety in what you'd expect, and that would change based

on um on sex on age on activity levels. So we're certainly not in a position where we could say right this number's good anything else is bad. So but I would say my ballpark figure, and it's the common one that you'll hear, I think if people are managing about 25 reps, I think they're doing fairly well with the calf raises or the single leg rise test or the single leg Bridge test. I think that's a fairly good score. But that doesn't mean that the assessment stops. What that might mean is that we want to explore it in more detail into in the next session. We want to load it up more, we going to challenge it more to find their deficits. Yeah, we actually did a video about a be losier study and the numbers were quite high. So I was actually surprised how high they were and I was really questioning how strict they were in technique, to be honest. That's it my age group, it would have been 35 or so as the average. And I was like

okay, this is pretty tough. Yeah, and we do it as part of the running repairs course that I run. We get people to do it like as a practical. We all do it together, and most people are really, but you know, he buy as little as 20 reps. They're struggling, and they're finding it hard to get to 25. And you'll see within that room quite often the people on our courses, they're runners. They're all running happily and successfully, but some of them are getting nowhere near 25 reps. So, I think we've got to be very careful that those things don't become barriers. You can have someone that's running very, very happily without any problems and not hitting those numbers. So, we don't want to use them as a way to prevent people returning when they're ready to do so. Yeah, gotcha. And uh, do you do any running analysis in your assessment process? I do. I don't tend to do it in the initial session. Um, I think there's already a lot to fit in.

in those first, uh, you know, couple of sessions, but once I've, I feel like I've found a nice level of exercise for the runner, and we've got some good rehab stuff in place, and they understand the injury, that will often be when I'll say, okay, well, let's have a look at your running. So maybe session three, some somewhere around that point. And really what we're looking for is, is there anything in their style that may be putting more stress on the shin. And if there's not, we're not going to change it just for the sake of it, really. So it's, it's specific to their injury, okay. And, and what would that be in their running, um, like certain styles that put more stress on a on a shin, yeah. So there's, there's probably two main, um, sort of broad styles that, that will do that. So over striding, uh, which you tend to see in Runners with a lower step rate, and there is actually some evidence to show that Runners with a low step rate are more likely to develop Shin pain so.

um overstriding is likely to increase the stress on the shin, so that would be something that we would look out for. Um, and that is more common in your rearfoot strikers. It's quite hard to overstride onto a forefoot strike, so that would be one factor. The other thing is um stride width. So if someone has a narrow stride width, there is some evidence that increases medial tibial load, and that commonly you'll see with increased pelvic drop, which again has been found to be a factor associated with this um, an increased hip adduction as well. So those are probably some of the bigger things that we would um look out for, um, and then potentially try and change. Okay, and would you say that's all stuff that you can see on a treadmill like with the bare eye, or do you use any equipment for that? Yeah, I, I personally would say it's a good idea to video people. I think you can see things, uh, with the bare eye, um, but I think it's

it's harder to get the details so personally what I tend to do um is video people both on the treadmill and overground so off the treadmill on a nice flat surface um to give us an idea of their running gate so both approaches have got pros and cons to them but a combination of the two seems to work better um and then use some slow-mo software so we can actually have a look at the running style in a bit more detail yeah I'm actually curious because um uh uh We've tested the device from run easy so bit bit of a plug like uh but um have you used that one like we found it quite interesting we pretty skeptical uh towards new stuff and devices and gimmicks uh but that was actually a very interesting device yeah I like run easy um so that's something I I do use in clinic um it's I think it's one of the better wearable options actually because it's very easy to use um one of the things that's

particularly nice about that one is that you can give it to a runner and say, Go out and do a run, and then they come back and you can download the data. So I think definitely there there is potentially a role for these wearable Technologies. What they often do is sort of cement the decision that you're you're going to make. So let's say we have a runner with um with medial tibial stress and uh the impact um is looking higher when we assess it with a wearable tech. Um, we think that impact may play a role to some degree in these bone stress injuries. So we try an intervention. Uh, you might tell I you know suggest they run quietly or you might try and increase the step rate. And then you can immediately see whether there's a reduction in that measure on the wearable tech. Um, the question mark we always have is accuracy and reliability. That's the thing. Whatever tech you do choose to use, it has to be accurate and reliable. Otherwise, it's it's not that

useful, yeah, I agree. And, and, and last question about running technique. Um, is there any particular step rate that you're aiming for? Um, short answer, no. Um, I know a lot of, a lot of runners like this idea of running 180 steps per minute. Um, but our step rate actually changes to some degree with things like height, leg length. Actually changes with speed. So, the idea of everyone running all the time at one set step rate really doesn't make sense and isn't supported by the research. So, it's more about where the person is starting from. So, um, I mentioned earlier that there is a bit of evidence that those with a step rate of, I think it's less than 164, are more likely to develop shin pain. Um, but what we look, look at is what is that person's starting point. Let's say they're at, you know, 160. Um, we might increase that by 5 to 10% rather than say, let's go from 160 to 180, which is a very big increase for a runner to manage. Yeah, definitely, okay. Um.

moving on towards uh treatment so you've carried out your assessment. You found a couple of things that uh are interesting maybe uh weaknesses or or like you determined the level of irritability of the patient. So how does your general treatment process look like maybe you can take us through different stages. Yes so um in the you know the initial assessment I'm really trying to find out what is a pain-free level of loading. And this is where our bone stress injuries do differ from things like say tendonopathy. The current thinking is that optimal loading for bone stress injuries is pain-free both during and after uh now that makes sense from a clinical standpoint if you keep people loading in pain it just seems to take a lot longer to get better. So in that first session one of our main goals is can we find a pain-free level of loading is there an amount of their goal activity perhaps running or the sport they're doing that is pain-free so this is why it's really important to explore and delve into that history to find out.

um, if there is a pain-free level, we would advise them to stick to that for a little while to get the body used to it before we then progress on. Now, a majority of people I see, I would say, are probably, they're coming to see me when they're irritable, so they're often not tolerating any running. So, in that situation, we're going to recommend a short break from the running and typically replace it with pain-free cross-training um, to keep them fit and just that break from impact. Even as little as a couple of weeks can let things settle quite significantly. Now, usually alongside that, whilst they're not running if that's the choice that we that they've made, we would give them some strength and conditioning work to strengthen up the muscles but also because our strength and conditioning lads the bone. So, we're going to get some adaptation in the bone too. So, that's often how those early stages look like. Find a pain-free level of loading, stick with that to let symptoms settle, and

then in the second or third session, we're looking to see if we can progress. Can we start to then gradually build up, keeping it pain-free towards where you want to be? So that's really the principle and the process. We're going through. It's not all about load though. As I said, things like stress levels, sleep, recovery, we explore those with people because if someone's not sleeping very well, they're not taking on enough nutrition, they're highly stressed, it, in my experience, will impair their healing. Yeah, so basically the biopsychosocial approach for mtss as well. I mean, absolutely for any other condition. Yeah. And of course, we know that that term's been around first for so long now. It's, we know that term, but I mean it's about knowing that person, isn't it? I think I always think you get the best results with someone when you get to know them as a person because that's when you can really problem solve together and find solutions together. And yes, that is biopsychosocial, but it's also a

little bit more than that. I think getting to know someone, yeah. And if we look at the strengthening program, what kind of exercises would you prescribe? Or are there certain muscle groups that you would focus on? I would focus on the weak muscle groups as a general rule. But we think the calf complex is particularly important as one of the main shock absorbers around the foot and ankle. Um, where possible, I'd like the exercises to be weight-bearing because we're going to get a little bit more stimulation of the bone. So we might typically choose about three exercises to do because we don't want to overload someone with hundreds of things to do. And I would usually be loading them up somewhere around about roughly 10 rep max initially. Um, now with the bone stress injuries because they're aggravated by impact, they often can tolerate some reasonable loading in terms of challenging the muscle. Um, so we might end up with three exercises to target the weaker muscles, loading at roughly about 10 rep max.

so that yeah might include one or two for the calf something for the quads perhaps something for the glutes all depending on what we're finding on our assessment. Yeah, so uh I'm thinking of C raises, um lunges, squats, absolutely, yeah, calf raises and calf raises variations so straight leg, uh bent leg, uh calf raises, um yes, you know lunges, squats, single leg squats, deadlifts, single leg deadlifts, um, you know weightbearing stuff that's challenging the these these big muscles while it's also encouraging a bit of adaptation in the bone is going to be a good way to go, um, but but as ever there's never a recipe, um, you'll know it yourself when you work with people that everyone's needs is so so different, um, that some people we might need to start a lot lighter other people already lifting fairly heavy loads in the gym, yeah, that's that's like if if if it wasn't like that if it was a cookie cutter approach then we could just be

replaced by YouTube videos. Yes, yeah. Um, and, you know, this is the thing. I think giving, you know, the what we're giving people to do is important, but it is only one part of, you know, one part of it. The other side is the support, the encouragement, the guidance, the problem-solving, the what to do when things go wrong, like that. That, I think, is often a really important part of what we're doing, that kind of support, um, you know, that when people are distressed and anxious, I think goes a long way. Absolutely agree. Yeah. Hey, and, uh, sometimes times if you, if you just Google for mtss, then you'll see a lot of people, maybe they're not, um, yeah, physios, or I don't know, but they focus a lot on tbis interior, um, I mean, which kind of makes sense because it's in the same area, but is there any particular interest of that muscle or do you focus on that muscle at all? Um, I personally don't. I think, um, you know, we don't have a lot of

evidence generally on the management of medor tib stress syndrome. So I certainly can't sit here and say that, you know, we must do x, y, and Zed because the evidence says so. You know, there isn't a lot of evidence there. But my reasoning process would be that we probably want to strengthen the muscles that manage high peak loads in running, and tibialis anterior typically isn't one of those. It's most active at Terminal swing. It's probably less active during the loading phase. So yes, we might look at it, but normally there are other priorities, as I said, like the Cal cods or glutes that I I'd usually work with as a preference. Yeah, okay. I'm also looking at the questions that we got in from the uh followers, and which one is actually uh fitting our conversation at the moment. I think there's one question from uh David who said, what is the maximum pain uh patient should run with, and how to we kind of covered that, but and how to manage a flare up in terms of rest and

load management after. Okay, so I would say current current thinking is um we want running to be pain-free both during and afterwards. Uh, when we're managing a bone stress injury, there are some slightly grayer areas um so you will come across patients have had a very persistent um history of champagne. I've I've worked with some that have had it for two or three years um and they will have a bit of an awareness that's there a lot of the time even when not loading. So in those situations, say okay, it's okay okay to have a bit of an awareness there um. We what we don't want is is a noticeable significant increase in pain during or after loading but in new episodes, you know, First episodes of of pain, I really would keep it as pain-free as possible um and that is about then exploring with them what is manageable. And I do think this is a pathology where sometimes a couple of weeks of rest from Impact can go a really long way in terms of helping. So part of the assessment as I mentioned

we'll do our impact tolerance tests. So what we'll often find when they're in flare is jogging on the spot will be painful. Um, you know we test typically for a minute. They might immediately have pain with jogging on the spot. So that tells us they're not going to cope with impact. They're not going to be able to go and run. So how we might manage that flare is, say, okay, well, let's take a rest from running. Like I said, maybe do some cross-training, do some strength work, look at your recovery and your sleep, and those kind of things. Come back and see me in a couple of weeks, and we retest the impact, and we see, is it now pain-free for you to jog on the spot? And if it is, we then might test them a bit more and say, okay, well, let's look at jumping, let's look at bounding. Okay, that's all seems okay. You can also hop pain-free. Now, let's try a test run, and we then gradually take them back in, um, but it's that process of

testing looking at symptom response reasoning through and deciding what you what you'll do next thank you for answer that's a perfect segue to my next question which is like when you decide uh that a patient is ready to run again oh yes great question so you know obviously we we're kind of coming into this question and assuming we got the diagnosis right we know this isn't a high-risk stress fracture you know you've you've risk assessed for this patient but that uh so we know they're safe but the things I'm looking out for I I would like my Runners to be walking for half an hour without any pain that gives us an idea that they can do weight-bearing activity and they're not irritable um I want to see that there's there's no night symptoms they're not reporting any night pain or anything like that there's no swelling or anything over the shin um and then we want to do our impact tolerance tests so certainly I want them jogging on the spot for a minute

pain-free. Ideally, I want them hopping at least 10 reps on each leg, pain-free, and then the next step is a test run. So that doesn't give them the green light to say, Right, you can go and do 5K. I usually will cap a test run at a maximum of 5 minutes, um, and that's because otherwise people, if they're fit and they're able, they'll go and do a lot more and they'll flare themselves straight back up again. So I'll say, you know, even if you're feeling fantastic, no pain, please stop at 5 minutes maximum. Typically, I usually say about 3 minutes, to be honest, and then let me know how you get on. So I do quite a lot of communication between appointments. You know, do that test run, pop me an email, let me know how it goes, then I can offer some guidance, okay? So 3 minutes was good, right? Let's try and nudge that on, see if you can get to four or five minutes, and let me know how that goes. The more runs they do

the more information we've got to guide that process in terms of what's pain free, and then we can start to build a bit of a program to get them back to where they want to be. And I guess they keep on doing their strengthening during that return to running phase. They do. Yeah, so when you're doing the early part of a return to running phase, and the running is very small, as I say, we're typically looking at minutes. In many cases, the strength training doesn't really interfere with that process too much. So we might keep them doing their rehab two to three times a week. Once their mileage is coming up, particularly if you've got high volume runner that's doing a lot of training or aiming for a lot of high intensity work, we might choose to drop the rehab down to maybe once a week, twice a week maximum. So there's this kind of tradeoff you're trying to achieve with strength work. It gets you stronger, which is good, but it can lead to fatigue, and fatigue can be a

risk factor for bone stress so it's just trying to strike that right balance at each point. Okay, and I have another question from a follower who said, How does your treatment strategy change for different types of sports? So for example, soccer versus volleyball versus running. Because now we're talking about runners, how is it in other sports? Yeah, good question. So I think a few things. Selection would perhaps be different because we might look at other muscles having to work harder in those different sports. You think about football, for example, soccer, lots of change of direction going on, so you might be looking at more work around the adductors involved in changing direction, hamstring injuries we know are problematic in that group so our exercise selection would be different. The other thing that's definitely going to be different is if you're going to use some metrics in your program, they need to be adapted to the needs of the sport. So if you think about a volleyball player, there is lots

of jumping at the net, jumping, and spiking, so we need to include probably more challenging Plyometrics and try and mirror the demands of their sport. So running does have a plyometric load, but it's not so multidirectional. It's probably not such high peak loads, so we would use different excise selection to prepare them for that. The return to sport, it's also more fiddly with team sports, so as I'm sure you have encountered return to running, you can do just do three minutes at a slow pace. It's quite easy to quantify return to soccer or volleyball is more difficult, so we might typically start to. Once they're ready and their symptoms are settled and they're passing their impact tolerance, expose them to training for a period of time, and look at using, you know, a pain-free amount of training. Once they're then able to complete a full training session, we might do short periods of competitive sport. So we might say, right, you know, come on as a

substitute last 10-15 minutes of a football game, and gradually we increase the exposure to competitive sport until they're back, you know, back doing the full, uh, the full game. Yeah, okay, great stuff. Uh, I have one more question from a follower, and that's a question I would have asked anyways, is, uh, from Gex Lox on YouTube, What is the typical duration of MTSS? Yeah, that's a really good question. It's a difficult one to answer. Um, I believe once there is one study said that the median duration was somewhere around 70 days, I believe. Um, you will see huge variety in the patients that you see, um, and I think part of the problem is what do we define recovery with. So, if recovery is full return to activity, including sports, I think it can be, you know, 3 to 6 months sometimes or beyond because we, it's not just settling symptoms down, that's only part of it. It's getting people back to where they want to be, and that's the longer part of the

process the longer people are away from their sport, the longer it takes to get back. In my experience, so if we're going to use an offload period, we're trying to keep it as short as we can while also letting symptoms settle. So much of this is kind of risk management judgment, working with the patient to try and find what works. Yeah, okay. I have one question remaining on my list, which is about edun treatments. Is there anything that makes sense in mtss that can add value like Shockwave or braces or ice NSAIDs? What does the evidence say? I would say personally I don't tend to use junks like that very much at all. I think there is a little bit of evidence to support shock waving bone stress injury, although not a lot. From the recent stuff that I've seen, so you could possibly justify that if they're not responding to purely conservative management without any extra interventions. We want to be honest.

and say this this isn't an area where we've got huge amounts of evidence. There isn't really a gold standard of this, you know mustu XY and Zed, but in my experience clinically, I think an offload period will often settle symptoms quite quickly. Um, so then you don't need to um do much more, you know. You don't need to add in ice and shock wve or whatever else. What you need is a graded return, and there's not really much that speeds things that speed up that process. And there's a bit of a debate around anti-inflammatories because there is a bit of evidence that they may delay bone healing, um, although different research does tend to find slightly different things on that. So again, we know it's likely to get better with some offloading, so I wouldn't tend to go down that route unless pain is a really significant barrier. And if it is, you've got to be asking why, you know. Do we actually have something more serious going on here if this person is

struggling to walk the length of your corridor because their pain is so severe. Um, do we need to look into these more high-risk injuries? Could we be looking at a stress fracture, and does that then need more investigation and more cautious management? Yeah, maybe. Maybe to add to that, can MTSS evolve into a stress fracture if you just negate the pain and you keep running? Um, I believe it can. Um, again, it's another area that's debated a bit in the literature, so there's this idea of a continuum of bone stress, uh, injury that, you know, there's lots of debate about exactly what's included but possibly starts with periosteal inflammation and then goes on to bone edema and can progress onto stress fracture, but some studies have questioned that and see stress fracture is almost a separate entity. So I think yes and no, but the message here is generally running through bony shin pain and continuing to run with pain or exercise with pain is not normally what we'd recommend. Um, so you know, I always

say to people get it checked out. You know, get a good idea of what it is, um, and then get some help with management, okay. All right, um, we are coming towards the end of the podcast, and I always ask our guests, uh, is there anything that we haven't talked about that you would like to add to the podcast. Oh, good question. Um, I think it's probably just to make sure we think bigger picture, um, with not just with medial tibial stress syndrome but with bone stress injuries in general. Um, quite often when people have persistent bone stress injuries, there are other general health factors going on. So, um, it is worth exploring those things like, as we said, nutrition, stress, sleep, general health factors, um, because bone stress injuries can be part of RED-S, you know, relative energy deficiency in sport. So, it's having that suspicion, and if you do have that suspicion that it's a more complex presentation, it teamwork with people, you know, some for those more complex cases. It's better to work in.

multidisciplinary team. So, you can have, say, a dietitian or sports nutritionist look at the nutrition side of things. You can work with the sports physician so that they can explore the other general health factors. So, you know, if you're looking at complex, persistent bone stress injuries, you know, don't be afraid to think bigger picture and team up to get better results. Yeah, yeah, great, great stuff. And lastly, where can people find you if they want to know more about you? So, I'm doing a fair amount on Instagram these days, particularly sharing kind of graphics and evidence-based stuff around running injury. So, I'm running.physio on Instagram. And there's also my website that you mentioned, runnings.com. So, you can find me there. Do say hello on Instagram. Always like chatting about running injuries and stuff. So, always happy to chat in the DMs. Okay, great. Tom, thank you so much for your time and for your knowledge. It was a pleasure. Thank you so much for inviting me. Yeah, it's been really

good to do this together and hope we can do another one in the future sure why not. okay so thanks a lot also to everyone out there listening to this episode. and to access the transcript and additional resources make sure to download our new and free physio tutors app and benefit from more useful physio content. and if you enjoyed this episode hit the Subscribe button or follow our podcast on Spotify or apple podcast. and also consider leaving a review if you really enjoyed it. and with that being said this was KY Physio tudas and until next time bye. [Music]

A Complete Guide to Conquering Shin Splints (MTSS) with Tom Goom  | EP 63

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