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Ankle Specialist

Use of Foot Orthoses and Calf Stretching for Individuals With Medial Tibial Stress Syndrome
Janice K. Loudon and Martin R. Dolphino
Foot Ankle Spec 2010 3: 15 originally published online 18 December 2009
DOI: 10.1177/1938640009355659

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vol. 3 / no. 1 Foot & Ankle Specialist 15

〈 Clinical Research 〉
Use of Foot Orthoses and Calf
Stretching for Individuals Janice K. Loudon, PT, PhD, and

With Medial Tibial Stress

Martin R. Dolphino, PT, CMPT

Syndrome

M
Abstract: Use of orthotics and calf edial tibial stress syndrome fresh cadaver limbs that contraction of
stretching may alleviate symptoms in (MTSS) is one of the most com- the superficial and deep posterior com-
runners with medial tibial stress syn- mon causes of exercise-related partment muscles creates a traction force
drome (MTSS). The objective of this leg pain.1 The term describes a spe- to the distal tibia fascia. Muscles that have
study was to determine which patients cific overuse injury, which produces been identified as possible culprits include
with MTSS have a positive response pain along the posteromedial aspect of the posterior tibialis,9,10 soleus,11,12 and the
to off-the-shelf foot orthoses and calf the distal two thirds of the tibia. MTSS flexor digitorum longus.11 Another theory

stretching based on selected clinical
tests to establish a clinical prediction
rule. This prospective cohort/predictive
validity study enrolled 23 women and
men aged 22 to 44 years with symp-
toms of MTSS. Interventions included
off-the-shelf basic foot orthotics and
calf stretching. Fifteen of the 23 run-
ners had a 50% reduction of pain in
3 weeks of intervention. Duration was
a significant factor that differentiated
groups. Although an initial treatment
for runners with MTSS may include off-
the-shelf orthotics and calf stretching,
this regimen should be only one com-
ponent of an individualized rehabili-
tation program.
Keywords: shin splints; sports podiatry;
running; jogging; medial tibial stress syn-
drome; orthotics
“
excludes diagnoses of
stress fracture or poste-
rior compartment syn- Treatment for MTSS is largely based
drome.2-4 The sports in
which athletes are most on anecdotal reports rather than
commonly afflicted are
cross-country, track, bas- evidence-based practice.”
ketball, and volleyball.
The incidence of MTSS
in long-distance runners can be as high was put forward by Tweed et al13 that
as 16.8% and is more prevalent in the MTSS “is not an inflammatory process
female runner.5,6 In the military, the of the periosteum but instead a stress
incidence has been reported to be as reaction of the bone that has become
high as 35%, with women being more painful.”
afflicted.6,7 The diagnosis of MTSS is based on clin-
The pathogeneses of MTSS is contro- ical history and symptoms. Pain and ten-
versial, with some authors describing derness are usually diffuse and located
the condition as a periostitis (inflamma- along the medial distal two thirds of
tion of the periosteum) due to strain of the tibia. Commonly, athletes will com-
the medial tibial fascia, whereas others plain of pain at the beginning of a run
describe it as tearing of the muscle bone that may subside during the middle but
interface. Bouche and Johnson8 found in recurs at the end of the run. Provocative

DOI: 10.1177/1938640009355659. From the University of Kansas Medical Center, Kansas City, Kansas. Address for correspondence to Janice K. Loudon, PT, PhD,
University of Kansas Medical Center, 3901 Rainbow, Mailstop 2002, Kansas City, KS 66160; e-mail: jloudon@kumc.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2010 The Author(s)

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16 Foot & Ankle Specialist
tests to rule in MTSS include pain with
passive ankle dorsiflexion, resisted plan-
tarflexion, toe raises, or single-leg hops.13
Radiographs and compartment pressures
will be normal.
Potential risk factors for MTSS include
excessive foot pronation,6,14,15 increased
velocity of pronation, and rear- and fore-
foot varus.15,16 Theoretically, muscles
fatigue over time, increasing the amount
of force absorbed by the bone and peri-
osteal tissue. Other potential risk factors
that are identified in the literature are
limited ankle dorsiflexion7,17 and lack of
hip flexibility.18 Bennett et al19 measured
125 high school cross-country runners
for tibiofibular varum, weightbearing
resting calcaneal position, and gastrocne-
mius length prior to their cross-­country
season. All athletes were monitored for
symptoms of MTSS. After 8 weeks, 25
limbs from the runners had symptoms of
MTSS. These 25 limbs were compared to
a randomly selected 25 limbs of the non-
symptomatic runners. Navicular drop test
(NDT) was measured in these 50 limbs.
A paired t test resulted in a significant
difference in NDT between injured and
noninjured limbs, with the injured limb
having greater navicular drop. A pro-
spective study by Plisky ­et al20 exam-
ined bilateral navicular drop, foot length,
height, body mass, previous running
injury, running experience, and use of
orthotic or tape. The runners were fol-
lowed during the season to determine
athletic exposure and occurrence of
MTSS; overall injury rate was higher in
females. Only gender and body mass
index (BMI) were significantly associated
with occurrence of MTSS. In addition,
those runners with a previous running
injury were more than 2 times as likely
to develop MTSS. Michael and Holder21
use pronated feet as a clinical character-
istic of MTSS. The researchers found that
the insertion of the soleus on the medial
border of the calcaneus is vulnerable to
excessive elongation with the foot pro-
nated. Viitasalo and Kvist4 reported that
patients with shin splints had more pro-
nation at the subtalar joint. In conclu-
sion, it appears from the literature that
sex, BMI, previous injury, and alignment
issues such as excessive pronation are
causative factors of MTSS.
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February 2010
Treatment for MTSS is largely based on ity stress fracture, recent history of trauma
anecdotal reports rather than evidence- or surgery to the lower extremity or knee
based practice. Based on the previously pathology/surgery, or paraesthesia in the
mentioned contributing factors related to lower leg. Participants were required to
foot biomechanics, it was theorized that be fluent in the English language. All par-
some type of orthotic would be benefi- ticipants signed an informed consent
cial to individuals with MTSS. Eickhoff form approved by the university’s internal
et al22 surveyed cross-country runners review Board prior to beginning the study.
who were prescribed foot orthotics and
found that the orthotics helped with Procedure
symptoms of MTSS. Plisky et al20 reported
Initial visit. Initially, participants were
that runners with MTSS injury were 3
screened for the symptoms of medial tibial
times as likely to report orthotic use, but
stress syndrome by one of the investiga-
the researchers did not mention the effec-
tors. They were also questioned about
tiveness of their use. There appears to be
their activity level. If participants were
a link between tight calf musculature and
eligible and decided to participate in the
the development of MTSS.23 However, no
study, they were required to attend one
published literature has investigated the
30-minute visit. On this visit, investiga-
effectiveness of gastroc-soleus stretching
tors collected data on age, height, weight,
on the symptoms of MTSS.
duration of symptoms, and alignment
The purpose of this study was to deter-
measurements. The alignment measure-
mine the effectiveness of a basic treat-
ments included the navicular drop test and
ment protocol, consisting of gastroc-soleus
talocrural dorsiflexion range of motion. In
stretching and foot orthotics in dimin-
addition, participants were asked to rate
ishing the pain level in individuals with
their average pain level during their last
MTSS. Second, we wanted to identify if
week of running or walking on a 0 to 10
sex, age, BMI, duration of symptoms, dor-
numerical pain rating scale (NPRS), with
siflexion range of motion, and foot pro-
10 being the worst pain imaginable and 0
nation distinguished between those who
being no pain. This type of pain scale has
succeeded and those who did not.
been shown to be reliable.24 If participants
had bilateral pain, the limb with the high-
Methods est pain rating was used for data analyses.
Participants Each measurement was obtained by the
same investigator throughout the study.
Twenty-three individuals were recruited
In supine, active talocrural dorsiflex-
to participate in the study. Eleven women
ion range was assessed using the tech-
and 12 men, aged 22 to 44 years (mean =
nique described in Norkin and White.25
28.1, SD = 5.9) participated. To partici-
The participant stood for the recording
pate in the study, the participants had to
of the navicular drop test. A fine-tipped
be avid runners/walkers who ran/walked
marker was used to mark the most prom-
at least 10 miles/wk. They also needed to
inent point of the navicular tubercle with
have symptoms of medial tibial stress syn-
the participant standing. Next, the par-
drome that included (1) a dull ache along
ticipant’s subtalar joint position was pal-
the middle or distal posteromedial tibia
pated, and the participant was asked to
that spread over a minimum of 5 cm, (2)
maintain the foot position. The height
pain that was provoked by running and/
of the navicular was measured from the
or walking, and (3) palpation of the pos-
ground to the distal-most point on the
teromedial border of the tibia that elic-
navicular bone.26 Participants then stood
ited pain that was diffuse and not focal.
with the foot in a relaxed position, and
In addition, participants presented with
the navicular distance was re-measured.
symptoms in at least one of the following
The difference between the 2 navicular
provocation tests: (1) passive ankle dor-
distances was calculated and recorded to
siflexion, (2) resisted plantarflexion, (3)
the nearest millimeter (mm).
20 toe raises, and (4) 10 single-leg hops.
Participants were excluded from the study Intervention. Following the measure-
if they had a history of a lower extrem- ments, the participant was fitted with an
vol. 3 / no. 1
Figure 1.
Gastrocnemius stretch.
off-the-shelf basic foot orthotic (BFO)
and given a home stretching program.
The orthotic was a BFO shell by AliMed.
Participants were asked to wear the
orthotics during waking hours for 3 weeks.
The orthotic could be switched between
different shoe wear. The stretching pro-
gram consisted of standard gastrocne-
mius and soleus stretching against a wall,
as illustrated in Figure 1. Participants were
instructed on how to maintain a neutral
foot position as they stretched 3 × 30 sec-
onds with the knee straight and 3 × 30
seconds with the knee bent. This time
for stretching has been demonstrated to
be effective.27 Stretching was to be per-
formed 2 times a day. A printed exercise
sheet accompanied the instructions. Each
participant documented his or her com-
pliance with the stretching program by
using a paper-based daily log to record the
number of sets, repetitions, and duration
of the gastroc-soleus stretching. In addi-
tion, activity level and numeric pain rating
were also recorded on the log. Participants
were asked not to seek further intervention
between the initial visit and each follow-up.
Follow-up. One week after the visit, par-
ticipants were contacted via e-mail to
check on the intervention and to solicit
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any questions from the participants.
Twenty-one days following the initial
visit, participants were again contacted
via electronic mail to report their pain
level for the last workout and to fill out
the Global Rating of Change (GRC) ques-
tionnaire (see the appendix). The GRC
is a 15-point scale that measures an indi-
vidual’s overall change in quality of life
following an intervention. This scale has
been shown to be a valid measurement.28
Data Analysis
Statistical analyses were performed
using SPSS software, Version 16.0 (SPSS,
Inc, Chicago, Illinois). Descriptive sta-
tistics and measures of central tendency
and variability were calculated for the
sample. Body mass index was calcu-
lated from height and weight with the
following formula: weight in kilograms
divided by height in meters2.
In this study, the results from each par-
ticipant were classified as successful or
not successful based on the NPRS. Fifty
percent improvement in NPRS score after
3 weeks was considered a success.29 This
information was used to form 2 groups
of data for each variable that could be
Foot & Ankle Specialist 17
used as a predictor of success. After
participants were dichotomized by suc-
cess, univariate analyses were conducted
as summarized in Table 1. Alpha level
was set at 0.10. We used Bonferonni
adjustment to account for the 4 compar-
isons (BMI, duration, dorsiflexion range,
NDT), resulting in an alpha level of 0.02.
Results
Twenty-three individuals participated
in the study, including 11 women and 12
men, aged 22 to 44 years (mean = 28.8,
SD = 6.3). Two participants were unable
to tolerate the orthotics, so they did not
complete the 3-week intervention. Their
data were included in the nonsuccess-
ful group. Descriptive characteristics for
all variables measured on each of the 23
participants are shown in Table 1.
Forty-four percent of the women in our
sample improved to a successful level,
whereas 83% of the men successfully
improved. The mean duration of symp-
toms for the participants in our study was
262.1 ± 225.6 weeks. For the success-
ful group, the duration was 181.6 ± 180.1
weeks, which was significantly less than
the unsuccessful group. Age was not sig-
nificantly different between groups.
The 2 impairment measures, ankle dor-
siflexion and navicular drop test, were not
different between the 2 groups (Table 1).
Body mass index on average was similar
between groups. The average value, 25.2,
is considered on the high end of BMI.
Pain level did not change after the
3-week intervention in 2 participants.
The remaining participants had some
improvement of pain level after 3 weeks.
However, participants were considered
to have successful intervention based on
a 50% improvement on the final NPRS.
This resulted in 15 participants with
a successful outcome (65.2%) and 8
­without a ­successful outcome. Table 2
displays the pain levels and GRC. The
mean NPRS was 5.7 ± 1.8 preinterven-
tion and 3.3 ± 2.1 postintervention. The
successful group’s pain level on average
dropped from 5.3 ± 1.9 to 1.9 ± 1.3. This
was statistically significant (P < .00).
The unsuccessful group averaged a pain
level of 5.8 ± 2.2 before the intervention
and 5.5 ± 1.3 after the intervention.
18 Foot & Ankle Specialist February 2010

Table 1.
Demographics and Clinical Examination Results

All Participants = 23 Successful = 15 Unsuccessful = 8

Women = 11 Women = 5 Women = 6
Men = 12 Men = 10 Men = 2
Characteristic Mean SD Mean SD Mean SD P
Age, y 28.8 6.3 29.5 6.5 27.5 6.1 .47
Duration, wk 262.1 225.6 181.6 180.1 412.8 225.9 .015*
BMI 25.2 5.0 24.6 5.4 26.2 4.1 .52
NDT, mm 8.4 2.4 8.6 2.6 8.1 2.3 .63
Dorsiflexion, degree 11.3 4.0 11.4 4.2 11.2 3.7 .87
NDT, navicular drop test; BMI, body mass index.
*P < .02.

Table 2.
Numeric Pain Scores and Global Rating of Change

All Participants Successful Group Unsuccessful Group

Score Mean SD Mean SD Mean SD
NPRS pre 5.7 1.8 5.3 1.9 5.8 2.2
NPRS post 3.3 2.1 1.9 1.3 5.5 1.3
GRC 2.9 2.5 4.3 1.04 0.80 1.9
NPRS, numeric pain rating score; GRC, Global Rating of Change.

Each participant also completed the
GRC questionnaire. Juniper et al28 pro-
posed that a score of –1, 0, or 1 on
the GRC indicates that there is no real
change in a person’s condition, ±2 to 3
means minimal change, ±4 to 5 is a mod-
erate change, and >6 is a large change.
There was a significant difference
between groups (P < .0001). The success-
ful group scored a 4.3, which is consid-
ered “moderately to quite a bit better.”
The unsuccessful group averaged 0.80,
which is scored as “no change.”
Discussion
Participating in an exercise program
can be hampered by various musculo-
skeletal issues, one of which is medial tib-
ial stress syndrome.1,4,30 The incidence of
MTSS has been identified by Bennett et al19
to be 12% and by Plisky et al20 to be 15.2%
in high school cross-country runners.
Clement30 found the incidence to be higher
in female runners (16.8%) as compared to
males (10.7%).
Much has been written in the literature
regarding faulty lower extremity biome-
chanics as a possible causative factor for
MTSS.1,31 Sommer and Vallentyne15 found
that atypical foot mechanics in runners
were predictive of a previous history of
MTSS. Others have found that individuals
with MTSS had a greater degree of prona-
tion than control runners while running,
as measured by high-speed cinematog-
raphy.4,6 Bennett et al19 developed a pre-
diction model for identifying those high
school runners who may develop MTSS.
Based on their findings, the combination
of sex and navicular drop test provided
an accurate prediction.
The purpose of this study was
to determine the effectiveness of a
basic treatment protocol consisting of
­gastroc-soleus stretching and foot orthot-
ics in diminishing the pain level in
patients with MTSS. Second, we wanted
to identify if sex, age, BMI, duration of
symptoms, dorsiflexion range of motion,
and foot pronation distinguished between
those who succeeded and those who did
not. Clinicians would benefit from identi-
fying predictive measures that help with
the treatment of symptoms from MTSS.
Outcome Measures
Of the 23 partipants, 15 had successful
treatment outcome after 3 weeks of inter-
vention, producing a 62.5% pretest prob-
ability of treatment success. One variable
that we investigated was sex. Data from

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vol. 3 / no. 1
the literature indicate that females are
more likely to sustain MTSS than males.30
In our study, we were able to recruit 23
participants with MTSS, of whom 11 were
women. The setting for recruitment was a
medical center that houses a fitness center
with most of the participants being either
students or employees at the medical cen-
ter. This may have biased the percentage
of women in our sample. Nevertheless,
in our study, male participants responded
more positively to the use of orthotics and
stretching (83%) than the women (44%).
These results are similar to a study that
investigated the use of neoprene insoles
in minimizing the incidence of MTSS in
military recruits.32 The experimental group
that received the insoles experienced sig-
nificantly less MTSS symptoms and con-
sisted primarily of male recruits.
The next factor, duration, was the only
factor that differentiated success versus
nonsuccess in our sample. The unsuc-
cessful group on average had twice the
duration of MTSS as compared to the suc-
cessful group. However, the successful
group on the average experienced MTSS
for a relatively long period of time, over
3 years. Intuitively, a longer duration of
symptoms carries with it a negative prog-
nosis. Nothing was found in the literature
on duration as it relates to shin pain and
the recovery of symptoms.
Body mass index has been identified as
a contributing factor to MTSS. Plisky et al20
found that after adjusting for gender and
orthotic use, runners with a higher BMI
were at an increased risk of MTSS. Our
study is in agreement with these findings,
with the average BMI for both groups
equalling 25.2, which is on the high side
for BMI.33 The successful group did have
a slightly lower value, 24.6, compared to
the nonsuccess group, 26.2, but these val-
ues were not significantly different.
The 2 impairment measures that we
hypothesized would influence suc-
cess with the treatment of orthotics and
stretching were the navicular drop test
and dorsiflexion excursion. The NDT was
included in this study as a measure of
functional pronation. A value of 10 mm
is indicative of abnormal pronation.34,35
The mean value of navicular drop in
this study was 8.4 mm. This value is
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higher than the value that Bennett et al19
reported (6.8 mm) in high school runners
who developed MTSS. As with the NDT,
there was no difference in dorsiflex-
ion range between groups. The average
range was 11.3 degrees and considered
normal for gait (10 degrees) but deficient
for running (20 degrees).36
The possible mechanism for success-
ful outcome using orthotics and calf
stretching in runners with MTSS was not
revealed in this present study. It is appar-
ent that orthotics and stretching are bene-
ficial because more participants got better
than not. The BFO is designed to sup-
port the medial longitudinal arch and the
forefoot and perhaps minimize the tis-
sue stress that occurs with MTSS. A full
kinematic analysis of the lower extrem-
ity with and without the insert would
help to address its mechanistic influ-
ence. Stretching was added as part of
the intervention because of the possi-
ble relationship between limited talo-
crural dorsiflexion and its effect on
foot mechanics. It has been proposed
that compensation for a lack of dorsi-
flexion is overpronation at the subta-
lar joint.37 Dorsiflexion range was not a
distinguishing factor between groups,
and one may conclude that the stretch-
ing component of the intervention had
no effect. However, because we did not
measure dorsiflexion at the conclusion of
the 3 weeks, we have no way of know-
ing if this range improved. We can spec-
ulate that it did improve, and perhaps
with control of foot pronation with the
orthotic and improved dorsiflexion, tis-
sue stress along the medial tibia was
minimized.
The intervention used in this study is
only a part of the total treatment strat-
egy for runners with MTSS. Only 3 par-
ticipants reported no pain following the
3 weeks of intervention, indicating that
treatment should include other aspects.
Limitations
We chose a number of select variables
that were included in our initial model.
These variables are routinely mea-
sured, relatively quick to perform, and
described in the literature as contributing
Foot & Ankle Specialist 19
factors to MTSS. Certainly other variables
may emerge as predictors of interven-
tion success. For example, we did not
include any measures of muscle strength.
Future studies should include strength
measures.
Another limitation of the study is that
all measurements were taken preinter-
vention. Follow-up measurements after
intervention would have been helpful
to determine the mechanism for success
or nonsuccess. Also, the study includes
a small sample size and the use of only
a few clinical exam variables. A future
randomized controlled study would help
to validate the findings of this study.
Conclusion
This is the first study to investigate the
effect of in-shoe orthotics and calf stretch-
ing on symptoms of MTSS in runners. Our
results suggest that males respond more
favorably to this intervention than females.
In addition, runners with a shorter dura-
tion of symptoms have a better chance for
symptom reduction. Future studies need
to test this model using a wider range of
impairment and functional measure with a
longer follow-up period.
Appendix
Global Rating of Change Questionnaire
• A very great deal worse
• A great deal worse
• Quite a bit worse
• Moderately worse
• Somewhat worse
• A little bit worse
• A tiny bit worse (almost the same)
• About the same
• A tiny bit better (almost the same)
• A little bit better
• Somewhat better
• Moderately better
• Quite a bit better
• A great deal better
• A very great deal better
20 Foot & Ankle Specialist
Acknowledgment
We thank Ashley Friend and Aubree
Mullinix for their help with participant
recruitment and follow-up. Grant sup-
port: Kansas Partners in Progress. The
University of Kansas Medical Center’s
International Review Board approved
this study protocol.
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