Original Contribution
Shear Modulus of the Lower Leg Muscles in Patients with Medial Tibial Stress Syndrome

https://doi.org/10.1016/j.ultrasmedbio.2016.03.010Get rights and content

Abstract

This study aimed to investigate the in vivo kinematics of shear modulus of the lower leg muscles in patients with medial tibial stress syndrome (MTSS). The study population included 46 limbs with MTSS and 40 healthy limbs. The shear modulus of the medial head of the gastrocnemius, lateral head of the gastrocnemius, soleus, peroneus longus and tibialis anterior muscles were measured using shear wave ultrasound elastography. As a result, the shear modulus of the lower leg muscles was significantly greater in patients with MTSS than in healthy patients (p < 0.01). Based on the differences in shear modulus of lower leg muscles between the patients with MTSS and healthy patients, the measurements obtained via shear wave ultrasound elastography could be used to evaluate risk factors of MTSS.

Introduction

Medial tibial stress syndrome (MTSS) is a generic term for lower leg pain (Davey et al., 1984, Mubarak et al., 1982, Puranen, 1974), including tibial periostitis (Detmer 1986) and shin splint (Clement, 1974, Mubarak et al., 1982). In athletes, MTSS reportedly accounts for 9.5% of injuries and 60% of lower limb injuries (Orava and Puranen 1979). With MTSS, athletes should stop participating in competition for up to 16 wk, which could decrease their competitiveness (Beck 1998). Moreover, MTSS is known to have a high recurrence rate (Yates and White 2004). Thus, constructing an injury prevention procedure is warranted. Based on an injury prevention model proposed by Van Mechelen (1997), injury prevention relies on knowledge of risk factors and mechanisms. However, the mechanisms and risk factors for MTSS are not fully understood. Notably, objective evaluations of factors for recurrence could provide important information for prevention programs for MTSS.

Lower limb muscle tightness associated with impaired ankle range of motion has been extensively investigated as a risk factor for MTSS (Tweed et al., 2008, Yates and White, 2004, Yüksel et al., 2011), and lower limb muscle tightness is common in patients with MTSS (Newman et al. 2012). Increased tightness of the triceps surae muscle (medial head of the gastrocnemius [MG] lateral head of the gastrocnemius [LG], soleus [SOL]) is thought to result from a failure to absorb impact loads owing to decreased range of motion in ankle dorsiflexion. The ankle dorsiflexion angle during knee joint extension and knee joint flexion has been used to evaluate gastrocnemius muscle tigtness and SOL tightness, respectively (Yates and White 2004). However, no correlation between ankle dorsiflexion and MTSS has been reported (Burne et al. 2004). Therefore, consensus regarding the triceps surae muscle characteristics that represent risk factors for MTSS is lacking.

Furthermore, muscle tightness as a risk factor for MTSS remains controversial because of the typical subjective evaluation using palpation and the use of a push-in type muscle hardness meter—a precise, reliable measurement method is lacking. Therefore, a more reliable, objective technique to determine muscle tightness characteristics is needed to identify the condition for MTSS onset. In this context, shear modulus determined by shear wave ultrasound elastography has recently emerged to evaluate muscle tightness for an index, and its usefulness for objective muscle evaluation has been demonstrated (Akagi and Takahashi, 2013, Akagi and Takahashi, 2014). This technology might help understand the risk factor of MTSS. We hypothesized that triceps surae (MG, LG, SOL) shear moduli are greater in patients with a history of MTSS. Shear modulus of peroneus longus (PL) and tibialis anterior (TA) muscles were not significantly different between the healthy patients and patients with MTSS. The present study aimed to determine a shear modulus to quantify the tightness of lower limb muscles in MTSS using ultrasound elastography.

Section snippets

Patients

The experiment was performed in 40 limbs of 20 healthy male athletes and 46 limbs of 24 of male athletes (22 athletes had MTSS on both sides, 2 athletes had MTSS on one side) diagnosed with MTSS by a physician based on the definition given by Yates and White (2004). The characteristics of the healthy patients were as follows age, 19.4 y ± 2.9 y; height, 165.8 cm ± 7.3 cm; and weight, 65.2 kg ± 14.1 kg. The characteristics of the patients with MTSS were as follows age, 21.9 y ± 6.4 y; height,

Ankle dorsiflexion angle

Ankle dorsiflexion angles in both knee conditions were not significantly different between the healthy patients and patients with MTSS (Table 2). There was no significant correlation between the dorsiflexion angle in knee joint extension and shear modulus of MG or LG in the healthy patients (r = 0.282, r = 0.232) or patients with MTSS (r = 0.133, r = 0.129). In addition, there were no correlations between the dorsiflexion angle in knee joint flexion and shear modulus SOL in neither the healthy

Discussion

The main findings of this study were the lower leg muscle shear modulus (MG, LG, SOL, PL and TA) was significantly greater (p < 0.01) in the patients with MTSS than in the healthy patients. The results were concordant with a part of the hypothesis that triceps surae shear moduli are greater in patients with a history of MTSS.

The theory of traction-induced MTSS suggests that tension at the plantar flexor muscle origin on the tibia due to repeated loads causes the associated muscle and periosteum

Conclusions

In summary, the MTSS group had high shear modulus of the lower leg (MG, LG, SOL, PL and TA) than healthy patients at rest. Based on the differences in shear modulus among the patients with MTSS and healthy patients in the present study, the measurements could be used clinically to evaluate MTSS onset and rehabilitation as well as prevent future recurrence.

Acknowledgments

The present study was supported by a research fund from Japan Institute of Sports Sciences.

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