Speaker 1:
Jared Powell:
Welcome back to the show. Today we're talking about one of the most common and most poorly understood running injuries. You know, that diffuse nagging pain along the inner shin that gets called shin splints or medial tibial stress syndrome. My guest is Laura Anderson. Laura is a physiotherapist based in Geelong Victoria. She owns and works clinically in the injury clinic and she's currently completing a PhD focused on medial tibial stress in runners. She also recently published a viewpoint editorial paper in J-O-S-P-T, arguing that MTSS or medial tibial stress syndrome needs a new name because the current one is inaccurate. In this conversation, we unpack the case for a simpler label load induced medial leg pain or limp catchy name. But the logic is the important part. It shifts the story and narrative away from stress fracture or reaction panic and toward load tolerance management and progressive return to running. So without any further delay, I bring to you my conversation with Laura Anderson. Laura Anderson, welcome to the show.
Laura Anderson:
Thank you very much Jared. Thank you for having me. You're
Jared Powell:
Welcome. Laura, who are you and what do you do?
Laura Anderson:
I am a physiotherapist based down in Geelong in Victoria, the owner of a practice down there and still work clinically a couple of days a week and I'm also tackling a PhD investigating medial tibial stress in runners. Cool.
Jared Powell:
First things first, you are a Geelong resident. Are you a Geelong fan in the A
Laura Anderson:
FLI stay neutral in the A FL Jared, but I know that it is a, yes, it's a bit controversial to being Geelong and not a Geelong supporter, but no, I stay neutral there. Yep.
Jared Powell:
Are you a supporter of any team or are you, you strictly a fan of the game or not a fan of the game at all?
Laura Anderson:
No, strictly more a fan of the game. I think I like to, to follow along keenly without allegiance to, to anyone in wow
Jared Powell:
Respect. I don't know how you do that. Good on you. You'd be a good politician I reckon. literal, it's all about the ideas. It's all about the ideas. . And are you a runner yourself? Like why, why MTSS? How did you get into this?
Laura Anderson:
Yes, look, I dabble in running but to no particular level. Got interest in MTSS. I think I started research at Latrobe with Dan Bonano, who's one of my supervisors now many years ago. We're just looking at running injuries in biomechanics in general and MTSS kept popping up as one of the most common and one of the most prevalent, but there wasn't really a lot of other evidence to go along beside it. So I think I was just interested more by the lack of evidence that might have been around it, given it's one of the remains, one of the most common running injuries and has for a really long period of time. So yeah.
Jared Powell:
Good. Yeah, it's a, it's a super necessary research or gap to fill, so kudos to you. I'm sure it's been challenging. How's your PhD journey been? How are you holding up psychologically? You're right. Oh, that's
Laura Anderson:
A great, that's a great question. You've probably got me at a good moment in time, Jared, so I'm currently Okay. But you know, I'm sure as everyone will attest to, it definitely has its highs and lows and ebbs and flows, but I think I've hopefully got about a year left and no at the moment feeling pretty optimistic and I'm actually, I I have really enjoyed it. So Good.
Jared Powell:
Yeah, no, it's, it's certainly you'll feel better when you get the doctor when
Laura Anderson:
It's done. Yeah.
Jared Powell:
Correct. But yeah, there'll still be many. Anyway, I want to curse you. You're doing a great job. Congratulations. Let's get into your paper. So you published a really cool viewpoint editorial in J-O-S-P-T recently, last few months I'd say. Is that right? Yep, yep. And I'll let you tell, tell me all about it. Effectively it's about Shin splints, MTSS and another name that you introduced. Tell us, tell us sort of how the paper came about and the new name that you proposed to replace perhaps these outdated terms.
Laura Anderson:
It came about, I think we were, I suppose I was starting to look into the research around MTSS and, and I'm sure we'll get into it later, but it definitely seemed as though like the, yet the academic research around the PATHOANATOMY of MTSS was really starting toward to lean towards it being a bone stress injury. And it seemed like the conversation was really starting to exist in that space, but it wasn't really aligning with what we were then seeing with how people were managing MTSS. So we had this, you know, pathoanatomy movement towards bone stress injury, but the management of it certainly wasn't moving in that direction either. So I think that it definitely seemed to be some emerging confusion about what MTSS is and how it's managed. So we struck up conversation with Stuart Warden and Rich Willie who obviously on this paper and I feel incredibly lucky to have been able to get their opinions and their input on this 'cause they're obviously incredibly knowledgeable in these areas and I think it, the conversation then came around I suppose addressing some of that confusion by looking to rename it and moving it away from assuming that it is a bone stress injury or associating it so closely with a bone stress injury through its name.
Laura Anderson:
So we did propose load induced medial leg pain. So which does come out as a limp, but limp came second, the name came first. It's
Jared Powell:
A crazy coincidence. It
Laura Anderson:
Was just a great coincidence. So, and look, the premise for that is that it was mainly around getting rid of tibial stress. So I think that's, well for me that was probably the biggest problem. I'll say problem in that I think, well it suggests tibial bone and stress, so a tibial bone stress injury. So we removed that from IT syndrome, I certainly don't think really fits with MTSS. It doesn't really have a collection of symptoms. It's kind of got one which is pain. So we looked to remove those things and we thought we'd just keep it simple and call it what it was, which is medial leg pain that is load induced and that's how we landed on limp.
Jared Powell:
I love it. I mean it is obviously a very catchy term. So that's the biggest, that's the biggest issue with these terms. So let's, let's go into what's your issue Laura, with this tibial bone stress injury and why might limp be a different pathology in its own right? What do we see when we are looking, you know, like from a pathological perspective when an individual presents with limp, like what's going on in the tissue of these individuals?
Laura Anderson:
That is a great question and I don't think we really have any clear or consistent evidence yet to tell us what it is and that's okay. I don't know if we ever will there seem to, if we look at the patho anatomy of it and we look at the literature, there seem to be two leading theories and one is your like soft tissue traction and the soft tissues that have been named as being implicated over the years have been soleus tib post F-D-L-F-H-L and probably your like deep choal fascia. I think TIB post very much has kind of been scrubbed out of that now. So we've got that theory and then there is your more like tibial bending bone stress theory. A lot of the soft tissue traction theories seem to have been based on like anatomical studies of what attaches where you get your symptoms and some bone scan studies that argue that it is a very different entity to a tibial bone stress injury.
Laura Anderson:
So we've got that evidence in terms of just like tissues and what attaches where you get sore. But then we've got studies that have looked at what's happening at those tissues at those spots in symptomatic patients and they've found no greater, I suppose, prevalence of any of your PERS or soft tissue inflammation in symptomatic versus control. So again, it's a little bit conflicted and nothing's really clear. And then we've got our bone stress theories and we've got studies that have found local micro damage or you know, issues with cortical porosity but we've got other things that can also explain those findings and they are in many ways normal response to load. So we can't really directly link them to MTSS and in some of those studies those findings were in, you know, the asymptomatic leg of someone who had unilateral symptoms. So we can't directly, I don't think link that to MTSS. It can't fully explain MTSS. So we've got all of these things but we've got again studies that will conflict other findings and things that just suggest that there might be multiple tissues involved but nothing that's come out as being clear or concise.
Jared Powell:
When you have a patient present to you with medial tibial leg pain limp and you refer this person for imaging, if you do, we don't have to have a conversation about imaging. Perhaps we can in diagnosis a little bit later. What are, what do you normally see on average? Do you, do you normally see nothing come back in the tissues around that medial tibia? Is there some like high grade signal indicating something around the tibial border? What, what do you normally see on average? I know everybody's different but like if you were to see a hundred patients, what would you see 50% of the time?
Laura Anderson:
A lot of the ones that I think have got MTSS at MTSS, I'm not referring for imaging so there's probably a more tricky one for me to answer and then I'm So
Jared Powell:
You'd see nothing 'cause
Laura Anderson:
Yeah, I'd see nothing so I'm not, yeah not often choosing to get them imaged only really choosing to get them imaged if I'm like really feel like I'm struggling with that differential with a tibial bone stress injury. Mm-Hmm and in that case I think I've seen a mix of things. I've seen nothing. I've seen what you would probably describe as a tibial per, I've seen a tibial bone stress injury but absolutely nowhere near the location of their symptoms. So I dunno whether or not it was just a false positive and you know that tibial bone stress injury was still asymptomatic and we saw nothing for their MTSS. We've seen a whole range of things and I'd say I've seen nothing consistent.
Jared Powell:
Cool. Yep that's great. It sort of reflects, my interest is in the shoulder and it's the same sort of thing when we image someone's shoulder in terms of what shows up versus how they feel. I don't remember the last time I recommended somebody with non-traumatic shoulder pain that's you know, pretty basic that's load induced shoulder pain for example that I recommend go and get an image. I think the same thing is what you're saying with the medial tibia. So let's just have a conversation quickly about diagnosis. So I had Rich Willie on the show, you mentioned him before. We touch briefly on the difference between MTSS and maybe a a medial tibial bone stress injury and what, how it may present differently clinically from memory and I don't have the best memory, I think you said if the area of tenderness or soreness was 10 centimeters, like the bigger the area, the more likely it's to be MTSS versus if it was pinpoint it's more likely to be a bone stress injury. Is, does that ring a bell?
Laura Anderson:
Yeah, I think the more focal it is your obviously or focal tenderness, you're definitely gonna be suspicious of a medial tial stress. But if something's kind of more diffusely tender then without a area of focal tenderness, then definitely could be MTSS And I think there's some differences in symptom behavior. MTSS can sometimes warm up as people go tibial bone stress injuries are less likely to. Having said that, I have seen ones that seem to, so the severity of the symptoms is often I think a big one MTSS does seem to set definitely settle down the next day. Whereas I think you, you see like a progression of symptoms with a tibial bone stress injury. They said they worsen if the person continues to try and run unload. But MTSS kind of just seems to, once they've got it, it grumbles along and we don't really ever see it progress to be night pain or pain at rest or any of the things that we see a tibial bone stress injury progress to.
Jared Powell:
So let's formalize that. If somebody comes to you with medial tibial pain, they're a runner or something repetitive in terms of loading, what's making you hypothesize that this person may have MTSS as opposed to something else? What are the sort of clinical identifiers that you're looking for?
Laura Anderson:
Lack of focal tenderness. So they wouldn't have somewhere that was focal, their symptoms might warm up as they run. They might not, but they might be worse at the start of the run and then lessen as they go. They essentially, they don't stop their symptoms, don't stop them from running. There's no night pain, there's no pain at rest. They might give it a day or two and run and their symptoms behaving in exactly the same way. They haven't deteriorated on that next run compared to the run that they've just been on. Cool.
Jared Powell:
Good. And so you've got the diagnosis, we, we've made a point of saying that these individuals who we suspect may have limp don't need imaging so we don't need to go down that pathway. You then need to communicate to this individual what they have. And so the diagnostic label becomes important here. So why, why are you proposing that a more neutral term that doesn't implicate structure or doesn't implicate pathology is perhaps more be beneficial to a patient and their prognosis and their thoughts, feelings and beliefs about their condition? What's the value in a label here?
Laura Anderson:
I think it's physio's lang like language is incredibly, I think for everyone language it can be incredibly or it can be incredibly powerful. You know, shin splints I think is quite vague so it's not an overly helpful diagnostic term. MTSS, you know, yes the person you know might not as clinicians we might be drawing a line between MTSS and a tibial bone stress injury. In terms of the use of tibial stress patients, maybe not so much. But I certainly think being clear in terms of what we think it is, which is medial leg pain that is load induced is really important to then be able to explain next steps. And if we look at managing it and we are going to have an allowable amount of pain or discomfort and the management is so heavily going to be around how we balance their load tolerance and their load capacity, then you know, having something like load induced medial leg pain I think helps probably fit nicely with the education that we're going to need to do in terms of how it's managed and what to expect as opposed to something that's, you know, labeled as a A syndrome and doesn't give a lot away I don't think.
Laura Anderson:
Yeah,
Jared Powell:
Good. I think the load induced nature of it is super important because that feeds directly into how we manage it and I think patients they latch onto to the words that we say in regards to like as soon as you say bone stress injury, they look up bone stress injury and what comes up like stress fracture. Fracture, as soon as you see a stress fracture it's rest. Right. We were having a conversation before about, I've recently had limp myself and I had to reconceptualize how I needed to manage it. I sort of just happened upon it. I didn't, there wasn't a great moment of epiphany, it was frustration. I'm like, that, I still got pain. Yeah three months later I just need to, we're gonna talk about my case study at the end but it really made a difference when I started to think about it less of a bone stress injury and more about, I've just got a load intolerance issue here at my medial tibia and I sort of stopped caring about the bone so that was really helpful for me.
Jared Powell:
Can I ask uLaura about, this is not something that I've, I've listed in the outline. What, what's the natural history of MTSS? Do we have any data that suggests that you know, most people get better in in three months, in six months? Like what's the natural course of this condition? Do we have sort of data on the trajectory?
Laura Anderson:
It is a great question and no we don't, I personally think it is it, it is a long haul injury. I think the people that, and I've been seeing a lot of it and we're running a clinical trial at the moment so we're seeing a lot of it. It seems to be a condition that people have for months or years, either persistently or recurrent. I think, you know, listening to the stories or the anecdotes from the clients that have got it, I'd say that you know, and I dunno whether or not that's a reflection of the fact that we're not yet managing it appropriately so we're not able to get on top of it or it is just an incredibly persistent injury. But no, I don't think we have data or the time points. There was a study that was done that looked at kind of return to running in gateway training and things and it, it was, people were still painful and they'd returned to I think 20 minutes worth of running but it was, it was over a month I think. So like it was again, the progression in that was quite slow. So I think it is a slow to progress
Jared Powell:
Injury. Yeah, it really is. I think it's, I'm five months into it and I've sort of just reached some like very low grade symptom state so I can attest to that. Personally. Risk factors for developing MTSS or limp versus a bone stress injury. Is there overlap? Is MTSS simply a load issue or are there underlying factors that may sensitize or predispose us to avail to developing it?
Laura Anderson:
Another great question. A lot of the research I think like is a little bit mixed in terms of demographic too. So you've got like your military personnel who will get a lot of MTSS and then you've got your runners and there's some things out there in terms of obviously like your foot posture and navicular drop and BMI and some hip strength and hip biomechanic stuff. In terms of risk factors and contributing factors, I think the biggest one in terms of that will differentiate is more your like bone health type risk factors. So your tibial stress injury people and even if someone comes in and I think that they've got M probably got MTSS but if they're kind of ticking the boxes of our other, you know, high, high yield bone stress risk factors, I've got a much lower threshold to send them for imaging. So I think yeah MTSS ones are less likely to probably be really high load running at that period of time. They're less likely to have issues with gear red s or low energy availability in past history of bone stress injuries. They tend not to have that kind of cluster of things that might actually have an effect on their bone health or how their bones tolerate load versus the actual person that gets MTSS usually, or can be a lower level runner or less load. But yeah, the evidence on risk factors like biomechanical risk factors is mixed like we see in a lot of running
Jared Powell:
Injuries. Yeah, cool. Yeah, so let's, what about the bi? So what about step length, what about stride length? What about pronation on biomechanics? Are there any strong evidence to support those as risk factors?
Laura Anderson:
Navicular drop pops up and like some a propulsive gait stuff. So yeah, definitely through gait in terms of like your, your gait biomechanics, like we know that step length has been linked to tibial bone stress. I think like less so in MTSS at this point. There aren't a huge number of RCTs that have looked at MTSS so that probably stuff is you know, perhaps yet to come.
Jared Powell:
What about age and gender or sex? Any, any females,
Laura Anderson:
Yeah, again, so females tend to be more likely. Yeah.
Jared Powell:
Cool. Okay so that's MTSS, it's basically a very under research condition is what I'm hearing. It sounds, it's almost shocking given its ubiquity in running injuries as you've, as you've mentioned, it's everyone, like most people is have been through an episode of like medial shin pain with a return to running. It's super common in footy, right? Like after an off season. I remember like everyone's got shin splints after an off season of doing nothing and then the first few months of preseason, I don't know whether it was or whether it was just their body sort of getting used to the load again. But we all know what shin splints are either if we haven't been affected ourselves, we know someone who has it's ubiquitous crazy to think how little we know really considering that this is a pathology that's probably been recognized for 50 years more like I assume the first anecdotes would've been around early probably from the military or some sort of marching personnel. Yeah, so
Laura Anderson:
It goes back to like the fifties and early sixties like you know, chatter started about it. So yeah, it's been around for a very long time and I don't know whether or not what slowed it down is inability to reach a consensus on what we think it is and I dunno whether or not that's kind of, you know, the breaks have then come on in, you know looking and investigating you know, other parts of it perhaps and it wasn't, I don't think it wasn't that long ago. There's a great diagnostic criteria for it now. I think Winter's published it in only 2019. There's a really nice diagnostic flow chart but even before then, like the actual like, you know, diagnostic criteria that PE people were using, when you look at the research articles it does, there's not a huge degree of consistency in it. So that also makes it difficult. You know, some research articles are, you know, calling MTSS one thing and others are calling it something else. Mm-Hmm We do have mixed populations coming through in the evidence as well.
Jared Powell:
So the, the prevailing way of how we manage this condition in my experience, so certainly what I was taught at university and then in how I practiced in my first five to 10 years of clinical practice was pretty basic. You know, it was stretch the calves, strengthen the calves, maybe a bit of low dye tape on the foot, stop running for a bit and then you know, you get back into it and most people would have recurrences pretty quickly or they would take a hell of a long time that go through a boom bust period of of recovery. And I just found it really tricky to get these individuals back into the preexisting levels of of function. So where are we at now with treatment? Do we have any gold standard ways in which we should manage an individual with limp? Are we still fluffing around and throwing at a wall and hope something sticks? Like where are we at with how we manage someone with limp?
Laura Anderson:
In many ways we're still like throwing, throwing at the wall I think. Yeah, where you know, there's some research looking into shockwave. There's some has looked into like injection based therapies, some have looked into strengthening but you know the more nuanced specific strengthening around like toes and intrinsics and definitely more now is looking at some strengthening stuff and like good actual good gym-based well dosed strengthening. So there's that. But no, there's kind of little bits kind of dotted everywhere. I think if we look to get a general consensus, I think the general consensus is that it is something that requires load management as number one as a treatment. So yes that strengthening, there's mixed stuff out there for things like shockwave. The extreme cases I think used to go for surgery less so now, but no there's kind of little bits in E of everything out there and I don't think there is a general consensus in it.
Laura Anderson:
And you know, I've definitely having chatted to you know, final year students and emerging clinicians, I think there's probably a real mix in terms of what's being taught and there are some that are treating it like a low grade bone stress injury and assuming that it is. So they're applying those treatment strategies to MTSS. So we've got that happening versus some that are trying to manage load versus some that are still doing, you know, taping and aggressive massage of a shin and hoping that it settles down. So we've just got, we've got little bits and pieces everywhere. It's a bit of a mess I think.
Jared Powell:
Yeah, it brings back some memories. I remember being, you know, one or two years out of uni back in 2010 and just ripping to pieces, someone's medial calf or TID post, you know, and just aggressively trying to release something, some mythical structure in there. Yeah. That was gonna help them. I I sort of cringe as I reflect, but that's okay. We can make mistakes. Absolutely. but I, I actually don't think that that's too different to what people are are doing these days in clinics all around the world I imagine.
Laura Anderson:
No, like we still get some people in and you know, they've received treatment and it's been, you know, aggressive soft tissue stuff of a shin and you can look at them and they're, you know, bruised and sore and like, so again there's, I think people still very much don't know what to do. Mm-Hmm You know, got the best intentions but yeah, I think we're still probably applying some of those things to
Jared Powell:
It totally for better research there. Like achilles tendinopathy, patella tendinopathy, tendinopathy in general. We're, we still see a lot of people out there doing all friction massages on the Achilles and you know, so we can be a bit pejorative in how much we don't know about MTSS but even when we do know a lot more in the tendinopathies, we're still doing bat crazy stuff as well. So let me frame treatment through my case example, if you don't mind. This is a selfish episode. Yeah, . So I've 38-year-old male. I've had medial shin pain since July and so it's now November, so it's four or five months. I'd set a PB in the 5K park run in July and I was feeling on top of the world, I was just feeling myself. And then the next morning, the next day I went out to play tennis with my wife and I just had just worst pain in my medial shin and I'm like, this is my calf, is this my soleis?
Jared Powell:
What's going on? This feels very strange 'cause I had no pain during the run, no pain in the morning like I'm walking. But then I went to play tennis and as soon as I sort of went to go get some of these drop shots that my wife loves to hit, then my my shin was shin was getting sore. So anyway, I was like a couple of days is gonna be better, it's just like a tight calf, it's gonna be fun. You know, weeks went on. I had to get a couple of minor surgeries so my running was really up and down, up and down, up and down and I couldn't get a run at it And I just, every time I kept to go running and increase the intensity, like my, I could run pain free or one out of 10, two outta 10 pain at a really slow pace or a shuffle or even doing, I was doing an incline walk on the treadmill and that was fine and, but as soon as I would start to increase the pace, the pain would return.
Jared Powell:
And so this was the, this happened for about three, four months where I just couldn't increase the intensity. So I'm like, all right, I'm just gonna back it down. I'm just gonna do ultra like slow pace, like low intensity, just try and increase the volume very, very slowly over weeks and weeks and weeks. And I said to myself, I'm just gonna be okay with it hurting as long as the pain is less than three or four out of 10. I'm just gonna run through it as long as it feels okay the night of and the next morning and it's not really worse to walk on. And then I just did that for I would say a month and even two weeks ago it was still hurting for the first 500 meters for the first K at a really low symptom state. And then it would get better so I could run, I could run to a point where the pain went away and then think last week or the week before zero pain.
Jared Powell:
So I just be just became sort of a lot more aggressive with my running. I'm just gonna run through it as long as my symptoms were stable afterwards and the next morning. If I had come to you initially at the start of all of this, like would you have, would you have recommended a similar approach in terms of just sort of run through it as long as you can get it to a stable acceptable symptom state to you, would you have prescribed a period of rest? So in my circumstance, what do you think you would've done? What would be the core principles of how you would've managed it?
Laura Anderson:
I think, well number one, like you were, I love your story and your example 'cause it is like it really does kind of hammer home. I think the difference in MTSS and the tibial bone stress injury in that you know, you just, you keep trying to run and it's still sore and you rest and you try and run and it's still sore but you can run through it and it's not getting worse when not on a bone stress injury continuum where Jared keeps running and he goes from a grade one to a grade two to a grade three bone stress injury and he's walking with a limp. Ironically you don't limp with MTSS and he's got night pain and he's sore at rest. Like that hasn't happened to you. You've actually just keep kept running and it's gotten better. So like they're very different entities.
Laura Anderson:
So in terms of like the overarching principles, I think there's a couple of considerations and one is if someone comes acutely like yours came on quite suddenly and quite acutely so it might've been worth a bit of period of rest just to see if it could settle. I wouldn't have been confident. I would've made a huge degree of difference but I probably would've tried it Admittedly see a lot of low leg exercise related low leg pain down in the clinic, but most of it is long standing. People have had it for a really long period of time. So I think in that case, no I wouldn't rest someone if they've had it for a really long period of time. Most of the time they've already tried it and there's no point. So I might've rested you for a period of time, but no, then I would've had pretty much exactly as you would've done, I would've had an allowable amount of pain.
Laura Anderson:
I do have that for MTSS at about a three or four, but I do marry it to function. So pain's obviously subjective and I think, you know, every clinician out there knows the person that's come in with two outta 10 pain but can't walk properly. Or the person that's got nine outta 10 pain but can run 10 K. So I think it's, you've gotta also make sure that their three or four out of 10 seems appropriate and they've still gotta be able to function well and run well and not be running with a hobble and tolerate things. So we definitely would've kept you running. That would've been the allowable amount of pain would've had to trend towards improvement. And that's either improvement in low tolerance or improvement in your symptoms. Obviously like we do with most injuries would've looked for potential contributing factors. So we would've looked at your calf capacity, we would've looked at RSI measures and we're obviously in the privileged position of the clinic where we've got four stake so we can look at that stuff and we potentially would've started to work on some of those things.
Laura Anderson:
And that's where I suppose your journey might have differed a little bit in like you've been able to run through it and progress your running quite well over a month. I think it can probably take a little bit longer if we're adding other things into someone's rehab program in a gym environment, obviously just adding load and fatiguing tissues in a different way. Like you are just fatiguing your tissues and you know, challenging them from a low perspective with running, if we're putting gym stuff in and we're keeping them running, we're obviously fatiguing them in two different kind of ways. So it tends to slow down and run progression. But conversely I think it probably means that we can get them back to running at intensity maybe a little bit quicker than you have been able to. Hmm.
Jared Powell:
Yeah. Great. So I finally did the right thing after four or five months. That's great. As a as a physio. Yep. Take me for a little we're never
Laura Anderson:
First
Jared Powell:
Patient. Yeah, I'm a hundred percent and truly like I, I read so much literature on MTSS when I sort of, it became clear to me that's what it was and I really couldn't get a ton of guidance out of the literature until I read your, your viewpoint and that made me reconceptualize things re really quickly and it actually facilitated me taking a more aggressive approach in terms of just being okay psychologically with running through it and continuing to run. In the back of my mind it was only a month ago that I was thinking I'm just gonna go and get an MRI here 'cause I could have a bone stress injury and I'm just cooking myself by continuing to run here. Yeah, I've just had one bad run where I'm like, this is, this is really sore and I don't, I don't know what I'm doing here. So yeah, it's amazing how much even I would like to say I'm a knowledgeable person when it comes to general musculoskeletal conditions and I still couldn't get outta my own head. I started catastrophizing and thinking the worst when it wasn't following that trajectory that I just assumed it would. Yeah. Any insights to add there as to my fragile mental state?
Laura Anderson:
I think it's a, it's always a worthwhile thing as a physio to have experienced ourselves. I think 'cause it's a good reminder of the importance of educating as best we can probably to our clients the expected trajectory and you know, this is where being comfortable in managing these presentations, but particularly I think the ones where there is, it is safe to have an allowable amount of pain is really important. Far more challenging. Obviously having a condition where we know we have to have zero outta 10 pain is in many ways a lot easier than one where there is an acceptable degree of pain pain's, subjective. It will fluctuate if the person's stressed or they haven't had a good night's sleep or they're worried or they're frustrated or they're over it. So I think, you know, tracking that both for the client and for yourself is really, really important. So you can kind of get a really good gauge of where they're at. But yeah, it is a, I think it's a very frustrating journey for people. So making sure you educate them if there is gonna be an allowable amount of pain, what that looks like, but what we're looking for and also what improvement looks like is really important.
Jared Powell:
Yeah, let's touch on that for a moment. So let's say we're allowing someone to keep running with acceptable pain three, four out of 10, but they get a flare up or they get some sort of worsening of symptoms after a particular run and they're asking you, Laura, what's happening in my tissues here? I I stuck to your instructions, to your regime diligently like, have I done something, have I injured myself further? Have I caused more damage? Like how do we have these conversations about perhaps disentangling a flare in symptoms with, you know, you've worsened the pathology of what's going on in your peripheral tissues.
Laura Anderson:
M-T-S-S-I think makes this more challenging because it can, I believe it can definitely coexist with other things like a tibial bone stress injury. So I think number one it is like make sure that they've not actually done the thing they think they've done and they haven't, you know, managed to get a low grade tibial bone stress injury as well. And differentiating those things can become a little bit more challenging. So I think number one, ensure that they haven't done that. But if you are tracking their loading and you've got a patient who's, you know, reasonably compliant or at least honest with you about their load nine times out of 10, I think you can usually find in there a load reason for their exacerbation and that then gives confidence to the fact that it will probably settle down. So obviously you're then gonna give it that little bit of extra time to settle, but more often than not, they've done something that they might not have thought would worsen their situation, spent a big day on their feet and then done something. Or they've run on the same day that Jim did because they had to, or they've changed their load in some way that has probably just progressed them sooner than you'd planned and they've not appreciated that.
Jared Powell:
Can I ask, can we pivot now to rehab from like a strengthening perspective? So I'm gonna give an example, let's say Achilles tendinopathy because it's close to the medial tibia. All the rage now for the past 15 years has been heavy loading of the Achilles to generate some sort of adaptation within the Achilles to increase the capacity of the achilles tendon to do what that person wants to do. So there's, you know, obviously you're gonna get changes in the calf muscle as well, but it's designed to increase the stiffness or the integrity of that tissue so it can handle repetitive loading. If we were to embark down a similar pathway with the medial tibia and do some sort of comprehensive strength and conditioning program of the, of the calf complex, what benefit would that give somebody with MTSS or limp? What does being strong in the calf actually do in terms of perhaps rehabilitating MTSS or preventing the injury from coming on in the first place? Like how does it, what are the mechanisms of getting stronger in the calf complex in terms of helping someone get better or preventing somebody from getting it in the first place?
Laura Anderson:
Well, we don't really know because we don't really know what it is. So we don't know what tissues are implicated. But I think if we look at a lot of injuries and you know, take, probably take a step back and go, well most tissues or most injuries will come about if we load a tissue beyond what it's capable of tolerating, obviously some nuances with bone stress injuries and bone health aside, then if we improve the strength and capacity of our calf complex, let's say, then it will be better. It should be better placed to be able to tolerate the run load that we wanna place on it, I suppose is the best way
Jared Powell:
Straight back to those mechano biological principles. Yep. Where you're just trying to increase the tolerance of that tissue correct to handle what you wanna do. Do we have any RCTs that support comprehensive strengthening as a, an effective approach for rehabilitating someone versus usual care or versus do nothing or versus modalities? There's
Laura Anderson:
A couple that look at I think like neuromuscular, so some strengthening. I think one of them was looking at it from a preventative perspective and that was certainly pro doing strengthening and that had a mix of kind of just, you know, kinetic chain hip calf strengthening and suppliers. So that certainly had some good evidence in it. We're looking at an RCT at the moment into the management of MTSS and we hope that'll be published next year. Strengthening is definitely a part of that. So hopefully we'll learn a little bit more about that. But no, there's not, there aren't a huge amount of RCTs done in MTSS.
Jared Powell:
Can we talk about your trial for a minute?
Laura Anderson:
We can talk about Delicate, the fact that it compares two interventions. Yeah, it is, it is blinded in some ways, so, okay,
Jared Powell:
That's fine. I can, 'cause there's, let's, I'm gonna talk about it and relate it to a different, to a different joint. So I think in patellofemoral pain we have evidence that suggests, I think just a graduated return to running program for patellofemoral pain is as effective as like a comprehensive strength and conditioning blah blah blah blah blah rehab program where you throw the kitchen sink at somebody's need, do everything and just a simple load management or graduated return to run program is just as effective. Part of me thinks that MTSS might be similar, we don't tend to get over-focused, but we tend to sort of drill in on the deficits that we may see in somebody. So we come in, we do a strength test and so all of a sudden their strengths down because they're in pain. So there's probably pain inhibition, but we're like, ah, that's the reason, that's the mechanism that explains why you have it and that's what we need to correct in order to get you better.
Jared Powell:
And that's okay. That's really appealing and seductive logic, I'm, I'm not poo-pooing that at all, but part of me, in my own experience, I've been very ad hoc and random in doing my strength exercises. I I I now try and do calf raises a couple of times a week. Not every week, some days sometimes I, I haven't done a calf raise for two weeks now, but my pain is significantly better. The, the one consistent thing that I've done throughout this whole thing has been more aggressive with my load management and my running and trying to be really systematic and quantify how I'm feeling my, my volume and inten intensity especially. And so I just, I'm going off topic here a little bit but can you sort of add anything to do we tend to just overcomplicate this because we look for deficits in our assessment and then we tend to associate fixing those deficits with somebody getting better. Is there a more efficient or simple way we can manage these individuals?
Laura Anderson:
Look, you're very right, we, if we look hard enough we're gonna find something in everyone and it doesn't mean that we can associate it with their symptoms for sure. And MTSS is often a bilateral presentation so you know, it can be hard to interpret, it can be difficult to interpret things. I think we have a choice a lot of the time and we can address tissues locally with like our calf raises and our calf strengthening and our pliers and progress their run load at the same time but progressing their run load's probably gonna happen a little bit slower. I agree with you. Or we can just, you know, progress their run load and that's gonna give gradual, you know, progressive load to their tissues anyway perhaps more. So it depends on that person and the runner and where they want to go with their running.
Laura Anderson:
A lot of the time people want to, will want to progress either in volume or intensity or something and I dunno then whether or not we can look at it more in terms of the argument being that if we put some other load on their calf or we teach them better attenuation of that load with RSI and some PLIs and some calf strength, then are we kind of staying one step ahead for when they get to the point that they might be feeling fitter and want to run a little bit quicker and elements like that start to come into their run programming, perhaps it's more that it's placed exists that it's more beneficial for that. Could they just slowly and gradually increase the intensity of their running with a really slow gradual run program? Yes. Do people do their, are people as diligent as you in terms of just kind of slowly and progressively ticking up? They often no and often be more impatient and they want to take bigger jumps and they feel fitter and they want to go quicker. So maybe it's helping make your tissues a little bit more resilient to that. But I do think I agree in the beginning phase we probably have a choice and there is no right or wrong and it probably depends on the person in front of you. Yeah,
Jared Powell:
I agree. I I mean in a perfect world you would have a strong calf, you would be good at trics and you would do your return, you know a hundred percent. I just wonder whether there's a simpler way, I also wonder whether we've just created work for ourselves in terms of finding deficits and fixing it and making a little bit more complex than it needs to be. I'm very happy to be proven wrong and I really want to see the outcomes of your trial and so I'm gonna get you back on, I'm gonna hold you to that at the publication of your trial. Are we looking 12 months? What are you thinking? We
Laura Anderson:
Hopefully have, we'll have wrapped up recruitment I think in the first three or four months of next year. So mid next year hopefully. Awesome.
Jared Powell:
Yeah. Great. Is there anything else you want to add Laura? We've had a pretty comprehensive conversation. Is there anything we haven't touched on that you'd like to?
Laura Anderson:
No, I don't think so. I think the only other thing that people seem to ask a little bit around MTSS is the gateway training side of it, but I think that probably more fits into the chat we were just having then about, you know, are we overcomplicating things and there isn't a huge amount of evidence at the moment for gateway training and I think we have to appreciate that it does a similar thing. We're just gonna change load and potentially increase load on tissues that we're kind, we're trying to gradually overload in other ways. So I think if we are going to do it, and I know there's a lot of clinicians out there that do it at the moment, I obviously do a bit of gateway training with my clients. We have to know what we're doing and where we're shifting the load to and we probably have to be doing it for a good reason.
Jared Powell:
Yeah. Can we just spend a couple minutes talking about gateway training? So what, what do you look to do if somebody comes in, they're a classic, you know, overs strata or where do you go? What's your little algorithm that you might look at? And then what do you look to address?
Laura Anderson:
I suppose with MTSS in some ways I suppose it have been looking at it more with some similarities tibial load. So in, there's more evidence for gait retraining, tibial bone stress injuries and that a lot of that exists with your stride length or your step length. And a lot of the evidence is then for shortening step length. A lot of clinicians seem to these days go about that by increasing someone's cadence. So step length is definitely something that I look at if someone is, you know, taking an aggressively long step. But I do think we have to be careful in how they execute the queue. I think there is sometimes a bit of a tendency to kind of blanket give these cues and go, okay well now 'cause they're running with a quicker cadence that'll be fixed. Yeah. But they've not actually executed the queue in the way that you want.
Laura Anderson:
The big thing if we're looking at low limb loads is if we're giving someone a cue to increase their cadence or reduce their step length, there's every chance we change their foot strike. And if that person's gone to landing more on their forefoot, we've just increased their plani flexor loads and if we think that's gonna be a problem or we want to increase their run load or we do think that there's, you know, a tibial bone component and we know that the muscle loads from your plantar flexors are actually contributing or we do think it's your choal fascia, then your plantar flexor loads are gonna be contributing and we're also putting plantar flexor load into a gym program, then that's potentially really not gonna be a helpful addition to have made. So you've really go to decide when and why you might have put that in and whether or not that is gonna be helpful or not to have done or be really careful with the way that they've actually executed that queue.
Laura Anderson:
So we did a lab study a couple of years ago and warranted it was on a treadmill but we looked at different running queues but actually looked at how they executed them and a queue to increase your cadence versus reduce your step length we're executed really differently even though technically they probably should produce the same thing. So I think we've gotta be careful but in short step length, yes, but they've gotta execute it well and I think we have to be incredibly mindful of planner flexor loads in their execution of that if we're dealing with someone with exercise related leg pain.
Jared Powell:
Yeah, makes a lot of sense. And and it's just physics, right? You change the load going from somewhere, it's gotta go somewhere else. Yeah, it doesn't just disappear. I've noticed the same thing, I've started to get a little bit of calf hotness in the last couple legs even though my TIB is feeling better. But anyway, it's okay. It's all good. You've gotta ignore that for a while, Laura. That's been incredibly helpful. Where can people find, are you on social media at all? Do you have anywhere where you sort of publish your stuff and your thoughts? Where can people find you? Not
Laura Anderson:
Really. The clinic, the injury clinic's got social media, so through there. Otherwise LinkedIn's probably the best thing if people wanna strike up a conversation. I'm always interested in hearing people's thoughts on MTSS. So yes, if anyone wants to reach out or has an anecdote to share or LinkedIn's probably the place to do it.
Jared Powell:
Cool. And that's just Laura Anderson? That's
Laura Anderson:
It? Yeah.
Jared Powell:
And your clinic is called
Laura Anderson:
The Injury Clinic.
Jared Powell:
The Injury Clinic in your long, okay. Awesome. Laura, this has been, this has been really helpful for me, selfishly, I hope it's helpful for some people out there as well. Thanks so much for your time.
Laura Anderson:
No, thank you. And I look forward to hearing how you conquer your M-T-S-S-A. Maybe we can turn that into a case study. Yeah,
Jared Powell:
If I've got chronic pain next year, then look out. I'm gonna come back
Laura Anderson:
Next. .
Jared Powell:
Thanks Laura. Cheers.
Laura Anderson:
Thanks Jared.
Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with Laura Anderson. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really does help the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
