admin
Fri, 02/09/2024 - 19:49
Edited Text
THE KNOWLEDGE OF MEDIAL TIBIAL STRESS SYNDROME OF PARENTS
AND COACHES OF ADOLESCENT ATHLETES
A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science
by
Joseph J. McShane
Research Advisor, Dr. Ellen J. West
California, Pennsylvania
2012
ii
iii
AKNOWLEDGEMENTS
I would like to recognize the following people who
have significantly impacted my life.
Without them, there
wouldn’t be even the slightest chance that I could’ve
completed this.
First, I would like to thank my advisor,
Dr. Tom West, my thesis chair, Dr. Ellen West, and the
members of my thesis committee: Dr. Shelly DiCesaro and Dr.
Jodi Dusi and the rest of the faculty at Cal U for their
help and guidance throughout the completion of my thesis
and the master’s program.
Next, I would like to thank Jamison Roth, Jamie Weary,
and Miss Carolyn for their guidance, tremendous amounts of
help and patience with me throughout this year while
getting the Cal U Club Sports GA position up and running.
I’d also like to thank all my athletes for putting up with
all the changes I subjected them to this year.
Please try
to stay concussion free in the coming years.
At this point, I’d like to personally thank the
permanent and honorary residents of Apartments 2 and 3 at
947 Cross Street: Mark Webber, Paul Rucci, Sean Rentler,
and Ted Vandermeuse.
Between the catfishing, visits to the
local establishments, and adventures to the various
cultural hotspots of southwestern Pennsylvania, you guys
iv
either have managed to keep me sane or completely throw me
off the deep end.
I would also like to acknowledge Curt Snyder’s
mustache, which brightened my day, reminded me to laugh,
and allowed me to be a free spirit and an overall better
person each and every day I set foot in the athletic
training room.
To my Mom, Dad, Jen, Jason, Denny, and the rest of my
family and friends, thank you for all you’ve done
throughout this entire “education” thing that I’ve stumbled
and staggered through over the past 20-odd years.
Although
I still haven’t, nor do I intend to perfect the whole
“growing up” thing, I’d like to thank you for at least
attempting to get me to do so.
Last, but certainly not least, I’d like to thank my
beautiful girlfriend, Abby, for dealing with my stress,
keeping me grounded and putting up with all my crap (for
lack of a better word) throughout the past year of being
apart and being the most patient (saint-status-patience)
and greatest person I’ve ever met.
v
TABLE OF CONTENTS
Page
SIGNATURE PAGE
. . . . . . . . . . . . . . . ii
AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES
. . . . . . . . . . . . . . . viii
LIST OF FIGURES .
INTRODUCTION
METHODS
. . . . . . . . . . . . . . v
. . . . . . . . . . . . . . ix
. . . . . . . . . . . . . . . . 1
. . . . . . . . . . . . . . . . . . 7
Research Design
Subjects
. . . . . . . . . . . . . . 7
. . . . . . . . . . . . . . . . . 8
Preliminary Research. . . . . . . . . . . . . 9
Instruments . . . . . . . . . . . . . . . . 10
Procedures
. . . . . . . . . . . . . . . . 11
Hypotheses
. . . . . . . . . . . . . . . . 12
Data Analysis
RESULTS
. . . . . . . . . . . . . . . 12
. . . . . . . . . . . . . . . . . . 13
Reliability Testing . . . . . . . . . . . . 13
Demographic Data . . . . . . . . . . . . . . 14
Hypotheses Testing
. . . . . . . . . . . . . 21
Additional Findings . . . . . . . . . . . . . 25
DISCUSSION . . . . . . . . . . . . . . . . . 31
Discussion of Results . . . . . . . . . . . . 31
Implications to the Profession
. . . . . . . . 37
vi
Recommendations for Future Research. . . . . . . 39
Conclusions
. . . . . . . . . . . . . . . . 41
REFERENCES . . . . . . . . . . . . . . . . . 42
APPENDICES . . . . . . . . . . . . . . . . . 43
APPENDIX A: Review of Literature
. . . . . . . . 44
Introduction . . . . . . . . . . . . . . . . 45
Definition and Incidence . . . . . . . . . . . 46
Functional Anatomy and Risk Factors. . . . . 49
Functional Anatomy and Physical Findings
. 50
Risk Factors . . . . . . . . . . . . . . 54
Diagnostic Testing
. . . . . . . . . . . . 56
Management of MTSS
. . . . . . . . . . . . 61
Rehabilitation and Treatment . . . . . . . 61
Prevention . . . . . . . . . . . . . . . 65
Knowledge of MTSS . . . . . . . . . . . . . 70
Summary . . . . . . . . . . . . . . . . . . 73
APPENDIX B: The Problem . . . . . . . . . . . . 75
Statement of the Problem . . . . . . . . . . . 76
Definition of Terms . . . . . . . . . . . . . 77
Basic Assumptions . . . . . . . . . . . . . . 77
Limitations of the Study . . . . . . . . . . . 77
Significance of the Study
. . . . . . . . . . 78
APPENDIX C: Additional Methods .
. . . . . . . . 80
MTSS Knowledge Survey (C1) . . . . . . . . . . 81
vii
IRB: California University of Pennsylvania (C2) . . 93
Letter to Panel of Experts (C3) . . . . . . . . 106
Cover Letter for Survey (C4)
. . . . . . . . . 108
Letter to Athletic Directors (C5)
. . . . . . . 110
REFERENCES . . . . . . . . . . . . . . . . . 112
ABSTRACT
. . . . . . . . . . . . . . . . . 116
viii
LIST OF TABLES
Table
Page
1
Frequency Table of Demographic
. . . . . . . 14
2
Frequency Table of Demographic by School
District . . . . . . . . . . . . . . . . 16
3
Mean and Standard Deviation for Knowledge Scores
by Category . . . . . . . . . . . . . . . 22
4
T-value, Degrees of Freedom and Significance for
Knowledge Scores by Category . . . . . . . . 23
5
Mean and Standard Deviation for Additional
Knowledge Scores by Category . . . . . . . . 26
6
T-value, Degrees of Freedom and Significance for
Additional Knowledge Scores by Category . . . . 26
7
Mean and Std. Deviation from One-way ANOVA for
Parents, Coaches and both on The Knowledge of
Medial Tibial Stress Syndrome Survey . . . . . 28
8
One-way ANOVA Between Groups for Categories of
Parents, Coaches and Both on The Knowledge of
Medial Tibial Stress Syndrome for Sum of Squares,
df, Mean Squares, F-score and Significance . . . 29
9
Post-Hoc Tukey Comparing Rehabilitation Scores
of Parents, Coaches and Both for Mean Difference,
Std. Error and Significance . . . . . . . . . 30
ix
LIST OF FIGURES
Figure
Page
1
Frequency of Parents and Coaches With Regard to
Student Athletes’ Sport(s) Played or Sport
Coached
. . . . . . . . . . . . . . . . 15
2
Frequency of Children by Gender of Parents
Surveyed . . . . . . . . . . . . . . . . 17
3
Frequency of Coaches by Coaching Position Title . 17
4
Frequency of Coaches by Gender of Athletes
Coached . . . . . . . . . . . . . . . . . 18
5
Frequency of Parent-Coaches With Regard to
Student Athletes’ Sport(s) Played . . . . . . 19
6
Frequency Sport(s) Played by Children by Gender
of Parent-Coaches Surveyed . . . . . . . . . 19
7
Frequency Sport(s) Coached by Parent-Coaches
Surveyed . . . . . . . . . . . . . . . . 20
8
Frequency of Parent-Coaches by Coaching Position
Title
. . . . . . . . . . . . . . . . . 20
9
Frequency of Parent-Coaches by Gender of Athletes
Coached . . . . . . . . . . . . . . . . . 21
1
INTRODUCTION
The purpose of the study is to examine the knowledge
of parents and coaches with regard to medial tibial stress
syndrome (MTSS).
If we, as athletic trainers, are able to
identify problem areas and gaps in knowledge bases to
further educate those with this lack of knowledge, the
overall care of the athletes suffering from medial tibial
stress syndrome may be improved.
Medial tibial stress syndrome is a continuum of
overuse trauma to the lower leg, more specifically, the sum
of repetitive microtraumas to the medial tibia induced by
activity which lead to pain and dysfunction in the lower
extremity.
The overall management of MTSS can be
considerably more arduous for the sports medicine team
(parents, coaches, athletes, athletic trainers and
physicians), as it must deal with all aspects including
prevention, management and treatment and must take a
multifaceted approach when doing so.
The athletic trainers
and coaches are typically on the front lines of the
prevention aspect in the adolescent athlete.
These
individuals are typically responsible for both the
2
conditioning prior to the season and training program
throughout the season.
The parents become much more
involved when the athlete sustains MTSS as they must try to
help their adolescent athlete manage the problem.
Since
the parents and coaches are such a large part in the
prevention and management aspects of MTSS, their knowledge
of the prevention and treatment must be adequate to prevent
mismanagement or further injury to the athlete.
Understanding the incidence rates of MTSS in different
populations is just as important as knowing how or why it
occurs. Yates and White studied the incidence of MTSS among
naval recruits.1 In their literature review, they reference
Murbarak et al’s2 characterization of MTSS, stated as “a
symptom complex seen in athletes who complain of exercise
induced pain along the posteriormedial border of the
tibia.”5,7
Collating from several sources, Yates et al5
expanded on this generic definition to both rule out older
thought processes, such as MTSS as an inflammatory response
process.
This led the authors to create a more accurate
and complete definition of “a bone stress reaction that
becomes painful,” citing metabolic changes in the bone due
to exercise and increase osteoclastic activity on the
posteriormedial border; often from compression of the bone.
This increase in osteoclastic activity coupled with the
3
bone’s inability to replace the broken down tissue fast
enough, leads to increasingly porous bone tissue.
As the
bone is broken down more easily, the athlete begins to feel
pain as the bone is subjected to microtraumas which can
ultimately result in a stress fracture of the tibia.
Though a good definition is crucial to its correct
diagnosis, knowing its incidence among the active
population is equally helpful in coming to the correct
conclusion and identifying potential athletes who may be at
risk.
Additionally, Yates and White5 defined MTSS in their
study based on each subject’s pain history, location of
pain and positive palpation of pain on the posterior-medial
border of the tibia.
The authors found forty of the
recruits (35%) developed MTSS and female recruits were
significantly more prone to developing MTSS (incidence
rates of 53% and 28% for male and female recruits
respectively).
They concluded that controlling foot
pronation and enabling male and female recruits to train
separately could potentially decrease the incidence of MTSS
in their sample. Furthermore, the authors stated that MTSS
accounts for 13.2% to 17.3% of all running injuries.5
The main focus of Galbraith et al’s3 study was to delve
into some conservative treatment approaches taken to
4
expedite the process of returning the athlete to play after
he or she has been diagnosed with MTSS.
The authors
concluded that there are in fact several factors that can
be classified as both prevention and rehabilitation.
These
factors that can also aid in the recovery process included
relative rest, which can be defined as remaining physically
active while still removing the activity which causes the
unwanted stresses to the body, such as cross training or
implementing low-impact exercises into the a modified
training routine.
Additionally, the use of cryotherapy and
electrical stimulation with soft tissue mobilization and
whirlpool baths were also indicated for both the acute and
subacute phases.3
Though there is much literature on the rehabilitation
methods for dealing with MTSS, The NATA issued a position
statement, spearheaded by McLeod et al,4 focusing on the
prevention of overuse injuries in the pediatric population,
including MTSS.
The position statement highlights some of
the profiles of both male and female athletes that may
predispose athletes to overuse injuries such as tall
stature, more explosive strength, large Q angles, increased
muscle tightness and decreased muscle flexibility.
The
authors also stated that a decrease in the overall fitness
level in the general population means that training
5
routines must be more gradually introduced to help prevent
overuse injuries.
They concluded that the athletic trainer
must be able to identify risk factors associated with
overuse injuries as well as taking the appropriate steps as
to help prevent these injuries.
The evaluation, management and risk factors of MTSS
should all be common knowledge among athletic trainers (who
deal with several cases every year) in the high school
setting; however, the coaches and parents of these athletes
are not as well-versed on the subject, nor should they be
expected to be.
Several studies5-7 have taken a look at the
knowledge of coaches with regard to athletic injuries.
Although this is a huge step, none of the studies surveyed
looked at MTSS or overuse injuries in any form.
Additionally, none of the literature surveyed dealt with
the knowledge of parents of injuries in the adolescent
athlete.
Therefore, this study will be significant, as it will
provide feedback to the knowledge base of parents and
coaches with regard to medial tibial stress syndrome.
This
can aid in the care of the athlete suffering from MTSS by
having the athlete’s parents and coaches be able to
potentially identify signs and symptoms and refer their
athlete to their athletic trainer or doctor, potentially
6
cutting down recovery time.
With this knowledge,
communication between the athletic trainer, parents and
coaches will be made easier as all three will be greater
informed.
Additionally, the risk of MTSS being mismanaged
in the adolescent athlete can be minimized as both the
coaches would be less likely to have the athlete “walk it
off,” and, similarly, parents will be less likely to push
their children through the pain.
7
METHODS
The primary purpose of this study was to examine the
knowledge levels of parents and coaches with regard to
medial tibial stress syndrome (MTSS) in the adolescent
athlete.
This section will include the following
subsections:
Research Design, Subjects, Instruments,
Procedures, Hypotheses, and Data Analysis.
Research Design
This research was a descriptive study utilizing a
research questionnaire.
The independent variable was the
group surveyed (either parents or coaches).
The dependent
variable was the subjects’ score as measured by the MTSS
knowledge survey, each question being worth one point. This
overall score on the knowledge survey also had two
subscores which were analyzed during hypothesis testing.
The subscores were the prevention knowledge score and
rehabilitation and treatment knowledge score.
These three
scores (prevention, rehabilitation and treatment, and
overall score) were separated by the independent variable;
either parent or coach.
8
Subjects
The subjects used for this study were parents and
coaches of high school athletes in western Pennsylvania in
PIAA districts 7 and 10.
The survey was distributed to
athletic directors who agreed to distribute it following
contact with the primary researcher.
The athletic
directors then distributed the cover letter containing the
link to the survey to the parents and coaches by sending
home with the school’s athletes.
The surveys were then
completed online using SurveyMonkey.
Subjects were
included if they were a coach or a parent of a high school
athlete in western Pennsylvania.
If a subject fit both
categories of parent and coach, they were excluded from the
main study; however, they were examined as independent data
to see if the overlap showed a significant difference in
the knowledge level.
Each subject was asked via an attached cover letter
(Appendix C1) to participate in the study by completing an
online survey to assess their knowledge of MTSS (Appendix
C4).
Subject participation was completely voluntary and
consent was implied if they chose to complete the survey.
9
The study was approved by the Institutional Review Board
(IRB) at California University of PA(Appendix C2) prior to
any data collection.
Surveys were completed anonymously
and each participant’s identity remained confidential.
Preliminary Research
A preliminary study was conducted with this research
project.
The survey was administered to a panel of experts
in the field, four athletic trainers, for content validity
evaluation.
Additionally, nineteen subjects were given
the MTSS knowledge survey to assess their knowledge of MTSS
and aid the researcher by providing data on the difficulty
level and reliability of the survey. Of the nineteen
subjects, fourteen completed the survey twice; once upon
reception of the survey and once one week later, in order
to assess reliability.
The survey was comprised of a set
of questions derived from the literature outlined in the
Literature Review (Appendix A).
Comprised of questions
ranging from “easy” to “hard,” the survey tested the
knowledge in each of the areas of MTSS knowledge including
prevention, mechanism of injury, relative functional
anatomy, treatment and management, as well as some of the
diagnostic testing associated with the evaluation of MTSS.
10
Instruments
The Knowledge of Medial Tibial Stress Syndrome Survey
(Appendix C1) was created by the researcher to assess the
knowledge level of parents and coaches of adolescent
athletes.
The survey consisted of thirty questions testing
different knowledge areas of MTSS.
To support the
management and prevention areas of the hypotheses, the
sections of prevention and management were not only counted
toward the overall knowledge score, but as an independent
score as well.
Although parents and coaches may not know
anatomy and other risk factors, prevention and the
management are the most critical areas they would need to
recognize to provide the minimal level of care for MTSS.
The areas tested included mechanism of injury, relative
functional anatomy, prevention, treatment and management,
and diagnostic testing used for the evaluation of MTSS.
There were between three and five questions pertaining to
demographic information, depending on whether the subject
was a parent, coach or both, which assisted the researcher
in classification of subjects.
11
Procedure
The researcher obtained Institutional Review Board
(IRB) approval (Appendix C2) at California University of
Pennsylvania before beginning any data collection or
distribution of surveys.
Approval to distribute the survey
to parents and coaches was obtained though the athletic
directors (AD’s) of each high school surveyed. The athletic
directors were contacted via email, found on the PIAA
website. Once approval to distribute the surveys by the ADs
was obtained, the AD’s distributed the cover letters to the
school’s student-athletes to bring home to their parents.
The cover letter (Appendix C3) explained the purpose of the
study to each potential subject to be surveyed.
Surveys
were collected for a 4-week period following distribution
from March 7 to April 4, 2012.
The survey link was then
deactivated and submissions could no longer be submitted.
This timeframe was selected to allow for adequate time for
both the subjects to complete the survey as well as the
researcher to collect adequate data.
The survey data was
anonymous and all online submissions were kept
confidential.
The data was collected, entered into an
electronic spreadsheet and analyzed and grouped according
to the relevant demographic classification.
12
Hypotheses
The following hypotheses of the researcher were based
on previous research and clinical assumptions.
1.
Coaches will have a significantly greater
knowledge of the prevention of MTSS than parents.
2.
Coaches will have a significantly greater
knowledge of the rehabilitation and treatment of
MTSS than parents.
3.
Coaches will have a significantly greater overall
knowledge of MTSS than parents.
Data Analysis
All data was analyzed by SPSS version 18.0 for Windows
at an alpha level of less than or equal to 0.05.
research hypotheses were analyzed using a T-test.
The
13
RESULTS
The following section is comprised of the information
gathered through data collection and the analysis of the
Knowledge of Medial Tibial Stress Syndrome Survey
distributed to parents and coaches at six western
Pennsylvania high schools.
The results have been divided
into these subsequent sections:
(1) Reliability Testing,
(2) Demographic Data, (3) Hypothesis Testing, and (4)
Additional Findings.
Reliability Testing
The Knowledge of Medial Tibial Stress Syndrome Survey
was distributed to a sample of convenience of parents and
coaches of adolescent athletes.
The survey was distributed
to the same subjects one week later to determine its
reliability, which was found by correlation testing to be r
= 0.374; a low positive correlation. Nine of thirty
questions had a very high correlation (above r > 0.80),
six had a strong correlation (0.60 ≤ r ≤ 0.80), and seven
had a moderate correlation (0.40 ≤ r ≤ 0.60) Eight of the
thirty questions returned with a correlation value r <
14
±0.30 and were modified in an attempt to eliminate any
unclear language and increase their reliability and the
reliability of the survey overall.
Demographic Data
Of the 691 surveys handed out to the parents and
coaches at the western Pennsylvania high schools, 91
responses were received for a 13.17% return rate.
The
sample consisted of 45 parents, 31 coaches, 13
parent/coaches (both) and 7 who did not fit either
category.
61 of these subjects (40 parents and 21 coaches)
completed the survey fully and were able to be analyzed
during hypothesis testing (Table 1).
Table 1. Frequency Table of Demographic
Group
Frequency
Percent of Total
(Completed)
Responses Received
Parents
45 (40)
49.4%
Coaches
31 (21)
34.1%
Both
13 (11)
14.3%
7 (7)
7.7%
Neither
15
The study focused on parents and coaches in the
western Pennsylvania region of the PIAA, specifically
Districts 7 and 10.
Figure 1 shows the collected responses
with regard to what sport(s) each subject coached and/or
their student athlete(s) played.
Additionally, Table 2
reports the findings with regard to the number and
frequency of the cover letter distribution for the six high
schools surveyed within the two districts.
Frequency
Figure 1. Frequency of Parents and Coaches With Regard to
Student Athletes’ Sport(s) Played or Sport Coached
30
25
20
15
10
5
0
Parents
Coaches
Sport Played by Student Athlete(s)/Coached
Although additional demographic data were collected
with regard to number and gender of student athletes for
parents and coaching position and gender of athletes
coached, the data were not utilized as there was an
insufficient amount to examine for any additional findings.
16
Table 2. Frequency Table of Number of Surveys Distributed
by School District
School
District
Surveys
Percent
Distributed
Brownsville
7
197
28.5%
Burgettstown
7
159
23.0%
California
7
103
14.9%
Cathedral
Prep
10
27
3.9%
Iroquois
10
145
21.0%
McDowell
10
60
8.7%
Table 2 shows the distribution of surveys by school
district.
The surveys were primarily distributed by cover
letter as well as by email, as per athletic directors’
instruction.
Figure 2 shows the frequency of children by gender of
parents surveyed, n=45.
The subjects were able to choose
if they had 0 to 4 or more children of each gender.
Responses were recorded, but were not tethered to each
subjects’ responses to maintain confidentiality.
17
Figure 2.
Surveyed
Frequency of Children by Gender of Parents
30
Frequency of Parents
25
20
15
Male
10
Female
5
0
0 Children
1 Child
2 Children
3 Children
4 or more
Children
Number of Children
Figures 3 and 4 show the responses of coaches by
coaching position title and the gender of the athletes they
coach respectively.
Figure 3.
Frequency of Coaches by Coaching Position Title
25
Frequency
20
15
10
5
0
Head Coach
Assistant Coach
Coaching Title
Other
18
Figure 4.
Coached
Frequency of Coaches by Gender of Athletes
16
14
Frequency
12
10
8
6
4
2
0
Male
Female
Both
Gender of Athletes Coached
Additionally, 10 subjects who identified themselves as
both a parent and a coach (parent-coaches) were asked the
same demographic questions.
The following figures
(Figures5-9) display the “Both” category responses to the
demographic questions both the parents and coaches were
asked.
The questions asked were the same questions asked
of both the parents and the coaches.
19
Figure 5. Frequency of Parent-Coaches With Regard to
Student Athletes’ Sport(s) Played
5
Frequency
4
3
2
1
0
Sport Played by Student Athlete(s)
Figure 6. Frequency Sport(s) Played by Children by Gender
of Parent-Coaches Surveyed
6
Frequency
5
4
3
Male
2
Female
1
0
0 Children
1 Child
2 Children
Number of Children
3 Children
4 or More
Children
20
Figure 7.
Surveyed
Frequency Sport(s) Coached by Parent-Coaches
Frequency
3
2
1
0
Sport Coached
Figure 8.
Title
Frequency of Parent-Coaches by Coaching Position
7
6
Frequency
5
4
3
2
1
0
Head Coach
Assistant Coach
Coaching Title
Other
21
Figure 9. Frequency of Parent-Coaches by Gender of
Athletes Coached
5
Frequency
4
3
2
1
0
Male
Female
Both
Gender of Athletes Coached
Hypothesis Testing
The following hypotheses were investigated by this
study:
Hypothesis 1: Coaches will have a significantly
greater knowledge of the prevention of MTSS than parents.
An independent sample t-test was used to compare the
mean scores for each category used in hypothesis testing as
well as the overall mean score and standard deviation of
the scores with regard to parents and coaches.
These
results can be found below in Tables 3 and 4.
Results: An independent-samples T-test was conducted
to compare the mean prevention knowledge score of
22
participants who identified themselves as parents (n = 40)
to the mean prevention knowledge score of participants who
identified themselves as coaches (n = 21).
No significant
difference was found ((t(59) = .200, p > 0.05)).
Conclusion: The mean prevention knowledge score of
parents (m = 65.83, sd = 13.582) was not significantly
different from the mean prevention knowledge score of
coaches (m = 65.08, sd = 14.818).
Table 3. Mean and Standard Deviation for Knowledge Scores
by Category
Category
Group
N
Mean
Standard Deviation
Prevention
Parents
Coaches
40 65.83
21 65.08
13.582
14.818
Rehabilitation*
Parents
Coaches
40 63.57
21 76.87
18.850
15.957
Overall*
Parents
Coaches
40 60.33
21 65.87
7.874
9.939
*significant findings indicated for this category
23
Table 4. t-value, Degrees of Freedom and Significance for
Knowledge Scores by Category
Category
t
df
Sig
Prevention
.200
59
.842
Rehabilitation
-2.754
59
.008
Overall
-2.382
59
.020
Hypothesis 2: Coaches will have a significantly
greater knowledge of the rehabilitation and treatment of
MTSS than parents.
An independent samples t-test was used to compare the
mean scores for each category used in hypothesis testing as
well as the overall mean score and standard deviation of
the scores with regard to parents and coaches.
These
results can be found above in Tables 3 and 4.
Results: An independent samples T-test was conducted
to compare the overall mean score of participants who
identified themselves as parents (n = 40) to the overall
mean score of participants who identified themselves as
coaches (n = 21).
The researcher found a significant
difference between the means of the two groups
24
(t(59) = -2.754, p < 0.05) with regard to the knowledge of
the rehabilitation and treatment of MTSS.
Conclusion: The mean rehabilitation and treatment
knowledge score of the parents was significantly lower (m =
63.57, sd = 18.850) than the mean score of the coaches (m =
76.87, sd = 15.957).
Hypothesis 3:
Coaches will have a significantly
greater overall knowledge of MTSS than parents.
An independent samples T-test was calculated to
compare the mean scores for each category used in
hypothesis testing as well as the overall mean score and
standard deviation of the scores with regard to parents and
coaches.
These results can be found above in Tables 3 and
4.
Results: An independent samples T-test was conducted
to compare the overall mean score of participants who
identified themselves as parents (n = 40) to the overall
mean score of participants who identified themselves as
coaches (n = 21).
A significant difference between the
means of the two groups (t(59) = -2.382, p < 0.05) with
regard to the overall knowledge score was found.
25
Conclusion: The mean overall knowledge score of the
parents was significantly lower (m = 60.33, sd = 7.874)
than the mean score of the coaches (m = 65.87, sd = 9.939).
Additional Findings
Several tests were conducted using the other areas
examined in the The Knowledge of Medial Tibial Stress
Syndrome Survey (Appendix C1) with the intent of
discovering additional findings.
An independent samples T-test was used to compare the
mean scores for each additional category which was not used
in hypothesis testing as well as the overall mean score and
standard deviation of the scores with regard to parents and
coaches.
6.
These results can be found below in Tables 5 and
26
Table 5. Mean and Standard Deviation for Additional
Knowledge Scores by Category
Category
Group
N
Mean
Standard Deviation
Definition
Parents
Coaches
40
21
68.13
66.67
21.917
26.615
Anatomy
Parents
Coaches
40
21
59.17
62.70
18.852
19.653
Diagnostic
Testing
Parents
Coaches
40
21
48.93
57.82
17.388
20.935
Table 6. t-Value, Degrees of Freedom and Significance for
Additional Knowledge Scores by Category
Category
t
df
Sig
Definition
Anatomy
Diagnostic Testing
.229
59
.820
-.685
59
.496
-1.768
59
.082
Results: An independent-samples T-test was calculated
to compare the mean definition knowledge score of
participants who identified themselves as parents to the
mean prevention knowledge score of participants who
27
identified themselves as coaches.
No significant
difference was found (t(59) = .229, p > 0.05).
Conclusion: The mean definition knowledge score of
parents (m = 68.13, sd = 21.917) was not significantly
different from the mean prevention knowledge score of
coaches (m = 66.67, sd = 26.615).
Another independent samples T-test was used to
determine the mean scores for each additional category,
including anatomy and risk factors, definition and
incidence, and diagnostic testing, which were not used in
hypothesis testing as well as the overall mean score and
standard deviation of the scores with regard to parents and
coaches.
These results can be found above in Tables 5 and
6.
Results: An independent-samples T-test was conducted
to compare the diagnostic testing knowledge score of
participants who identified themselves as parents to the
mean prevention knowledge score of participants who
identified themselves as coaches.
No significant
difference was found (t(59) = -1.768, p > 0.05).
Conclusion: The mean diagnostic testing knowledge
score of parents (m = 48.93, sd = 17.388) was not
28
significantly different from the mean prevention knowledge
score of coaches (m = 57.82, sd = 20.935).
A one-way ANOVA was conducted to compare the mean
knowledge scores between individuals who identified
themselves as parents, as coaches, and individuals who
identified themselves as both a parent and a coach.
The
results of the analysis between groups are shown below in
Tables 7 and 8.
Table 7. Mean and Std. Deviation from One-way ANOVA for
Parents, Coaches and Both on The Knowledge of Medial Tibial
Stress Syndrome Survey
Category
Demographic
N
Mean
Std.
Deviation
Definition
Parents
40
68.13
21.917
Coaches
21
66.67
26.615
Both
11
70.45
21.847
Prevention
Parents
Coaches
Both
40
21
11
65.83
65.08
60.61
13.582
14.818
11.237
Anatomy and
Risk Factors
Parents
Coaches
Both
40
21
11
59.17
62.70
68.18
18.852
19.653
21.672
Diagnostic
Testing
Parents
Coaches
Both
40
21
11
48.93
57.82
53.25
17.388
20.935
22.215
Rehabilitation* Parents
Coaches
Both
40
21
11
63.57
76.87
74.03
18.850
15.957
21.013
Overall
40
21
11
60.33
65.87
64.85
7.874
9.939
11.388
Parents
Coaches
Both
*significant findings indicated for this category at .05
level
29
Table 8. One-way ANOVA Between Groups for Categories of
Parents, Coaches and Both on The Knowledge of Medial Tibial
Stress Syndrome for Sum of Squares, df, Mean Square, Fscore and Significance
Category
Sum of
df
Mean
F
Sig.
Squares
Square
Definition
104.01
2
52.00
.095
.909
Prevention
237.82
2
118.91
.639
.531
Anatomy and
Risk Factors
738.66
2
369.33
.970
.384
Diagnostic
Testing
1104.13
2
552.07
1.494
.232
Rehabilitation* 2757.40
2
1378.70
4.071
.021
Overall
2
242.99
2.946
.059
485.98
*significant findings indicated for this category at .05
level
Results: A one-way ANOVA was conduced to compare the
knowledge scores of participants who were either parents,
coaches or both.
A significant difference was found among
the groups (F(2,2) = 4.07, p < .05) with regard to
rehabilitation knowledge scores.
Tukey’s HSD was used to
determine the nature of the differences (Table 9) between
the demographics for rehabilitation scores.
This analysis
revealed that Parents scored lower (m = 63.57, sd 18.850)
than Coaches (m = 76.87, sd = 15.957).
Participants who
30
identified themselves as “both” (m = 74.03, sd = 21.013)
were not significantly different than the other two groups.
Table 9. Post-Hoc Tukey comparing rehabilitation scores of
parents, coaches and both for mean difference, std. error
and sig.
Demographic Demographic
Mean
Std. Error
Sig.
1 (D1)
2 (D2)
Difference
(D1-D2)
Parents
Coaches
-13.299*
4.959
.025
Both
Parents
10.455
6.265
.225
Both
Coaches
-2.845
6.849
.909
*significant findings indicated for this category at .05
level
Conclusion: Coaches will have a significantly higher
knowledge of the rehabilitation of MTSS than subjects who
identify themselves as parents or parent-coaches or “both.”
No other statistically significant scores were found
for parents, coaches or “both” in any other knowledge
category or overall knowledge score for the one-way ANOVA
between groups analysis.
31
DISCUSSION
The discussion section will be divided into four
subsections: 1) Discussion of Results, 2) Implications to
the Profession, 3) Recommendations for Future Research, and
4) Conclusions.
Discussion of Results
The purpose of this study was to examine the knowledge
level of parents and coaches of adolescent athletes with
regard to the management of medial tibial stress syndrome
(MTSS).
The researcher examined specific knowledge areas
of MTSS such as definition and incidence, anatomy and risk
factors, prevention, diagnostic imaging methods, and the
rehabilitation and treatment protocols associated with
MTSS.
These areas were combined to make up the overall
knowledge of MTSS.
Hypothesis 1 stated that coaches will have a
significantly higher knowledge score with regard to the
prevention of MTSS than parents.
The researcher proposed
this hypothesis on the assumption that since the subjects
had an insignificant knowledge of both the rehabilitation
and treatment as well as their overall knowledge, their
32
knowledge of prevention would also be lacking. Baron et al5
examined the knowledge levels of mid-Michigan area coaches’
knowledge of injury prevention in adolescent athletes by
way of a paper survey with an attached demographic sheet;
similar to this study’s with the exception of the media by
which it was delivered.
The researchers found that only 15
of their 290 subjects, or about five percent, received a
passing score on their survey.
As this study by Baron et
al5 showed general injury prevention knowledge was lacking
in the coaching population, the researcher observed similar
results and found no significant findings with regard to
prevention of medial tibial stress syndrome.
Although the
overall numerical score was not looked at for any of the
categories, the researcher noted that the mean scores for
the prevention section were only at 65%; a somewhat low
percent correct.
Similar to Baron et al’s5 study, Iverson and Friden’s6
examined the knowledge of injury prevention of female high
school basketball players; again by paper survey and
informed consent. They reported no significant difference
in knowledge scores in the female student athlete subjects
whether they were subjected to a prevention program or
place in a control group which not participate in a
preventative exercise program.6 The researcher’s results,
33
like both of the previously mentioned studies examining
prevention knowledge of athletic injuries, did not show a
significant difference in the prevention knowledge levels
of parents and coaches.
Hypothesis 2 stated that coaches will have a
significantly higher knowledge of the rehabilitation and
treatment of MTSS than parents.
The researcher formed this
hypothesis with respect to the O’Donoghue et al study7,
which cited “management” as the weakest area of knowledge
with regard to sport-related concussions in the high school
coaches population and to see if it could be applied to
other athletic injuries as well.7 A significant difference
was found in the knowledge levels of coaches with regard to
rehabilitation and treatment of MTSS compared to the
parents surveyed.
Cross et al8 examined the state of South Dakota’s high
school coaching population’s knowledge of injury
management.
The population included 1050 coaches from 14
sports, finding that less than 50 percent of the coaches
surveyed had current CPR or first aid certifications and,
overall, the coaches’ knowledge of the management of acute
athletic injuries was lacking.
Although this study was
with regard to general first aid and CPR and did not
examine the lower extremity specifically, it did look at
34
situations such as concussions, spinal cord injuries, neck
injuries, and, most relevant to the current study and MTSS,
fractures.
The authors found that only 49.40% of their
subjects felt they were prepared to handle fractures,
providing insight that coaches’ knowledge is lacking for
injury management.8
Although the previous studies5-9 looked at a specific
knowledge score for one athletic injury or another, all of
those reviewed by the researcher reached the same
conclusion that there was an insufficient overall knowledge
of all areas of athletic injuries with regard to sports
medicine.
The sports medicine team, in the adolescent
athletic population typically involves the student
athletes’ athletic trainers, coaches and parents.
This
study showed a weakness in the area of the knowledge of
rehabilitation and treatment of MTSS in parents even more
than coaches as their score was significantly lower.
Hypothesis 3 stated coaches would have a significantly
greater overall knowledge of MTSS than parents.
The
researcher hypothesized that regardless of what the overall
score each subject received on the survey, the coaches’
scores would be significantly higher than the scores of the
parents.
This was based on previous research which
examined the knowledge levels of different populations with
35
regard to different areas of athletic training including
knowledge of injuries and management of injuries.5-9
The results showed a significant difference between
the two groups, stating the mean score for coaches was
significantly higher than the mean score for parents.
O’Donoghue et al7 studied the knowledge of coaches with
regard to sport-related concussions and found that their
population of coaches displayed an overall moderate
knowledge of the subject matter.
Although this study did
not compare populations (i.e. coaches to parents) it still
showed that overall there was a gap in knowledge in the
coaching population.
When comparing this overall knowledge
score on the survey to the areas that comprised it, this
score may most closely relate to the rehabilitation and
treatment knowledge score as it was the only individual
category with a significant difference between parents and
coaches.
This difference, as identified above, shows that
the parents may be the least knowledgeable as far as the
care of the adolescent athlete suffering from medial tibial
stress syndrome when compared to coaches.
In addition to hypothesis testing, several other
statistical analyses were conducted in an attempt to find
significant differences between the parents and coaches as
36
well as with subjects who identified themselves as both a
parent and a coach.
The first additional findings examined the other areas
of knowledge tested in the survey including definition and
incidence, anatomy and risk factors, and diagnostic testing
by way of independent samples t-tests.
This was done to
see if there were any significant findings similar to those
found in the hypothesis testing with the rehabilitation and
overall knowledge scores.
The results showed no
significant difference in knowledge levels of parents and
coaches for any of the three categories.
Although the
researcher did not examine the knowledge of anatomy and
risk factors or of diagnostic testing, O’Donoghue et al7
found that their subjects’ highest area of knowledge was in
“recognition,” a similar classification by their
explanation as definition and incidence.7 Even though the
mean scores were similar to scores in other categories, no
significant difference was found in the mean scores of
parents and coaches in any of the additional categories
tested.
The final additional findings examined the mean scores
for each of the categories for subjects who identified
themselves as parents, coaches or both by way of a one-way
analysis of variance test between groups.
A significant
37
difference was found between groups with regard to the
knowledge of rehabilitation and treatment knowledge scores.
Although a significant difference was found, post-hoc
testing revealed it merely reinforced the findings from the
hypothesis testing as the analysis between the “both” group
when compared to the other two groups did not show
significance.
As stated before, this merely reinforced
O’Donoghue et al’s study showing that the knowledge of the
management of injuries in different populations is lacking.7
Implications to the Profession
The findings of this research provide possible
implications for the profession of athletic training.
The
research in this study shows that although many parents and
coaches of high school athletes know about medial tibial
stress syndrome, they may only be able to identify it as an
injury and not through symptoms or know common proper
prevention or rehabilitation practices.
As many athletic
trainers practice in the secondary school setting, two of
the vital components of the sports medicine team in a high
school are the coaches and parents.
This lack of knowledge
could be an area that athletic trainers attempt to increase
38
to allow their athletes suffering from MTSS to have a
better overall management of their injury.
The sports medicine team in the secondary school
setting consists professionally of the athletic trainer(s)
and possibly a team physician who is assigned to the
school; however, this physician may be contracted by a
hospital or clinic and assigned to many schools.
In the
collegiate and professional settings where athletic
trainers practice, there is almost always a team physician
readily available as well as chiropractors, physical
therapists and other allied health professionals to aid in
the care of the athletes.
This lack of personnel in the
secondary school sports medicine team is one of many
reasons that parents and coaches are often much more
involved in the management of athletic injuries.
The
results of this study illustrated a lack of knowledge of
medial tibial stress syndrome.
Therefore, the overall
knowledge level of how to manage athletes suffering from
this injury is lacking.
By educating parents and coaches,
the athletes may be able to be given a higher level of care
and the sports medicine team in the secondary school
setting will be more effective and efficient in managing
MTSS as proper management is closer to common knowledge
among the parents and coaches involved.
Additionally,
39
communication with a population of parents and coaches who
have a higher knowledge of MTSS will be easier as the
learning curve would start with more those more educated on
MTSS.
Recommendations for Future Research
Based on the results of this study, the following
suggestions for future research will be made.
First, the
researcher’s study surveyed six western Pennsylvania high
schools.
Although these high schools represented a diverse
group of parents and coaches, they may not be
representative of other areas of the country’s
socioeconomic state, level of education, population
diversity ratios and the size of individual school
districts both in number of residents and geographically.
This is both with regard to the type of schools that should
be surveyed as well as the number of schools surveyed.
Second, future studies should consider using a
different tool for examining knowledge levels of parents
and coaches. This study compared coaches to parents and not
the actual quantitative level that each group knows.
Although the survey created was effective for this study,
it may not be effective for studies testing a single
40
population as the researcher did not determine pass/fail
scores which would need to be applied to a single
population.
Third, future studies should include a more effective
communication method to the parents than disseminating
cover letters to athletic directors who distribute it to
their coaches who hand it to their players who take it home
to their parents.
This may account for the low response
rate. A more direct way of communicating with the parents
and coaches may yield a larger sample size and an increased
response rate.
Finally, future studies should examine the interaction
between coaches, parents and the athletic trainer with
regard to the management of injuries.
Similarly, more
studies should be performed to understand the level of
parents and coaches with regard to more athletic injuries.
By doing this, athletic trainers will generally know how
knowledgeable the parents and coaches, with whom they are
working, are with regard to the injuries the student
athletes are sustaining.
41
Conclusions
The results of the study revealed the following major
conclusions:
1.
Coaches have an overall greater knowledge of medial
tibial stress syndrome than parents of adolescent
athletes.
2.
Coaches have a greater knowledge of the rehabilitation
and treatment of medial tibial stress syndrome than
parents of adolescent athletes.
3.
There is no significant difference in the knowledge
levels of parents and coaches of adolescent athletes of
medial tibial stress syndrome with regard to
prevention, definition and incidence, anatomy and risk
factors, and diagnostic testing.
4.
There is no significant difference in the knowledge
level in any of the tested categories for subjects who
were both a parent and a coach of adolescent athletes.
42
REFERENCES
1.
Yates B, White S. The incidence and risk factors in
the development of medial tibial stress syndrome among
naval recruits. Am J Sports Med. 2004;32(3):772-780.
2.
Mubarak S, Gould R, Lee Y. The medial tibial stress
syndrome. Am J Sports Med. 1988;10:201-205.
3.
Galbraith RM, Lavallee ME. Medial tibial stress
syndromes: conservative treatment options. Curr Rev
Musculoskelet Med. 2009;2:127-133.
4.
McLeod TCV, Decoster LC, Loud KJ, Micheli LJ, Parker
JT, Sandrey MA, White C. National Athletic Trainers’
Association Position Statement: prevention of
pediatric overuse injuries. J Athl Training.
2011;46(2):206-220.
5.
Baron MJ, Powell JW, Ewing ME, Nogle SE, Branta CF.
First aid and injury prevention knowledge of youth
basketball, football and soccer coaches. Intl J
Coaching Science. 2009;3(1):55-67.
6.
Iversen MD, Friden C. Pilot study of female high
school basketball players’ anterior cruciate ligament
injury knowledge, attitudes and practices. Scand J Med
Sci Sports. 2009;19:595-602.
7.
O’Donoghue EM, Onate JA, Van Lunen B, Peterson CL.
Assessment of high school coaches’ knowledge of sportrelated concussion. Athletic Training and Sports
Health Care Journal. 2009;1(3):120-132.
8.
Cross PS, Karges JR, Adamson AJ, Arnold MR, Meier CM,
Hood JE. Assessing the need for knowledge on injury
management among high school athletic coaches in South
Dakota. J South Dakota Medicine. 2010: 241-245.
9.
Ward CW. Teens’ knowledge of risk factors for sports
injuries. J School Nursing. 2004;20(4):216-220.
43
APPENDICES
44
APPENDIX A
Review of Literature
45
REVIEW OF LITERATURE
Medial tibial stress syndrome (MTSS), often referred
to as “shin splints,” is an overuse injury referred to as a
continuum of injuries often associated with athletes
participating in endurance sports at the high school,
college, and professional levels.1-4 Although the certified
athletic trainers (ATCs) dealing with these injured
athletes are familiar with MTSS, oftentimes the parents and
coaches of the athletes experiencing it are uneducated on
the subject. This lack of knowledge could potentially lead
to improper management and possibly even make these
athletes’ symptoms worse.
The purpose of this review is to examine MTSS
including current recommendations for best practices
related to prevention, management and treatment. This
review will have five separate sections: 1) The definition
and incidence of MTSS, 2) The functional anatomy associated
with MTSS found upon examination of the athlete with MTSS
and associated risk factors, 3) Diagnostic testing used in
conjunction to the evaluation of the injured athlete, 4)
Management of MTSS, and finally, 5) The overall knowledge
of parents and coaches of athletes of injuries sustained by
46
the adolescent athlete.
A summary of the literature will
be provided at the end of this literature review.
Definition and Incidence
Medial tibial stress syndrome (MTSS) is defined as the
most common overuse injury seen in the running and active
population.5,6 Although it is very common, the definition is
often inconsistent throughout the literature.
Additionally, the incidence of MTSS throughout the
literature is often inconsistent as well.
Definition
Yates and White studied the incidence of medial tibial
stress syndrome among naval recruits.5 In their literature
review, they reference Murbarak et al’s characterization of
MTSS, stated as “a symptom complex seen in athletes who
complain of exercise induced pain along the posteriormedial
border of the tibia.”5,7
Drawing information from several
sources, Yates et al5 expanded on this generic definition to
dismiss the previous assumptions that MTSS is merely an
inflammatory response process.
Instead, Yates and White
presented that MTSS is a “a bone stress reaction that
becomes painful,” citing metabolic changes in the bone due
47
to exercise as well as an increase in osteoclastic activity
on the posteriormedial border; often from compression of
the bone. This increase in osteoclastic activity coupled
with the bone’s inability to replace the broken down tissue
fast enough, leads to increasingly porous bone tissue.
As
the bone is able to be broken down more easily, the athlete
begins to feel pain as the bone is subjected to
microtraumas which can ultimately result in a stress
fracture of the tibia.
Though a good definition is crucial
to its correct diagnosis, knowing its incidence among the
active population is equally helpful in coming to the
correct conclusion and identifying potential athletes who
could be predisposed to MTSS and other overuse injuries.
Incidence
As previously referenced, Yates and White5 examined the
incidence of medial tibial stress syndrome in a population
of 124 naval recruits, aged 17 to 35 with a mean age of
21.06 years (mean age=20.95 years in MTSS group), by way of
entrance and exit interviews during their ten week training
program. The authors began by taking a baseline history,
anthropometric and biomechanical data on each subject and
monitored the subjects throughout their training regime.
They defined MTSS based on each subject’s pain history,
48
location of pain and positive palpation of pain on the
posterior-medial boarder of the tibia.
They found that
forty of the recruits, 35%, developed MTSS.
The authors
also reported that female recruits were significantly more
prone to developing MTSS (52.9% of female recruits versus
28.2% of male recruits; p=0.012).
They concluded that
controlling foot pronation and enabling male and female
recruits to train separately could potentially decrease the
incidence of MTSS in their sample.5
Furthermore, Yates et al stated that MTSS accounts for
anywhere between 13.2% to 17.3% of all running injuries.5
Though this number is quite low, Orava et al’s findings
were quite different.6
Orava and Puranen6 examined the overall occurrence and
frequency of medial tibial stress syndrome, as well as
several other overuse conditions in the lower leg, in 2750
athletes in Finland, 73% of their subjects falling within
the 16 to 29 year old population.
MTSS was the most common
of the injuries, accounting for 60 percent of all the
cases, and when combined with tibial stress fractures, it
accounted for 75% of all injuries and the authors noted
that both occurred typically at the same site with the same
symptoms.
The authors of this article also examined the
49
underlying causes of MTSS and noted that pain was most
often elicited by exertional ischemia.
As Orava et al’s study involving a sample size of over
2,000 individuals showed that incidence can be as high as
60 percent of injuries,6 diagnosis of MTSS early is
critical.
Using an array of devices and methods during
evaluation for diagnosis can give the clinician the edge
against this syndrome and help catch it before it becomes
severe.
Functional Anatomy and Risk Factors
The anatomy associated with medial tibial stress
syndrome (MTSS) is typically consistent throughout the
literature. Repetitive microtrauma and chronic overuse
were outlined in the sources as the main causes of MTSS
with secondary causes consisting of the culmination of
several other injuries to the lower leg.5,6 This section
will examine; 1) the functional anatomy associated with
MTSS as well as the examination and physical findings of
MTSS, and 2) the risk factors often predisposing athletes
to MTSS.
50
Functional Anatomy and Physical Findings
A study by Cosca et al1 examined the causes of common
overuse injuries including MTSS through an anatomy
overview. The authors outlined basic causes, linking MTSS
as being a part of a continuum of stress injuries and
microtraumas to the posteriomedial tibia. The main cause
noted was hyperpronation.1 The authors additionally examined
the common sign of “shin splints” with regard to pain
patterns associated with the relative severity of MTSS. The
occurrence of more anterior focal tenderness was more
indicative of a stress fracture than more generalized
tenderness showed.1
Similar to Cosca, Reinking et al2 examined the anatomic
and physiologic aspects of exercise related leg pain.
Their study outlined concurrent issues often associated
with MTSS such as chronic exertion compartment syndrome,
tendinopathies of the lower extremity, tibial and peroneal
nerve entrapment and stress fractures of the tibia and
fibula.
They further examined the anatomy associated with
MTSS as well as the typical epidemiology and pathology
behind it.
More specifically, the authors noted that the
cause of MTSS is typically more lateral than the pain
presents with the anatomical sources of the medial leg pain
associated with MTSS as the tibialis posterior muscle,
51
flexor digitorum longus, soleus, and the deep crural fascia
of the shank.
Reinking et al also noted that external risk
factors such as training volume, surfaces and shoes
contributed to MTSS.
Additionally, it examined intrinsic
factors such as fore-foot and rear-foot pronation and
navicular drop as other key anatomic factors contributing
to MTSS.2
A retrospective study performed by Lau et al3 examined
pediatric patients, mean age 11.5 years, diagnosed with
overuse injuries.
The authors studied 506 cases of overuse
injuries in the pediatric population. Seventy-three percent
of the patients in this study were male and findings stated
that the knee and lower leg were the most common part of
the body for an overuse injury to occur. The authors went
on to examine the differences in functional anatomy between
the adolescent and adult athlete citing open and closed
epiphyseal plates as one the main difference. The authors
concluded that there must be caution taken when diagnosing
the pediatric patient as to not overlook issues only seen
in adults, most commonly the higher occurrence of avulsions
with muscular injuries in children.
Bates,4 in similar methodology to Lau’s retrospective
study3 of the pediatric patient, examined the signs and
symptoms, incidence, pertinent anatomy and diagnostic
52
procedures behind MTSS in the form of a literature review.
The symptoms included pain during walking and, in more
severe cases, at rest as well as tenderness at the sight of
pain, typically over the same anatomical landmarks as found
by Reinking et al2. Additionally, the review stated that the
athlete may present with compartment syndrome of the lower
leg. The author found that “shin splints” accounted for up
to 15% of all running injures and up to 60% of all lesions
in the lower leg.4
In the same vein, Stauch aimed to
examine shin pain in the athletic population.
Strauch et al8 provided an in-depth analysis on the
evaluation methods of shin pain in the athletic patient,
most specifically, the runner. They noted that palpation,
especially along the medial boarder of the distal third of
the fibula is key to the diagnosis of MTSS.
In an exploratory surgery case study by Percy,9 the
author presented a case study in which an adolescent male
presents with persistent discomfort in the right lower leg,
categorized as shin splints, with a metatarsal fracture in
the ipsilateral foot.
The patient’s pain persisted for
eight months without reduction in symptoms following
treatment of rest and ice.
The symptoms continued to
persist and the author hypothesized that exploratory
surgery to solve the problem.
During the surgery, unlike
53
the previous studies1-5, Percy found the athlete’s lower leg
musculature to be anomalous and continued to decompress the
sheath around the muscle with a biopsy revealing a
significant difference in muscle physiologic make-up than
that of the un-injured leg.
This difference showed atrophy
on the injured side with increased fibrosis within the
tissues, linking this early article to the more current
diagnosis of MTSS.6
Though many of the studies reviewed have listed their
own approach to diagnosing MTSS, Edwards et al10 found a
more standardized approach to diagnosing chronic leg pain
in the athletic population. The conditions each case had to
meet to be included under the blanket of “chronic leg pain”
included medial tibial stress syndrome, stress fractures,
chronic exertional compartment syndrome, nerve entrapment
and popliteal artery entrapment syndrome. For each
condition, the authors created an algorithm to be used in
differential diagnosis these conditions and provided a
short summary of any confounds between the diagnoses. The
authors concluded that this could help differentiate
between several of the chronic conditions in the event that
the symptoms were masked or common between several overuse
syndromes.
54
Identifying the anatomic structures involved is just
one of the pieces to the puzzle of diagnosing and
eventually treating MTSS.
However, diagnosis can be
simplified greatly if the ATC is able to identify certain
factors putting their athletes at risk.
Risk Factors
In addition to anatomical and physical findings
present in patients with MTSS, multiple risk factors were
identified in several studies as contributors and the
incidence of MTSS in the athletic population.4-6,8
In their review, Bates4 examined the biomechanical risk
factors, including running gait, with regard to foot
rigidity in the supinated position during heel strike. The
author stated rigidity during heel strike in conjunction
with overpronation and/or tibial varum could influence the
incidence of MTSS.
They concluded that this was one of the
underlying causes of MTSS.
Similar to Bates,4 Rassi et al11 looked at the
relationship between alignment of the lower extremity and
MTSS with regard to navicular drop, Q-angle, Achilles
angle, tibial angle and intermalleolar and intercondylar
distances in the non-professional athlete. Additionally,
the subjects had their Body Mass Index (BMI) and history
55
taken prior and were observed over 17 weeks. Overall, the
results showed that navicular drop was the only significant
variable that could predict the occurrence of MTSS.
However, regarding the authors additional findings (Qangle, Achilles angle, tibial angle and intermalleolar and
intercondylar distances), Rassi et al concluded that these
did not apply to their population of non-professional
athletes, as they were not statistically significant.8
As Bates4 looked at static, measured risk factors, in a
study examining ballet dancers, Gans12 examined more dynamic
risk factors in the ballet dancer.
In their study, Gans
looked at eight dancers with a history of previous MTSS and
eight without with regard to heel contact during the ascent
and descent of jumps and if it contributed to their
developing MTSS. The author examined the dancers from the
push-off to the landing phase of their jumps to determine
any abnormalities contributing to MTSS. The author found no
significant evidence in the single heel strike, however
there was significance in the double heel strike. Though
there were significant findings, Gans concluded that there
could be confounding issues with Achilles tendon tightness,
however they did note that heel strike could contribute to
MTSS.
56
Similar to Rassi’s lower leg study11, Barnes et al13
examined the association between foot type and medial
tibial stress syndrome by way of systematic review of the
literature. The foot types examined included pes cavus, pes
planus and the “normal” arch. The authors concluded that
there was no significant relationship between foot type and
the incidence of medial tibial stress syndrome.
An accurate evaluation of the athlete and paying
attention to important functional anatomy are key to
correctly diagnosing MTSS. Though the evaluation of MTSS is
critical, it is equally as important to know the definition
and incidence of medial tibial stress syndrome to aid in
the care of the athletic population.
Diagnostic Testing
Although a thorough evaluation of the associated
anatomic structures of the patient experiencing symptoms is
important, diagnostic testing is an important step in the
diagnosis, prevention and treatment of MTSS.
This section
will outline and examine some of the diagnostic imaging
procedures used in the diagnosis of MTSS.
Gaeta et al14 examined the use of CT scans in on
runners with MTSS.
The purpose of their study was to
57
determine if runners who were asymptomatic would have
abnormalities on CT scans of their tibias as well as
determine how accurately the CT scan is in diagnosing
medial tibial stress syndrome.
They did this by performing
CT scans on 20 asymptomatic runners and 21 runners who had
either uni- or bilateral tibial pain.
The study found that
of the painful tibias, 14, all of them showed CT
abnormalities and the testing’s specificity, sensitivity,
positive predictive value and negative predictive value
were all very high as well and concluded that high
resolution CT scanning is clinically accurate in indicating
MTSS.
In a similar study by Holder et al15, the authors
examined scintigraphic patterns of MTSS in 10 patients.
The patient population consisted of 5 male and 5 female
athletes who were clinically diagnosed with “shin splints”
or MTSS.
The patients were subjected to three-phase
scintigraphy to help diagnose medial tibial stress
syndrome.
The typical findings that the authors found were
longitudinally oriented lesions on the posterior tibia,
involving about one third of the bone.
The authors
concluded that this indicated soleus involvement and that
these scintigraphic findings were significant in their
58
ability to help in the determining of medial tibial stress
syndrome from stress fractures and reactions.
In another study examining bone scans and MTSS,
Spencer et al16 described the use of bone scan to determine
abnormalities in patients with medial tibial stress
syndrome, described in this article as “shin splints.”
The
subjects, all young athletes, had previously had
radiographs taken on their lower legs, all of which came
back displaying no abnormalities.
In each of the patients,
there was a significantly noticeable lesion on both tibias
and, in one case, on the tarsal bones.
The author noted
that this further supported the evidence that bone scans
can be a very crucial step in the diagnosis of medial
tibial stress syndrome.
Though the Holder et al and Spencer et al studies15,16
showed the efficacy of bone scans, they can be very
expensive.
Samsi et al17 chose to look at the more cost
efficient x-ray imagining method as a means for diagnosing
MTSS.
The authors examined the efficacy of x-rays and bone
scans in the diagnosis of medial tibial stress syndrome.
The study used a total of twenty patients, the majority
with tibial pain in the middle or lower 1/3 of the bone,
however 3 patients had tenderness over their fibula.
In
the x-ray films, all the films appeared normal with the
59
exception of one patient with significant stress fractures,
while the bone scan revealed an abnormality in twelve of
the twenty patients.
The authors concluded that bone
scanning is indicated for the diagnosis of medial tibial
stress syndrome because of its high sensitivity and
specificity after x-rays were performed.
Similarly, Kijowski et al18 found that x-rays were
ineffective of diagnosing MTSS.
However, in their study,
the authors examined the correlation of x-ray/radiographic
imaging with magnetic resonance imaging in patients who
were previously diagnosed with medial tibial stress
syndrome and were either currently receiving treatment or
had just recently returned to participation in their given
activity.
Their 80 subjects each had underwent MRI and
radiographic imaging.
The study concluded that there was a
strong association between the reaction on the radiographs
at the site of the patients’ symptoms and the MRI findings.
Although MRI and bone scan findings were found
significant in diagnosing MTSS14-18, Magnusson et al19 looked
at the bone mineral density to find a link.
In their
study, the authors examined the radiographic data from 14
adult male athletes who had been previously been diagnosed
or were currently receiving treatment for medial tibial
stress syndrome.
The subjects’ bone mineral density was
60
measured at a baseline and then between 4 and 8 years later
to record the difference.
The study found that in the
regions where the pain was palpated, the bone mineral
density was significantly lower in the baseline test and
returned to normal at the final measurement.
The authors
concluded that although MTSS causes low bone mineral
density while its symptoms are present, post-recovery, the
athlete regains normal bone mineral density following an
increased uptake.
Moen et al’s20 critical review examined the different
methods of diagnosing medial tibial stress syndrome.
Unlike previous studies, the authors found that x-ray
absorptiometry was an effective imaging method for
detecting MTSS.
The authors concluded that though imaging
techniques are useful in diagnosing MTSS, they must be used
with caution.
Medial tibial stress syndrome, though somewhat of an
enigma at times, can be easily diagnosed if the correct
imagine procedure is utilized.14-19
Though the use of X-rays
has not been shown to have positive results,17,18 the
efficacy of MRI’s, CT scans, bone scans and bone mineral
density measurements have all been proven in the diagnosis
of MTSS.
14-16,18-20
61
Management of MTSS
Once an athlete has undergone an evaluation by their
athletic trainer, physical therapist or orthopedic
physician and have been formally diagnosed with MTSS, the
next step is to get them back to competition pain-free.
This involves not only a rehabilitation and management
program, but also a separate program to help prevent MTSS
from reoccurring.
Yates and White5 found a recurrence rate
of 28%, with a relative risk of 1.52, showing statistical
significance that an athlete will be more prone to
developing MTSS if he/she has been previously diagnosed.
Statistical significance in perspective, this section will
examine the management approaches with regard to
rehabilitation of the athlete with MTSS as well as the
prevention strategies implemented in the literature for
preventing MTSS in the future.
Rehabilitation and Treatment
The athlete suffering from MTSS may or may not undergo
rehabilitation.
Though this may seem like an inappropriate
management strategy to some, much of the literature
emphasizes rest as the main tool for helping recover from
MTSS.13,20-25
62
Orava and Puranen’s6 study mentioned earlier in the
definition and incidence section5,6 went further to state
that the only treatment examined which was noted to
decrease symptoms in both the fascial compartment as well
as at the site of MTSS was rest.
The authors concluded
that if rest was ineffective, a surgical intervention in
the form of a fasciotomy is recommended to alleviate
symptoms.6
Galbraith et al21 also examined the management of MTSS
by way of a systematic review.
Their review reinforced
several factors already mentioned by the authors in the
Functional Anatomy and Risk Factors section that contribute
to MTSS such as navicular drop, footwear, running distance
and intensity.
The main focus; however, was to delve into
some conservative treatment approaches taken to expedite
the process of returning the athlete to play after they
have been diagnosed with MTSS.
The authors concluded that
there are in fact several factors that can be classified as
both prevention and rehabilitation.
These factors, which
can also aid in the recovery process, included relative
rest such as cross training or implementing low-impact
exercises into the a modified training routine.
Additionally, the use of cryotherapy and electrical
stimulation with soft tissue mobilization and whirlpool
63
baths were also indicated for both the acute and subacute
phases.
In a case study using a less traditional approach than
that of Galbraith et al,21 Krenner22 examined a chiropractic
approach to managing medial tibial stress syndrome.
The
treatment consisted of breaking up of adhesions via muscle
stripping and massage.
Acupuncture was also utilized and
additionally, chiropractic manual adjustive techniques to
help restore normal biomechanical function bilaterally.
This continued 5 times over 10 days until the symptoms were
alleviated.
decreased.
Additionally, patient’s activity was sharply
Krenner concluded that treatment of MTSS must
be a multi-faceted process that not only alleviates pain
but also restores biomechanical function.
Strauch and Slomiany23 took a more traditional approach
to their study and examined the causes, treatments and
rehabilitation for patients with medial tibial stress
syndrome.
In the treatment phase of management, the
authors identified rest as the main treatment method
utilized; however, they noted that pool workouts were
effective in maintaining the athlete’s level of fitness.
Acute treatment for pain modulation consisted of NSAIDS,
ice massage, iontophoresis and compression to the area by
way of a neoprene sleeve worn on the lower leg.
64
Similar to the other authors,20-23 in an article from
the Journal of Athletic Training, Shaffer24 provided an in
depth look into the prevention and treatment of stress
fractures.
This article was an update to a previous
article by the same authors.
They updated their findings
from their initial study to include that pneumatic bracing
of the tibia, which used in conjunction with immobilization
and rest, aided in reducing the recovery period in the
athlete with stress reactions, stress fractures and MTSS.
Though there are many articles concerned with the
treatment of MTSS, very few of the articles surveyed
implement these methods into a high quality study testing a
larger sample size.
In a randomized controlled trial
however, Johnston et al25 examined the treatment of medial
tibial stress syndrome in 2700 navy recruits, which was
finally narrowed down to 25 subjects in their experimental
group following the exclusion of subjects who progressed to
stress fractures or concurrent lower extremity pathologies.
Their two treatment methods consisted of traditional
conservative treatment involving typical cyrotherapy
methods, a stretching and strengthening program, NSAIDs for
pain modulation, modification of training routines and
relative rest with the other group received pneumatic leg
brace orthoses.
Though the orthoses did aid in the
65
soldiers’ recovery, the authors weren’t able to draw any
conclusions from their findings and stated that more
research would be needed to verify if the orthoses are
effective in the prevention and treatment of medial tibial
stress syndrome.
Although many of the authors suggested different
methods such as leg orthoses,23,25 and traditional modality
use for pain modulation,21,22 the one thing that remained
consistent was the need of rest for the injury.
Whether it
was termed “relative” or “modified,” rest was the one true
generally accepted treatment option for the athlete
suffering from MTSS.6,20-23,25 However, once the athlete who
was suffering from MTSS is returned to participation, the
focus must now be changed from treating the syndrome to
preventing it.
Prevention
Once the athlete has completed resting and their
rehabilitation program for MTSS and has returned to
competition, the focus must shift from treating MTSS to
preventing it from occurring again.
Strauch and Slomiany23 noted that prevention can be
made considerably easier with the implementation of a
strength and conditioning program, even after the athlete
66
has fully recovered.
The program, the authors suggested,
should include flexibility exercises as well as
strengthening exercises, emphasizing the calves, hamstrings
and quadriceps.
Adverse to Strauch and Slomiany,23 Shaffer’s24 review
also examined two studies which integrated only a
stretching program to aid, but found that both were
ineffective in preventing MTSS.
The authors concluded that
evidence for preventing MTSS and tibial stress fractures is
generally lacking concrete strategies for effective
prevention.
Essentially, the prevention of MTSS must be a
multifaceted approach.
Examining MTSS on a larger scale, Rome et al26 created
a Cochran review examining the common techniques for
preventing stress fractures and reactions in young
athletes.
The authors went on to review 13 trials of
military recruits enrolled in MTSS prevention programs and
3 trials of treatment programs.
In the 10 trials involving
orthoses, data suggested that the interventions did
significantly prevent MTSS when compared to the nonorthoses groups.
Two trials concluded that muscle
stretching did not help prevent injuries when performed
prior to exercises, much like Shaffer.24
67
Similarly, a review by Craig27 examined the literature
on the prevention of MTSS.
The author examined studies in
which there was a controlled trial of an evidence based
prevention method for MTSS including insoles, stretching
programs, footwear and graduated running programs.
However, like previous literature,23,24 Craig concluded that
none of the studies of MTSS prevention had statistically
significant evidence that their respective prevention
method was effective, however, there was promise for shock
absorbing insoles from one of the studies reviewed.25
An NATA position statement by McLeod et al28 examined
the prevention of overuse injuries in the pediatric
population, including MTSS.
The statement highlights some
of the profiles of both male and female athletes that may
predispose athletes to overuse injuries such as tall
stature, more explosive strength, large Q angles, increased
muscle tightness and decreased muscle flexibility.
The
authors also stated that a decrease in the overall fitness
level in the general population means that training
routines must be more gradually introduced to help prevent
overuse injuries.
They concluded that the athletic trainer
must be able to identify risk factors associated with
overuse injuries as well as taking the appropriate steps as
to help prevent these injuries.
68
Similar to previous articles,23-25 A prospective
controlled study was conducted by Gardner et al29 to examine
the effect of shock absorbent insoles in the prevention of
stress fractures and other overuse injuries.
The authors
studied a group of 3,025 marine recruits over a period of
12 weeks and systematically issued elastic polymer insoles
to even and odd numbered platoons. After a period of time,
the authors found that the insoles did not prevent stress
reactions in the tibias.
They also included a control
group of those recruits who were wearing running sneakers
as opposed to boots during their workouts for about an hour
and a half a day, examining the age of the shoe relative to
the incidence of shin pain.
They found that though there
was a trend that the age of the shoe had somewhat an
effect, it was not large enough to be significant in
preventing stress reactions.
They concluded that neither
the shock absorbent insoles nor the age of sneakers of the
control group was significant in preventing lower extremity
stress reactions their subject pool.
Tolbert and Brinkley30 examined several articles on the
incidence of MTSS in athletics and created a program to
help counteract the underlying causes they found in a
review of the literature.
Including a warm up for 5 to 10
minutes greatly increased the efficacy of the program.
The
69
program also included hamstring stretching, soleus
stretching, gastrocnemius stretching and ice massage for
pain modulation.
The authors concluded that though rest is
the only treatment, by integrating a stretching and
strengthening program such as this, the athletic training
and strengthening and conditioning staff can greatly reduce
the incidence of MTSS.
Similar to Shaffer24 and Craig27 however, Brushoj et
al’s31 randomized controlled trial examined an exercise
program to aid in the prevention of MTSS and other overuse
injuries of the lower extremity.
The subjects were either
given an prevention program consisting of squats, lunges,
hip abduction and external rotation exercises, forefoot
lifts, coordination drills and quadriceps stretching or a
placebo program of abdominal curls, back extensions, biceps
and triceps towel curls and pectoral stretches.
The
authors found that the program did not help prevent the
incidence of MTSS in the recruits; however, it did increase
the recruits’ 12-minute maximal running test distance when
compared to the placebo group.
The authors concluded that
this may be caused by the lack of knowledge of all the risk
factors behind overuse injuries.
Though very few of the authors found any significant
evidence on the effective prevention of MTSS, making sure
70
to only gradually increase activity was shown to help
prevent MTSS.
Additionally, the integration of a warm-up
into a training routine can also decrease the incidence of
MTSS.
Knowledge of Athletic Injuries
Prevention, assessment and management of the athlete
with MTSS is built into the proficiency assessment of
athletic trainers as they complete their undergraduate or
entry-level masters’ programs.
On the other end of the
spectrum, however, the same cannot be said for the parents
and coaches of these athletes as they are not as versed in
these areas.
Injuries, generally, are easily recognized by
coaches, parents and other athletes, who typically possess
a basic understanding of the care and prevention aspects.
Several recent studies have been conducted looking at the
knowledge level of these three populations that are the
frontline in dealing with athletic injuries.
O’Donoghue et al32 conducted a study in the form of a
survey examining the knowledge of high school coaches with
regard to sport-related concussions. Looking at their
subjects’ knowledge, the authors split their survey into
prevention, management and recognition sections.
71
Additionally, the subjects were split into groups according
to sex and whether or not they had attended a concussion
workshop or not.
The authors found that overall, the
coaches’ scored best in the area of recognition and worst
in management and that male coaches, regardless of the sex
of their athletes or their sport, were more knowledgeable
than females.
In a more focalized study by Cross et al,33 the authors
examined only the state of South Dakota’s high school
coaching population’s knowledge of injury management.
The
population included 1050 coaches from 14 sports, the
majority of which indicated that they were in charge of the
initial evaluation of athletic injuries for their athletes.
The study found that less than 50 percent of the coaches
surveyed had current CPR or first aid certifications and,
overall, the coaches’ knowledge of the management of acute
athletic injuries was lacking.
Similar to O’Donoghue et al’s32 study, Baron et al34
conducted a smaller, but similar survey-based study with
regard to injury prevention and first aid knowledge of high
school coaches in the mid-Michigan area.
The results,
however; unlike O’Donoghue’s32 study, showed that only
fifteen out of the 290 coaches earned a passing score on
the Revised First-Aid Assessment Survey, suggesting that
72
overall, the population who was surveyed had insufficient
knowledge in the realm of first aid and injury prevention.
While many of these studies have examined the
knowledge of coaches,32-34 Iversen and Friden35 examined the
knowledge of female high school basketball players’
knowledge of anterior cruciate ligament injures with regard
to knowledge attitudes and practices associated with ACL
injuries.
The authors examined 113 players and 12 coaches
in these knowledge areas with 86 (74 players, 12 coaches)
completing the study.
The authors concluded that even
after the trial, there were no significant findings with
regard to any of the areas beings assessed.
Very much in the same context of Iversen and Friden’s
study,35 Ward36 also examined teens’ knowledge of the risk
factors associated with common sports injuries in the area
of prevention of athletic injuries.
In their study, the
author administered a survey during a physical education
class to students testing the subjects’ knowledge of
athletic injury prevention.
Ward concluded that the
subjects not only had a high level of athletic
participation, but they concurrently had a high level of
knowledge with regard to common injury prevention practices
and the equipment often utilized.
73
Although coaches are often the first responders to
their athletes when an acute trauma occurs, they are not
always as knowledgeable as many would like them to be.32-34
Although two of the studies surveyed looked at the
knowledge of athletes of injury prevention and
management,35,36 the athlete who is injured will not be the
first responder to their own ankle sprain, torn labrum or
other trauma, nor should they be expected to be.
Additionally, few studies have examined the knowledge level
of the parents of the athletes who are suffering these
injuries.
Because of this lack of knowledge, the athletes
can often be at risk and this can create a problem.
Summary
Medial tibial stress syndrome is a continuum of lower
leg traumas associated with overuse in athletics and other
physical activity.5-7 Though the evaluation of the
functional anatomy and risk factors associated with it are
very well defined, and all but set in stone,1-10 the
diagnostic testing for MTSS has been somewhat controversial
and, as far as the literature is concerned, very
indeterminate.14-19,24
74
The athletic trainer must recognize these risk factors
and be able to integrate prevention programs and educate
their athletes on the proper prevention techniques to help
them avoid MTSS and keep them in the game.22-29 Additionally,
when an adolescent athlete does end up with MTSS, rest and
a proper rehabilitation and management program is critical
in the athlete’s return to play.5,6,20-25
Although the athletic trainer is often very
knowledgeable on MTSS, the integration of these prevention
and management strategies can be difficult if the parents,
coaches and athletes they are working with are ignorant on
the subject.
As shown in the literature, coaches and
athletes are oftentimes well below the adequate knowledge
level in regard to athletic injury management and
prevention in general and the literature of the knowledge
of parents is all but non-existent.32-36
This can create an
issue for the Athletic Trainer during the management of the
athlete with MTSS.
75
APPENDIX B
The Problem
76
STATEMENT OF THE PROBLEM
The purpose of the study was to examine the knowledge
of parents and coaches with regard to medial tibial stress
syndrome.
If we, as athletic trainers, are able to
identify problem areas and gaps in knowledge bases and
educate those with this lack of knowledge, the overall care
of the athlete suffering from medial tibial stress syndrome
may be better. As MTSS is a continuum of overuse trauma to
the lower leg, the overall management of it can be
considerably difficult as everyone involved in the
prevention, management and treatment must take a
multifaceted approach.
The athletic trainer and coaches
are typically on the front lines of the prevention aspect
in the adolescent athlete. These are the individuals
typically responsible for the conditioning prior to the
season and training program throughout the season.
The
parents become much more involved when the athlete sustains
MTSS as they must try to help their children manage the
problem.
Since the parents and coaches are such a large
part in the prevention and management aspects of MTSS,
their knowledge of the prevention and treatment must be to
a certain level as to not mismanage or further injure the
athlete.
77
Definition of Terms
The following definitions of terms were defined for
this study:
1) Medial tibial stress syndrome (MTSS) - A continuum of
overuse injuries to the lower leg resulting in a loss
of function.
2) Adolescent Athlete- Any high school-aged person
competing in high school athletics.
Basic Assumptions
The following are basic assumptions of this study:
1)
The subjects will be honest when they complete their
demographic sheets.
2)
The subjects will answer the survey to the best of
their ability.
3)
Subjects will be representative of high school coaches
and parents in their knowledge of MTSS.
Limitations of the Study
The following are possible limitations of the study:
1)
The knowledge of MTSS in the populations being
surveyed may be skewed by overall education of the
community surveyed.
78
2)
Coaches and Parents may provide inconsistent
responses.
3)
The validity of the survey has not been established.
4)
There is no current research specifically regarding
this topic.
5)
The distribution method to both the parents and
coaches was indirect, which could account for the low
response rate.
Significance of the Study
This study will be significant as it will provide
feedback to the knowledge base of parents and coaches with
regard to medial tibial stress syndrome.
This can aid in
the care of the athlete suffering from MTSS by having the
athlete’s parents and coaches be able to potentially
identify signs and symptoms and refer their athlete to
their athletic trainer or doctor, potentially decreasing
recovery time.
With this knowledge, communication between
the athletic trainer, parents and coaches will be made
easier as all three will be greater informed.
Additionally, the risk of MTSS being mismanaged in the
adolescent athlete can be minimized as both the coaches
would be less likely to have the athlete “walk it off,”
79
and, similarly, parents will be less likely to push their
children through the pain.
80
APPENDIX C
Additional Methods
81
APPENDIX C1
MTSS Knowledge Survey
82
83
84
85
86
87
88
89
90
91
92
93
APPENDIX C2
Institutional Review Board –
California University of Pennsylvania
94
95
96
97
98
99
100
101
102
103
104
105
The following changes were submitted to the IRB and
accepted. They can be found in this email approval from
the IRB:
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair
Dear Joseph McShane:
Please consider this email as official notification that the modifications
(listed below) to your previously-approved study (#11-036 “Knowledge of
Medial Tibial Stress Syndrome of Parents and Coaches of Adolescent
Athletes") have been approved by the California University of Pennsylvania
Institutional Review Board.
-Modify methods to include online survey distribution (e.g. SurveyMonkey)
in addition to the pen and paper method already in place
NOTE: the cover letter/consent form must appear on the online site prior to
any survey questions.
-Addition of McDowell High School as a data collection site
(1)
(2)
(3)
(4)
This modification is effective 2-21-2012. The expiration date is the same as
for the original approval (2-19-2013). These dates must appear on the
consent form.
Please note that Federal Policy requires that you notify the IRB promptly
regarding any of the following:
Any additions or changes in procedures you might wish for your study
(additions or changes must be approved by the IRB before they are
implemented)
Any events that affect the safety or well-being of subjects
Any modifications of your study or other responses that are necessitated
by any events reported in (2).
To continue your research beyond the approval expiration date of 2-192013 you must file additional information to be considered for continuing
review. Please contact instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board
106
APPENDIX C3
Letter to Panel of Experts
107
November 28, 2011
Dear Athletic Training Colleague,
I am a graduate student at California University of Pennsylvania pursing a Master of Science
Degree in Athletic Training. I am conducting survey research to add to the bank of knowledge
within the Athletic Training profession. The objective of my study is to test the knowledge level
of my subjects with regard to medial tibial stress syndrome. The subjects for this study will
include parents and coaches of high school athletes. The participants will be contacted by their
children’s athletic directors and all information will be kept confidential.
I am the primary researcher and have developed the questionnaire to be used in this study. You
have been chosen to be an expert on this panel to assist in the validation of my study, due to
your expertise and experience. Your feedback is very important to the success of this study and I
greatly appreciate any suggestions you have. Any comments or suggestions you submit will be
used to revise and make the questionnaire more valid for use in this study.
Any additional comments about the survey would be appreciated. Please note this survey will be
delivered to the subjects via paper survey and not as a word document. I have given you the
word document version in order that you may make comments. Please return this document to
me with any comments you may have by December 1, 2011. If you have any questions do not
hesitate to contact me via email or phone at mcs4257@calu.edu or (814) 403-8266.
After completing and reviewing the survey, please answer the following questions:
1) Are the questions direct and understandable?
2) Are there any questions that are not coherent or should be excluded from the research?
3) Are there any questions that should be added to questionnaire that would aid in the
research?
Thank you in advance for your time, efforts, and consideration in helping me with my research.
Sincerely,
Joseph McShane, ATC
California University of PA
108
APPDENDIX C4
Cover Letter for Survey
109
110
APPENDIX C5
Letter to Athletic Directors
111
February 8, 2012
Dear Athletic Director:
My name is Joseph McShane and I am a Graduate Athletic Trainer at California University of
Pennsylvania seeking my Masters of Science degree in Athletic Training. A requirement for this
degree is the completion of a research based thesis project; my study’s title is “The Knowledge
of Medial Tibial Stress Syndrome (Shin Splints) of Parents and Coaches of Adolescent Athletes.”
Students participating in high school athletics are subjected to the rigors of not only training, but
competition as well. As their training regimes grow ever more intense to compete at a higher
level and beat their competition, the risk for injuries increases. Although many coaches and
parents think of an athletic injury consisting of a sprained ankle or a separated shoulder, many
are unaware of the injuries caused by overtraining and overuse; termed “overuse injuries.”
Medial tibial stress syndrome (MTSS), often referred to as “Shin Splints,” is one of these injuries
often seen in the pediatric population. Though its incidence is quite common, its management
for the children who are without the supervision of an athletic trainer at their high school is
often left up to their parents and coaches. A lack of knowledge of the proper management of
this injury can lead to more serious injuries such as stress fractures or neural damage from
compartment syndrome of the lower leg. My study is aiming to test the knowledge level of
these parents and coaches to see how knowledgeable they really are.
I am asking that the parents of athletes and coaches fill out a survey on their own time. This
survey will ask 30 questions regarding medial tibial stress syndrome and take about twenty
minutes. In addition to the knowledge questions, the subjects will be asked demographic
questions such as “are you a parent or a coach” and “what sport does your child participate in?”
Once the surveys are completed, they will be returned by each subject in a provided postage
paid envelope.
I am writing to seek your approval to use your High School athletes’ parents and coaches for
participation in my study.
In conclusion, I would like to thank you for your time, cooperation, and consideration with this
matter.
Sincerely,
Joseph McShane
California University of Pennsylvania
Graduate Assistant Athletic Trainer
112
REFERENCES
1.
Cosca DD, Navazio F. Common problems in endurance
athletes. Am Family Phys. 2007;76(2):237-244.
2.
Reinking MF. Literature Review: Exercise Related Leg
Pain (ERLP): A Review of the Literature. North
American Journal of Sports Physical Therapy. 2007;
2(3):170-181.
3.
Lau LL, Mahadev A, Hui JHP. Common lower limb sportsrelated overuse injuries in young athletes. Ann Acad
Med Signapore. 2008;37(4):315-319.
4.
Bates P. Shin splints- a literature review.
Sports Med. 1985;19(3):132-137.
5.
Yates B, White S. The incidence and risk factors in
the development of medial tibial stress syndrome among
naval recruits. Am J Sports Med. 2004; 32(3):772-780.
6.
Orava S, Puranen J. Athletes’ leg pains.
Sports Med. 1979;13:92-97.
7.
Mubarak S, Gould R, Lee Y. The medial tibial stress
syndrome. Am J Sports Med. 1988;10:201-205.
8.
Strauch WB, Slomiany WP. Evaluating shin pain in
active patients. J Musculoskeletal Medicine.
2008;25(3):138-140,144-146,148.
9.
Percy ECC. Case report: an epiphyseal stress fracture
of the foot and shin splint in an anomalous calf
muscle in a runner. Brit J Sports Med.
1980;14(2,3):110-113.
10.
Edwards PH, Wright ML, Hartman JF. A practical
approach for the differential diagnosis of chronic leg
pain in the athlete. Am J Sports Med.
2005;33(8):1241-1249.
11.
Raissi GRD, Cherati ADS, Mansoori KD, Razi MD. The
relationship between lower extremity alignment and
medial tibial stress syndrome among non-professional
athletes. Sports Medicine, Arthroscopy,
Rehabilitation, Therapy and Technology. 2009(1:11).
Brit J
Brit J
113
12.
Gans A. The relationship of heel contact in asscent
and descent from jumps to the incidence of shin
splints in ballet dancers. Physical Therapy.
1985;65(8):1192-1196.
13.
Barnes A, Wheat J, Milner C. Association between foot
type and tibial stress injuries: a systematic review.
Br J Sports Med. 2008;42:93-98.
14.
Gaeta M, Minutoli F, Vinci S, Salamone I, D’Andrea L,
Bitto L, Magaudda L, Alfredo B. High-Resolution CT
grading of tibial stress reactions in distance
runners. Am J Roentgen. 2006;187: 789-793.
15.
Holder LE, Michael RH. The specific scintigraphic
pattern of “shin splints in the lower leg”: concise
communication. J Nucl Med. 1984;25:865-869.
16.
Spencer RP, Levinson ED, Baldwin RD, Sziklas JJ, Witek
JT, Rosenberg R. Diverse bone scan abnormalities in
“shin splints.” J Nucl Med. 1979;20:1271-1272.
17.
Samsi AB, Tilve GH, Shikare S. Bone imaging in sports
medicine. J Postgraduate Medicine. 1997;43(3):71-72.
18.
Kijowski R, Choi J, Mukharjee R. Significance of
radiographic abnomalities in patients with tibial
stress injuries: correlation with magnetic resonance
imaging. Skeletal Radiol. 2007;36:633-640.
19.
Magnusson HI, Ahlborg HG, Karlsson C, Nyquist F,
Karlsson MK. Low regional tibial bone density in
athletes with medial tibial stress syndrome normalizes
after recovery from symptoms. Am J Sports Med.
2003;31:596-600.
20.
Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC.
Medial tibial stress syndrome: A critical review. J
Sports Med. 2009;39(7):523-546.
21.
Galbraith RM, Lavallee ME. Medial tibial stress
syndroms: conservative treatment options. Curr Rev
Musculoskelet Med. 2009;2:127-133.
22.
Krenner BJ. Case report: comprehensive management of
medial tibial stress syndrome. J Chiropractic
Medicine. 2002;3(1):122-124.
114
23.
Strauch WB, Slomiany WP. Shin pain treatments get
active patients back on track. Biomechanics.
2008;15(4):31-38.
24.
Shaffer SW, Uhl TL. Preventing and treating lower
extremity stress reactions and fractures in adults. J
Athletic Training. 2006;41(4):466-469.
25.
Johnston E, Flynn T, Bean M, Breton M, Scherer M,
Dreltzler G, Thomas D. A randomized controlled trial
of a leg orthosis versus traditional treatment for
soldiers with shin splints: a pilot study. Military
Medicine. 2006;171(1):40-44.
26.
Rome K, Handoll HHG, Ashford RL. Interventions for
preventing and treating stress fractures and stress
reactions of bone of the lower limbs in young adults
(Review). The Cochrane Library. 2009(1).
27.
Craig DI. Medial tibial stress syndrome: Evidencebased prevention. J Athl Training. 2008;43(3):316-318.
28.
McLeod TCV, Decoster LC, Loud KJ, Micheli LJ, Parker
JT, Sandrey MA, White C. National athletic trainers’
association position statement: prevention of
pediatric overuse injuries. J Athletic Training.
2011;46(2):206-220.
29.
Gardner LI. Dziados JE, Jones BH, Brundage JF, Harris
JM, Sullivan R, Gill P. Prevention of lower extremity
stress fractures: a controlled trial of a shock
absorbent insole. APJH. 1988;78(12):1563-1568.
30.
Tolbert TA, Binkley HM. Treatment and prevention of
shin splints. Strength and Conditioning Journal.
2009;31(5):69-72.
31.
Brushoj C, Larsen K, Albrecht-Beste E, Nielsen MB,
Loye F, Holmich P. Prevention of overuse injuries by
a concurrent exercise program in subjects exposed to
an increase in training load: a randomized controlled
trial of 1020 army recruits. Am J Sports Med.
2008;36(4):663-670.
32.
O’Donoghue EM, Onate JA, Van Lunen B, Peterson CL.
Assessment of high school coaches’ knowledge of sportrelated concussion. Athletic Training and Sports
Health Care Journal. 2009;1(3): 120-132.
115
33.
Cross PS, Karges JR, Adamson AJ, Arnold MR, Meier CM,
Hood JE. Assessing the need for knowledge on injury
management among high school athletic coaches in South
Dakota. J South Dakota Medicine. June 2010; 241-245.
34.
Baron MJ, Powell JW, Ewing ME, Nogle SE, Branta CF.
First aid and injury prevention knowledge of youth
basketball, football and soccer coaches. Intl J
Coaching Science. 2009;3(1):55-67.
35.
Iversen MD, Friden C. Pilot study of female high
school basketball players’ anterior cruciate ligament
injury knowledge, attitudes and practices. Scand J Med
Sci Sports. 2009;19: 595-602.
36.
Ward CW. Teens’ knowledge of risk factors for sports
injuries. J School Nursing. 2004;20(4): 216-220.
116
ABSTRACT
Title:
THE KNOWLEDGE OF MEDIAL TIBIAL STRESS
SYNDROME OF PARENTS AND COACHES OF
ADOLESCENT ATHLETES
Researcher:
Joseph J. McShane
Advisor:
Dr. Ellen J. West
Date:
May 2012
Research Type: Master’s Thesis
Context:
This study evaluated the knowledge of
parents and coaches of adolescent athletes
of medial tibial stress syndrome with regard
to different areas of knowledge associated
with athletic injuries within the scope of
practice of athletic trainers.
Objective:
The purpose of this study was to examine the
knowledge of parents and coaches of medial
tibial stress syndrome in the adolescent
athlete.
Design:
Descriptive research study
Setting:
The researcher distributed a cover letter
containing a link to the Internet based
survey to athletic directors at the high
schools to be surveyed. The athletic
directors then distributed the letter to the
parents and coaches at their respective
schools.
Subjects:
Parents and coaches of the six western
Pennsylvania high schools’ athletes
surveyed.
Interventions: The independent variables in the study were
the subjects tested (either parents or
coaches). The dependent variable was the
subjects’ score as measured by the MTSS
knowledge survey (r = 0.374), each question
being worth one point. The survey was
created by the researcher and administered
117
via a cover letter given to the athletic
directors at the high schools to be surveyed
who then distributed the cover letter to the
parents and coaches at their school. The
data was analyzed using SPSS at a
significance level at α ≤ 0.05.
Measurements:
All data analyzed at a significance level at
α ≤ 0.05 for all hypotheses. H1: an
independent samples t-test was used to
compare mean prevention knowledge scores
between parents and coaches. H2: an
independent samples t-test was used to
compare mean rehabilitation and treatment
knowledge scores between parents and
coaches. H3: an independent samples t-test
was used to compare mean overall knowledge
scores between parents and coaches.
Results:
Hypothesis 1 had findings that were not
significant. H1: (t(59) = .200, p > 0.05).
Hypotheses 2 and 3 had findings that were
significant. H2: (t(59) = -2.754, p <
0.05). H3: (t(59) = -2.382, p < 0.05).
Conclusion:
The study revealed that coaches of
adolescent athletes have a significantly
greater level of knowledge of the
rehabilitation and treatment of medial
tibial stress syndrome than parents of
adolescent athletes. Coaches also have a
significantly greater overall level of
knowledge of medial tibial stress syndrome.
AND COACHES OF ADOLESCENT ATHLETES
A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science
by
Joseph J. McShane
Research Advisor, Dr. Ellen J. West
California, Pennsylvania
2012
ii
iii
AKNOWLEDGEMENTS
I would like to recognize the following people who
have significantly impacted my life.
Without them, there
wouldn’t be even the slightest chance that I could’ve
completed this.
First, I would like to thank my advisor,
Dr. Tom West, my thesis chair, Dr. Ellen West, and the
members of my thesis committee: Dr. Shelly DiCesaro and Dr.
Jodi Dusi and the rest of the faculty at Cal U for their
help and guidance throughout the completion of my thesis
and the master’s program.
Next, I would like to thank Jamison Roth, Jamie Weary,
and Miss Carolyn for their guidance, tremendous amounts of
help and patience with me throughout this year while
getting the Cal U Club Sports GA position up and running.
I’d also like to thank all my athletes for putting up with
all the changes I subjected them to this year.
Please try
to stay concussion free in the coming years.
At this point, I’d like to personally thank the
permanent and honorary residents of Apartments 2 and 3 at
947 Cross Street: Mark Webber, Paul Rucci, Sean Rentler,
and Ted Vandermeuse.
Between the catfishing, visits to the
local establishments, and adventures to the various
cultural hotspots of southwestern Pennsylvania, you guys
iv
either have managed to keep me sane or completely throw me
off the deep end.
I would also like to acknowledge Curt Snyder’s
mustache, which brightened my day, reminded me to laugh,
and allowed me to be a free spirit and an overall better
person each and every day I set foot in the athletic
training room.
To my Mom, Dad, Jen, Jason, Denny, and the rest of my
family and friends, thank you for all you’ve done
throughout this entire “education” thing that I’ve stumbled
and staggered through over the past 20-odd years.
Although
I still haven’t, nor do I intend to perfect the whole
“growing up” thing, I’d like to thank you for at least
attempting to get me to do so.
Last, but certainly not least, I’d like to thank my
beautiful girlfriend, Abby, for dealing with my stress,
keeping me grounded and putting up with all my crap (for
lack of a better word) throughout the past year of being
apart and being the most patient (saint-status-patience)
and greatest person I’ve ever met.
v
TABLE OF CONTENTS
Page
SIGNATURE PAGE
. . . . . . . . . . . . . . . ii
AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES
. . . . . . . . . . . . . . . viii
LIST OF FIGURES .
INTRODUCTION
METHODS
. . . . . . . . . . . . . . v
. . . . . . . . . . . . . . ix
. . . . . . . . . . . . . . . . 1
. . . . . . . . . . . . . . . . . . 7
Research Design
Subjects
. . . . . . . . . . . . . . 7
. . . . . . . . . . . . . . . . . 8
Preliminary Research. . . . . . . . . . . . . 9
Instruments . . . . . . . . . . . . . . . . 10
Procedures
. . . . . . . . . . . . . . . . 11
Hypotheses
. . . . . . . . . . . . . . . . 12
Data Analysis
RESULTS
. . . . . . . . . . . . . . . 12
. . . . . . . . . . . . . . . . . . 13
Reliability Testing . . . . . . . . . . . . 13
Demographic Data . . . . . . . . . . . . . . 14
Hypotheses Testing
. . . . . . . . . . . . . 21
Additional Findings . . . . . . . . . . . . . 25
DISCUSSION . . . . . . . . . . . . . . . . . 31
Discussion of Results . . . . . . . . . . . . 31
Implications to the Profession
. . . . . . . . 37
vi
Recommendations for Future Research. . . . . . . 39
Conclusions
. . . . . . . . . . . . . . . . 41
REFERENCES . . . . . . . . . . . . . . . . . 42
APPENDICES . . . . . . . . . . . . . . . . . 43
APPENDIX A: Review of Literature
. . . . . . . . 44
Introduction . . . . . . . . . . . . . . . . 45
Definition and Incidence . . . . . . . . . . . 46
Functional Anatomy and Risk Factors. . . . . 49
Functional Anatomy and Physical Findings
. 50
Risk Factors . . . . . . . . . . . . . . 54
Diagnostic Testing
. . . . . . . . . . . . 56
Management of MTSS
. . . . . . . . . . . . 61
Rehabilitation and Treatment . . . . . . . 61
Prevention . . . . . . . . . . . . . . . 65
Knowledge of MTSS . . . . . . . . . . . . . 70
Summary . . . . . . . . . . . . . . . . . . 73
APPENDIX B: The Problem . . . . . . . . . . . . 75
Statement of the Problem . . . . . . . . . . . 76
Definition of Terms . . . . . . . . . . . . . 77
Basic Assumptions . . . . . . . . . . . . . . 77
Limitations of the Study . . . . . . . . . . . 77
Significance of the Study
. . . . . . . . . . 78
APPENDIX C: Additional Methods .
. . . . . . . . 80
MTSS Knowledge Survey (C1) . . . . . . . . . . 81
vii
IRB: California University of Pennsylvania (C2) . . 93
Letter to Panel of Experts (C3) . . . . . . . . 106
Cover Letter for Survey (C4)
. . . . . . . . . 108
Letter to Athletic Directors (C5)
. . . . . . . 110
REFERENCES . . . . . . . . . . . . . . . . . 112
ABSTRACT
. . . . . . . . . . . . . . . . . 116
viii
LIST OF TABLES
Table
Page
1
Frequency Table of Demographic
. . . . . . . 14
2
Frequency Table of Demographic by School
District . . . . . . . . . . . . . . . . 16
3
Mean and Standard Deviation for Knowledge Scores
by Category . . . . . . . . . . . . . . . 22
4
T-value, Degrees of Freedom and Significance for
Knowledge Scores by Category . . . . . . . . 23
5
Mean and Standard Deviation for Additional
Knowledge Scores by Category . . . . . . . . 26
6
T-value, Degrees of Freedom and Significance for
Additional Knowledge Scores by Category . . . . 26
7
Mean and Std. Deviation from One-way ANOVA for
Parents, Coaches and both on The Knowledge of
Medial Tibial Stress Syndrome Survey . . . . . 28
8
One-way ANOVA Between Groups for Categories of
Parents, Coaches and Both on The Knowledge of
Medial Tibial Stress Syndrome for Sum of Squares,
df, Mean Squares, F-score and Significance . . . 29
9
Post-Hoc Tukey Comparing Rehabilitation Scores
of Parents, Coaches and Both for Mean Difference,
Std. Error and Significance . . . . . . . . . 30
ix
LIST OF FIGURES
Figure
Page
1
Frequency of Parents and Coaches With Regard to
Student Athletes’ Sport(s) Played or Sport
Coached
. . . . . . . . . . . . . . . . 15
2
Frequency of Children by Gender of Parents
Surveyed . . . . . . . . . . . . . . . . 17
3
Frequency of Coaches by Coaching Position Title . 17
4
Frequency of Coaches by Gender of Athletes
Coached . . . . . . . . . . . . . . . . . 18
5
Frequency of Parent-Coaches With Regard to
Student Athletes’ Sport(s) Played . . . . . . 19
6
Frequency Sport(s) Played by Children by Gender
of Parent-Coaches Surveyed . . . . . . . . . 19
7
Frequency Sport(s) Coached by Parent-Coaches
Surveyed . . . . . . . . . . . . . . . . 20
8
Frequency of Parent-Coaches by Coaching Position
Title
. . . . . . . . . . . . . . . . . 20
9
Frequency of Parent-Coaches by Gender of Athletes
Coached . . . . . . . . . . . . . . . . . 21
1
INTRODUCTION
The purpose of the study is to examine the knowledge
of parents and coaches with regard to medial tibial stress
syndrome (MTSS).
If we, as athletic trainers, are able to
identify problem areas and gaps in knowledge bases to
further educate those with this lack of knowledge, the
overall care of the athletes suffering from medial tibial
stress syndrome may be improved.
Medial tibial stress syndrome is a continuum of
overuse trauma to the lower leg, more specifically, the sum
of repetitive microtraumas to the medial tibia induced by
activity which lead to pain and dysfunction in the lower
extremity.
The overall management of MTSS can be
considerably more arduous for the sports medicine team
(parents, coaches, athletes, athletic trainers and
physicians), as it must deal with all aspects including
prevention, management and treatment and must take a
multifaceted approach when doing so.
The athletic trainers
and coaches are typically on the front lines of the
prevention aspect in the adolescent athlete.
These
individuals are typically responsible for both the
2
conditioning prior to the season and training program
throughout the season.
The parents become much more
involved when the athlete sustains MTSS as they must try to
help their adolescent athlete manage the problem.
Since
the parents and coaches are such a large part in the
prevention and management aspects of MTSS, their knowledge
of the prevention and treatment must be adequate to prevent
mismanagement or further injury to the athlete.
Understanding the incidence rates of MTSS in different
populations is just as important as knowing how or why it
occurs. Yates and White studied the incidence of MTSS among
naval recruits.1 In their literature review, they reference
Murbarak et al’s2 characterization of MTSS, stated as “a
symptom complex seen in athletes who complain of exercise
induced pain along the posteriormedial border of the
tibia.”5,7
Collating from several sources, Yates et al5
expanded on this generic definition to both rule out older
thought processes, such as MTSS as an inflammatory response
process.
This led the authors to create a more accurate
and complete definition of “a bone stress reaction that
becomes painful,” citing metabolic changes in the bone due
to exercise and increase osteoclastic activity on the
posteriormedial border; often from compression of the bone.
This increase in osteoclastic activity coupled with the
3
bone’s inability to replace the broken down tissue fast
enough, leads to increasingly porous bone tissue.
As the
bone is broken down more easily, the athlete begins to feel
pain as the bone is subjected to microtraumas which can
ultimately result in a stress fracture of the tibia.
Though a good definition is crucial to its correct
diagnosis, knowing its incidence among the active
population is equally helpful in coming to the correct
conclusion and identifying potential athletes who may be at
risk.
Additionally, Yates and White5 defined MTSS in their
study based on each subject’s pain history, location of
pain and positive palpation of pain on the posterior-medial
border of the tibia.
The authors found forty of the
recruits (35%) developed MTSS and female recruits were
significantly more prone to developing MTSS (incidence
rates of 53% and 28% for male and female recruits
respectively).
They concluded that controlling foot
pronation and enabling male and female recruits to train
separately could potentially decrease the incidence of MTSS
in their sample. Furthermore, the authors stated that MTSS
accounts for 13.2% to 17.3% of all running injuries.5
The main focus of Galbraith et al’s3 study was to delve
into some conservative treatment approaches taken to
4
expedite the process of returning the athlete to play after
he or she has been diagnosed with MTSS.
The authors
concluded that there are in fact several factors that can
be classified as both prevention and rehabilitation.
These
factors that can also aid in the recovery process included
relative rest, which can be defined as remaining physically
active while still removing the activity which causes the
unwanted stresses to the body, such as cross training or
implementing low-impact exercises into the a modified
training routine.
Additionally, the use of cryotherapy and
electrical stimulation with soft tissue mobilization and
whirlpool baths were also indicated for both the acute and
subacute phases.3
Though there is much literature on the rehabilitation
methods for dealing with MTSS, The NATA issued a position
statement, spearheaded by McLeod et al,4 focusing on the
prevention of overuse injuries in the pediatric population,
including MTSS.
The position statement highlights some of
the profiles of both male and female athletes that may
predispose athletes to overuse injuries such as tall
stature, more explosive strength, large Q angles, increased
muscle tightness and decreased muscle flexibility.
The
authors also stated that a decrease in the overall fitness
level in the general population means that training
5
routines must be more gradually introduced to help prevent
overuse injuries.
They concluded that the athletic trainer
must be able to identify risk factors associated with
overuse injuries as well as taking the appropriate steps as
to help prevent these injuries.
The evaluation, management and risk factors of MTSS
should all be common knowledge among athletic trainers (who
deal with several cases every year) in the high school
setting; however, the coaches and parents of these athletes
are not as well-versed on the subject, nor should they be
expected to be.
Several studies5-7 have taken a look at the
knowledge of coaches with regard to athletic injuries.
Although this is a huge step, none of the studies surveyed
looked at MTSS or overuse injuries in any form.
Additionally, none of the literature surveyed dealt with
the knowledge of parents of injuries in the adolescent
athlete.
Therefore, this study will be significant, as it will
provide feedback to the knowledge base of parents and
coaches with regard to medial tibial stress syndrome.
This
can aid in the care of the athlete suffering from MTSS by
having the athlete’s parents and coaches be able to
potentially identify signs and symptoms and refer their
athlete to their athletic trainer or doctor, potentially
6
cutting down recovery time.
With this knowledge,
communication between the athletic trainer, parents and
coaches will be made easier as all three will be greater
informed.
Additionally, the risk of MTSS being mismanaged
in the adolescent athlete can be minimized as both the
coaches would be less likely to have the athlete “walk it
off,” and, similarly, parents will be less likely to push
their children through the pain.
7
METHODS
The primary purpose of this study was to examine the
knowledge levels of parents and coaches with regard to
medial tibial stress syndrome (MTSS) in the adolescent
athlete.
This section will include the following
subsections:
Research Design, Subjects, Instruments,
Procedures, Hypotheses, and Data Analysis.
Research Design
This research was a descriptive study utilizing a
research questionnaire.
The independent variable was the
group surveyed (either parents or coaches).
The dependent
variable was the subjects’ score as measured by the MTSS
knowledge survey, each question being worth one point. This
overall score on the knowledge survey also had two
subscores which were analyzed during hypothesis testing.
The subscores were the prevention knowledge score and
rehabilitation and treatment knowledge score.
These three
scores (prevention, rehabilitation and treatment, and
overall score) were separated by the independent variable;
either parent or coach.
8
Subjects
The subjects used for this study were parents and
coaches of high school athletes in western Pennsylvania in
PIAA districts 7 and 10.
The survey was distributed to
athletic directors who agreed to distribute it following
contact with the primary researcher.
The athletic
directors then distributed the cover letter containing the
link to the survey to the parents and coaches by sending
home with the school’s athletes.
The surveys were then
completed online using SurveyMonkey.
Subjects were
included if they were a coach or a parent of a high school
athlete in western Pennsylvania.
If a subject fit both
categories of parent and coach, they were excluded from the
main study; however, they were examined as independent data
to see if the overlap showed a significant difference in
the knowledge level.
Each subject was asked via an attached cover letter
(Appendix C1) to participate in the study by completing an
online survey to assess their knowledge of MTSS (Appendix
C4).
Subject participation was completely voluntary and
consent was implied if they chose to complete the survey.
9
The study was approved by the Institutional Review Board
(IRB) at California University of PA(Appendix C2) prior to
any data collection.
Surveys were completed anonymously
and each participant’s identity remained confidential.
Preliminary Research
A preliminary study was conducted with this research
project.
The survey was administered to a panel of experts
in the field, four athletic trainers, for content validity
evaluation.
Additionally, nineteen subjects were given
the MTSS knowledge survey to assess their knowledge of MTSS
and aid the researcher by providing data on the difficulty
level and reliability of the survey. Of the nineteen
subjects, fourteen completed the survey twice; once upon
reception of the survey and once one week later, in order
to assess reliability.
The survey was comprised of a set
of questions derived from the literature outlined in the
Literature Review (Appendix A).
Comprised of questions
ranging from “easy” to “hard,” the survey tested the
knowledge in each of the areas of MTSS knowledge including
prevention, mechanism of injury, relative functional
anatomy, treatment and management, as well as some of the
diagnostic testing associated with the evaluation of MTSS.
10
Instruments
The Knowledge of Medial Tibial Stress Syndrome Survey
(Appendix C1) was created by the researcher to assess the
knowledge level of parents and coaches of adolescent
athletes.
The survey consisted of thirty questions testing
different knowledge areas of MTSS.
To support the
management and prevention areas of the hypotheses, the
sections of prevention and management were not only counted
toward the overall knowledge score, but as an independent
score as well.
Although parents and coaches may not know
anatomy and other risk factors, prevention and the
management are the most critical areas they would need to
recognize to provide the minimal level of care for MTSS.
The areas tested included mechanism of injury, relative
functional anatomy, prevention, treatment and management,
and diagnostic testing used for the evaluation of MTSS.
There were between three and five questions pertaining to
demographic information, depending on whether the subject
was a parent, coach or both, which assisted the researcher
in classification of subjects.
11
Procedure
The researcher obtained Institutional Review Board
(IRB) approval (Appendix C2) at California University of
Pennsylvania before beginning any data collection or
distribution of surveys.
Approval to distribute the survey
to parents and coaches was obtained though the athletic
directors (AD’s) of each high school surveyed. The athletic
directors were contacted via email, found on the PIAA
website. Once approval to distribute the surveys by the ADs
was obtained, the AD’s distributed the cover letters to the
school’s student-athletes to bring home to their parents.
The cover letter (Appendix C3) explained the purpose of the
study to each potential subject to be surveyed.
Surveys
were collected for a 4-week period following distribution
from March 7 to April 4, 2012.
The survey link was then
deactivated and submissions could no longer be submitted.
This timeframe was selected to allow for adequate time for
both the subjects to complete the survey as well as the
researcher to collect adequate data.
The survey data was
anonymous and all online submissions were kept
confidential.
The data was collected, entered into an
electronic spreadsheet and analyzed and grouped according
to the relevant demographic classification.
12
Hypotheses
The following hypotheses of the researcher were based
on previous research and clinical assumptions.
1.
Coaches will have a significantly greater
knowledge of the prevention of MTSS than parents.
2.
Coaches will have a significantly greater
knowledge of the rehabilitation and treatment of
MTSS than parents.
3.
Coaches will have a significantly greater overall
knowledge of MTSS than parents.
Data Analysis
All data was analyzed by SPSS version 18.0 for Windows
at an alpha level of less than or equal to 0.05.
research hypotheses were analyzed using a T-test.
The
13
RESULTS
The following section is comprised of the information
gathered through data collection and the analysis of the
Knowledge of Medial Tibial Stress Syndrome Survey
distributed to parents and coaches at six western
Pennsylvania high schools.
The results have been divided
into these subsequent sections:
(1) Reliability Testing,
(2) Demographic Data, (3) Hypothesis Testing, and (4)
Additional Findings.
Reliability Testing
The Knowledge of Medial Tibial Stress Syndrome Survey
was distributed to a sample of convenience of parents and
coaches of adolescent athletes.
The survey was distributed
to the same subjects one week later to determine its
reliability, which was found by correlation testing to be r
= 0.374; a low positive correlation. Nine of thirty
questions had a very high correlation (above r > 0.80),
six had a strong correlation (0.60 ≤ r ≤ 0.80), and seven
had a moderate correlation (0.40 ≤ r ≤ 0.60) Eight of the
thirty questions returned with a correlation value r <
14
±0.30 and were modified in an attempt to eliminate any
unclear language and increase their reliability and the
reliability of the survey overall.
Demographic Data
Of the 691 surveys handed out to the parents and
coaches at the western Pennsylvania high schools, 91
responses were received for a 13.17% return rate.
The
sample consisted of 45 parents, 31 coaches, 13
parent/coaches (both) and 7 who did not fit either
category.
61 of these subjects (40 parents and 21 coaches)
completed the survey fully and were able to be analyzed
during hypothesis testing (Table 1).
Table 1. Frequency Table of Demographic
Group
Frequency
Percent of Total
(Completed)
Responses Received
Parents
45 (40)
49.4%
Coaches
31 (21)
34.1%
Both
13 (11)
14.3%
7 (7)
7.7%
Neither
15
The study focused on parents and coaches in the
western Pennsylvania region of the PIAA, specifically
Districts 7 and 10.
Figure 1 shows the collected responses
with regard to what sport(s) each subject coached and/or
their student athlete(s) played.
Additionally, Table 2
reports the findings with regard to the number and
frequency of the cover letter distribution for the six high
schools surveyed within the two districts.
Frequency
Figure 1. Frequency of Parents and Coaches With Regard to
Student Athletes’ Sport(s) Played or Sport Coached
30
25
20
15
10
5
0
Parents
Coaches
Sport Played by Student Athlete(s)/Coached
Although additional demographic data were collected
with regard to number and gender of student athletes for
parents and coaching position and gender of athletes
coached, the data were not utilized as there was an
insufficient amount to examine for any additional findings.
16
Table 2. Frequency Table of Number of Surveys Distributed
by School District
School
District
Surveys
Percent
Distributed
Brownsville
7
197
28.5%
Burgettstown
7
159
23.0%
California
7
103
14.9%
Cathedral
Prep
10
27
3.9%
Iroquois
10
145
21.0%
McDowell
10
60
8.7%
Table 2 shows the distribution of surveys by school
district.
The surveys were primarily distributed by cover
letter as well as by email, as per athletic directors’
instruction.
Figure 2 shows the frequency of children by gender of
parents surveyed, n=45.
The subjects were able to choose
if they had 0 to 4 or more children of each gender.
Responses were recorded, but were not tethered to each
subjects’ responses to maintain confidentiality.
17
Figure 2.
Surveyed
Frequency of Children by Gender of Parents
30
Frequency of Parents
25
20
15
Male
10
Female
5
0
0 Children
1 Child
2 Children
3 Children
4 or more
Children
Number of Children
Figures 3 and 4 show the responses of coaches by
coaching position title and the gender of the athletes they
coach respectively.
Figure 3.
Frequency of Coaches by Coaching Position Title
25
Frequency
20
15
10
5
0
Head Coach
Assistant Coach
Coaching Title
Other
18
Figure 4.
Coached
Frequency of Coaches by Gender of Athletes
16
14
Frequency
12
10
8
6
4
2
0
Male
Female
Both
Gender of Athletes Coached
Additionally, 10 subjects who identified themselves as
both a parent and a coach (parent-coaches) were asked the
same demographic questions.
The following figures
(Figures5-9) display the “Both” category responses to the
demographic questions both the parents and coaches were
asked.
The questions asked were the same questions asked
of both the parents and the coaches.
19
Figure 5. Frequency of Parent-Coaches With Regard to
Student Athletes’ Sport(s) Played
5
Frequency
4
3
2
1
0
Sport Played by Student Athlete(s)
Figure 6. Frequency Sport(s) Played by Children by Gender
of Parent-Coaches Surveyed
6
Frequency
5
4
3
Male
2
Female
1
0
0 Children
1 Child
2 Children
Number of Children
3 Children
4 or More
Children
20
Figure 7.
Surveyed
Frequency Sport(s) Coached by Parent-Coaches
Frequency
3
2
1
0
Sport Coached
Figure 8.
Title
Frequency of Parent-Coaches by Coaching Position
7
6
Frequency
5
4
3
2
1
0
Head Coach
Assistant Coach
Coaching Title
Other
21
Figure 9. Frequency of Parent-Coaches by Gender of
Athletes Coached
5
Frequency
4
3
2
1
0
Male
Female
Both
Gender of Athletes Coached
Hypothesis Testing
The following hypotheses were investigated by this
study:
Hypothesis 1: Coaches will have a significantly
greater knowledge of the prevention of MTSS than parents.
An independent sample t-test was used to compare the
mean scores for each category used in hypothesis testing as
well as the overall mean score and standard deviation of
the scores with regard to parents and coaches.
These
results can be found below in Tables 3 and 4.
Results: An independent-samples T-test was conducted
to compare the mean prevention knowledge score of
22
participants who identified themselves as parents (n = 40)
to the mean prevention knowledge score of participants who
identified themselves as coaches (n = 21).
No significant
difference was found ((t(59) = .200, p > 0.05)).
Conclusion: The mean prevention knowledge score of
parents (m = 65.83, sd = 13.582) was not significantly
different from the mean prevention knowledge score of
coaches (m = 65.08, sd = 14.818).
Table 3. Mean and Standard Deviation for Knowledge Scores
by Category
Category
Group
N
Mean
Standard Deviation
Prevention
Parents
Coaches
40 65.83
21 65.08
13.582
14.818
Rehabilitation*
Parents
Coaches
40 63.57
21 76.87
18.850
15.957
Overall*
Parents
Coaches
40 60.33
21 65.87
7.874
9.939
*significant findings indicated for this category
23
Table 4. t-value, Degrees of Freedom and Significance for
Knowledge Scores by Category
Category
t
df
Sig
Prevention
.200
59
.842
Rehabilitation
-2.754
59
.008
Overall
-2.382
59
.020
Hypothesis 2: Coaches will have a significantly
greater knowledge of the rehabilitation and treatment of
MTSS than parents.
An independent samples t-test was used to compare the
mean scores for each category used in hypothesis testing as
well as the overall mean score and standard deviation of
the scores with regard to parents and coaches.
These
results can be found above in Tables 3 and 4.
Results: An independent samples T-test was conducted
to compare the overall mean score of participants who
identified themselves as parents (n = 40) to the overall
mean score of participants who identified themselves as
coaches (n = 21).
The researcher found a significant
difference between the means of the two groups
24
(t(59) = -2.754, p < 0.05) with regard to the knowledge of
the rehabilitation and treatment of MTSS.
Conclusion: The mean rehabilitation and treatment
knowledge score of the parents was significantly lower (m =
63.57, sd = 18.850) than the mean score of the coaches (m =
76.87, sd = 15.957).
Hypothesis 3:
Coaches will have a significantly
greater overall knowledge of MTSS than parents.
An independent samples T-test was calculated to
compare the mean scores for each category used in
hypothesis testing as well as the overall mean score and
standard deviation of the scores with regard to parents and
coaches.
These results can be found above in Tables 3 and
4.
Results: An independent samples T-test was conducted
to compare the overall mean score of participants who
identified themselves as parents (n = 40) to the overall
mean score of participants who identified themselves as
coaches (n = 21).
A significant difference between the
means of the two groups (t(59) = -2.382, p < 0.05) with
regard to the overall knowledge score was found.
25
Conclusion: The mean overall knowledge score of the
parents was significantly lower (m = 60.33, sd = 7.874)
than the mean score of the coaches (m = 65.87, sd = 9.939).
Additional Findings
Several tests were conducted using the other areas
examined in the The Knowledge of Medial Tibial Stress
Syndrome Survey (Appendix C1) with the intent of
discovering additional findings.
An independent samples T-test was used to compare the
mean scores for each additional category which was not used
in hypothesis testing as well as the overall mean score and
standard deviation of the scores with regard to parents and
coaches.
6.
These results can be found below in Tables 5 and
26
Table 5. Mean and Standard Deviation for Additional
Knowledge Scores by Category
Category
Group
N
Mean
Standard Deviation
Definition
Parents
Coaches
40
21
68.13
66.67
21.917
26.615
Anatomy
Parents
Coaches
40
21
59.17
62.70
18.852
19.653
Diagnostic
Testing
Parents
Coaches
40
21
48.93
57.82
17.388
20.935
Table 6. t-Value, Degrees of Freedom and Significance for
Additional Knowledge Scores by Category
Category
t
df
Sig
Definition
Anatomy
Diagnostic Testing
.229
59
.820
-.685
59
.496
-1.768
59
.082
Results: An independent-samples T-test was calculated
to compare the mean definition knowledge score of
participants who identified themselves as parents to the
mean prevention knowledge score of participants who
27
identified themselves as coaches.
No significant
difference was found (t(59) = .229, p > 0.05).
Conclusion: The mean definition knowledge score of
parents (m = 68.13, sd = 21.917) was not significantly
different from the mean prevention knowledge score of
coaches (m = 66.67, sd = 26.615).
Another independent samples T-test was used to
determine the mean scores for each additional category,
including anatomy and risk factors, definition and
incidence, and diagnostic testing, which were not used in
hypothesis testing as well as the overall mean score and
standard deviation of the scores with regard to parents and
coaches.
These results can be found above in Tables 5 and
6.
Results: An independent-samples T-test was conducted
to compare the diagnostic testing knowledge score of
participants who identified themselves as parents to the
mean prevention knowledge score of participants who
identified themselves as coaches.
No significant
difference was found (t(59) = -1.768, p > 0.05).
Conclusion: The mean diagnostic testing knowledge
score of parents (m = 48.93, sd = 17.388) was not
28
significantly different from the mean prevention knowledge
score of coaches (m = 57.82, sd = 20.935).
A one-way ANOVA was conducted to compare the mean
knowledge scores between individuals who identified
themselves as parents, as coaches, and individuals who
identified themselves as both a parent and a coach.
The
results of the analysis between groups are shown below in
Tables 7 and 8.
Table 7. Mean and Std. Deviation from One-way ANOVA for
Parents, Coaches and Both on The Knowledge of Medial Tibial
Stress Syndrome Survey
Category
Demographic
N
Mean
Std.
Deviation
Definition
Parents
40
68.13
21.917
Coaches
21
66.67
26.615
Both
11
70.45
21.847
Prevention
Parents
Coaches
Both
40
21
11
65.83
65.08
60.61
13.582
14.818
11.237
Anatomy and
Risk Factors
Parents
Coaches
Both
40
21
11
59.17
62.70
68.18
18.852
19.653
21.672
Diagnostic
Testing
Parents
Coaches
Both
40
21
11
48.93
57.82
53.25
17.388
20.935
22.215
Rehabilitation* Parents
Coaches
Both
40
21
11
63.57
76.87
74.03
18.850
15.957
21.013
Overall
40
21
11
60.33
65.87
64.85
7.874
9.939
11.388
Parents
Coaches
Both
*significant findings indicated for this category at .05
level
29
Table 8. One-way ANOVA Between Groups for Categories of
Parents, Coaches and Both on The Knowledge of Medial Tibial
Stress Syndrome for Sum of Squares, df, Mean Square, Fscore and Significance
Category
Sum of
df
Mean
F
Sig.
Squares
Square
Definition
104.01
2
52.00
.095
.909
Prevention
237.82
2
118.91
.639
.531
Anatomy and
Risk Factors
738.66
2
369.33
.970
.384
Diagnostic
Testing
1104.13
2
552.07
1.494
.232
Rehabilitation* 2757.40
2
1378.70
4.071
.021
Overall
2
242.99
2.946
.059
485.98
*significant findings indicated for this category at .05
level
Results: A one-way ANOVA was conduced to compare the
knowledge scores of participants who were either parents,
coaches or both.
A significant difference was found among
the groups (F(2,2) = 4.07, p < .05) with regard to
rehabilitation knowledge scores.
Tukey’s HSD was used to
determine the nature of the differences (Table 9) between
the demographics for rehabilitation scores.
This analysis
revealed that Parents scored lower (m = 63.57, sd 18.850)
than Coaches (m = 76.87, sd = 15.957).
Participants who
30
identified themselves as “both” (m = 74.03, sd = 21.013)
were not significantly different than the other two groups.
Table 9. Post-Hoc Tukey comparing rehabilitation scores of
parents, coaches and both for mean difference, std. error
and sig.
Demographic Demographic
Mean
Std. Error
Sig.
1 (D1)
2 (D2)
Difference
(D1-D2)
Parents
Coaches
-13.299*
4.959
.025
Both
Parents
10.455
6.265
.225
Both
Coaches
-2.845
6.849
.909
*significant findings indicated for this category at .05
level
Conclusion: Coaches will have a significantly higher
knowledge of the rehabilitation of MTSS than subjects who
identify themselves as parents or parent-coaches or “both.”
No other statistically significant scores were found
for parents, coaches or “both” in any other knowledge
category or overall knowledge score for the one-way ANOVA
between groups analysis.
31
DISCUSSION
The discussion section will be divided into four
subsections: 1) Discussion of Results, 2) Implications to
the Profession, 3) Recommendations for Future Research, and
4) Conclusions.
Discussion of Results
The purpose of this study was to examine the knowledge
level of parents and coaches of adolescent athletes with
regard to the management of medial tibial stress syndrome
(MTSS).
The researcher examined specific knowledge areas
of MTSS such as definition and incidence, anatomy and risk
factors, prevention, diagnostic imaging methods, and the
rehabilitation and treatment protocols associated with
MTSS.
These areas were combined to make up the overall
knowledge of MTSS.
Hypothesis 1 stated that coaches will have a
significantly higher knowledge score with regard to the
prevention of MTSS than parents.
The researcher proposed
this hypothesis on the assumption that since the subjects
had an insignificant knowledge of both the rehabilitation
and treatment as well as their overall knowledge, their
32
knowledge of prevention would also be lacking. Baron et al5
examined the knowledge levels of mid-Michigan area coaches’
knowledge of injury prevention in adolescent athletes by
way of a paper survey with an attached demographic sheet;
similar to this study’s with the exception of the media by
which it was delivered.
The researchers found that only 15
of their 290 subjects, or about five percent, received a
passing score on their survey.
As this study by Baron et
al5 showed general injury prevention knowledge was lacking
in the coaching population, the researcher observed similar
results and found no significant findings with regard to
prevention of medial tibial stress syndrome.
Although the
overall numerical score was not looked at for any of the
categories, the researcher noted that the mean scores for
the prevention section were only at 65%; a somewhat low
percent correct.
Similar to Baron et al’s5 study, Iverson and Friden’s6
examined the knowledge of injury prevention of female high
school basketball players; again by paper survey and
informed consent. They reported no significant difference
in knowledge scores in the female student athlete subjects
whether they were subjected to a prevention program or
place in a control group which not participate in a
preventative exercise program.6 The researcher’s results,
33
like both of the previously mentioned studies examining
prevention knowledge of athletic injuries, did not show a
significant difference in the prevention knowledge levels
of parents and coaches.
Hypothesis 2 stated that coaches will have a
significantly higher knowledge of the rehabilitation and
treatment of MTSS than parents.
The researcher formed this
hypothesis with respect to the O’Donoghue et al study7,
which cited “management” as the weakest area of knowledge
with regard to sport-related concussions in the high school
coaches population and to see if it could be applied to
other athletic injuries as well.7 A significant difference
was found in the knowledge levels of coaches with regard to
rehabilitation and treatment of MTSS compared to the
parents surveyed.
Cross et al8 examined the state of South Dakota’s high
school coaching population’s knowledge of injury
management.
The population included 1050 coaches from 14
sports, finding that less than 50 percent of the coaches
surveyed had current CPR or first aid certifications and,
overall, the coaches’ knowledge of the management of acute
athletic injuries was lacking.
Although this study was
with regard to general first aid and CPR and did not
examine the lower extremity specifically, it did look at
34
situations such as concussions, spinal cord injuries, neck
injuries, and, most relevant to the current study and MTSS,
fractures.
The authors found that only 49.40% of their
subjects felt they were prepared to handle fractures,
providing insight that coaches’ knowledge is lacking for
injury management.8
Although the previous studies5-9 looked at a specific
knowledge score for one athletic injury or another, all of
those reviewed by the researcher reached the same
conclusion that there was an insufficient overall knowledge
of all areas of athletic injuries with regard to sports
medicine.
The sports medicine team, in the adolescent
athletic population typically involves the student
athletes’ athletic trainers, coaches and parents.
This
study showed a weakness in the area of the knowledge of
rehabilitation and treatment of MTSS in parents even more
than coaches as their score was significantly lower.
Hypothesis 3 stated coaches would have a significantly
greater overall knowledge of MTSS than parents.
The
researcher hypothesized that regardless of what the overall
score each subject received on the survey, the coaches’
scores would be significantly higher than the scores of the
parents.
This was based on previous research which
examined the knowledge levels of different populations with
35
regard to different areas of athletic training including
knowledge of injuries and management of injuries.5-9
The results showed a significant difference between
the two groups, stating the mean score for coaches was
significantly higher than the mean score for parents.
O’Donoghue et al7 studied the knowledge of coaches with
regard to sport-related concussions and found that their
population of coaches displayed an overall moderate
knowledge of the subject matter.
Although this study did
not compare populations (i.e. coaches to parents) it still
showed that overall there was a gap in knowledge in the
coaching population.
When comparing this overall knowledge
score on the survey to the areas that comprised it, this
score may most closely relate to the rehabilitation and
treatment knowledge score as it was the only individual
category with a significant difference between parents and
coaches.
This difference, as identified above, shows that
the parents may be the least knowledgeable as far as the
care of the adolescent athlete suffering from medial tibial
stress syndrome when compared to coaches.
In addition to hypothesis testing, several other
statistical analyses were conducted in an attempt to find
significant differences between the parents and coaches as
36
well as with subjects who identified themselves as both a
parent and a coach.
The first additional findings examined the other areas
of knowledge tested in the survey including definition and
incidence, anatomy and risk factors, and diagnostic testing
by way of independent samples t-tests.
This was done to
see if there were any significant findings similar to those
found in the hypothesis testing with the rehabilitation and
overall knowledge scores.
The results showed no
significant difference in knowledge levels of parents and
coaches for any of the three categories.
Although the
researcher did not examine the knowledge of anatomy and
risk factors or of diagnostic testing, O’Donoghue et al7
found that their subjects’ highest area of knowledge was in
“recognition,” a similar classification by their
explanation as definition and incidence.7 Even though the
mean scores were similar to scores in other categories, no
significant difference was found in the mean scores of
parents and coaches in any of the additional categories
tested.
The final additional findings examined the mean scores
for each of the categories for subjects who identified
themselves as parents, coaches or both by way of a one-way
analysis of variance test between groups.
A significant
37
difference was found between groups with regard to the
knowledge of rehabilitation and treatment knowledge scores.
Although a significant difference was found, post-hoc
testing revealed it merely reinforced the findings from the
hypothesis testing as the analysis between the “both” group
when compared to the other two groups did not show
significance.
As stated before, this merely reinforced
O’Donoghue et al’s study showing that the knowledge of the
management of injuries in different populations is lacking.7
Implications to the Profession
The findings of this research provide possible
implications for the profession of athletic training.
The
research in this study shows that although many parents and
coaches of high school athletes know about medial tibial
stress syndrome, they may only be able to identify it as an
injury and not through symptoms or know common proper
prevention or rehabilitation practices.
As many athletic
trainers practice in the secondary school setting, two of
the vital components of the sports medicine team in a high
school are the coaches and parents.
This lack of knowledge
could be an area that athletic trainers attempt to increase
38
to allow their athletes suffering from MTSS to have a
better overall management of their injury.
The sports medicine team in the secondary school
setting consists professionally of the athletic trainer(s)
and possibly a team physician who is assigned to the
school; however, this physician may be contracted by a
hospital or clinic and assigned to many schools.
In the
collegiate and professional settings where athletic
trainers practice, there is almost always a team physician
readily available as well as chiropractors, physical
therapists and other allied health professionals to aid in
the care of the athletes.
This lack of personnel in the
secondary school sports medicine team is one of many
reasons that parents and coaches are often much more
involved in the management of athletic injuries.
The
results of this study illustrated a lack of knowledge of
medial tibial stress syndrome.
Therefore, the overall
knowledge level of how to manage athletes suffering from
this injury is lacking.
By educating parents and coaches,
the athletes may be able to be given a higher level of care
and the sports medicine team in the secondary school
setting will be more effective and efficient in managing
MTSS as proper management is closer to common knowledge
among the parents and coaches involved.
Additionally,
39
communication with a population of parents and coaches who
have a higher knowledge of MTSS will be easier as the
learning curve would start with more those more educated on
MTSS.
Recommendations for Future Research
Based on the results of this study, the following
suggestions for future research will be made.
First, the
researcher’s study surveyed six western Pennsylvania high
schools.
Although these high schools represented a diverse
group of parents and coaches, they may not be
representative of other areas of the country’s
socioeconomic state, level of education, population
diversity ratios and the size of individual school
districts both in number of residents and geographically.
This is both with regard to the type of schools that should
be surveyed as well as the number of schools surveyed.
Second, future studies should consider using a
different tool for examining knowledge levels of parents
and coaches. This study compared coaches to parents and not
the actual quantitative level that each group knows.
Although the survey created was effective for this study,
it may not be effective for studies testing a single
40
population as the researcher did not determine pass/fail
scores which would need to be applied to a single
population.
Third, future studies should include a more effective
communication method to the parents than disseminating
cover letters to athletic directors who distribute it to
their coaches who hand it to their players who take it home
to their parents.
This may account for the low response
rate. A more direct way of communicating with the parents
and coaches may yield a larger sample size and an increased
response rate.
Finally, future studies should examine the interaction
between coaches, parents and the athletic trainer with
regard to the management of injuries.
Similarly, more
studies should be performed to understand the level of
parents and coaches with regard to more athletic injuries.
By doing this, athletic trainers will generally know how
knowledgeable the parents and coaches, with whom they are
working, are with regard to the injuries the student
athletes are sustaining.
41
Conclusions
The results of the study revealed the following major
conclusions:
1.
Coaches have an overall greater knowledge of medial
tibial stress syndrome than parents of adolescent
athletes.
2.
Coaches have a greater knowledge of the rehabilitation
and treatment of medial tibial stress syndrome than
parents of adolescent athletes.
3.
There is no significant difference in the knowledge
levels of parents and coaches of adolescent athletes of
medial tibial stress syndrome with regard to
prevention, definition and incidence, anatomy and risk
factors, and diagnostic testing.
4.
There is no significant difference in the knowledge
level in any of the tested categories for subjects who
were both a parent and a coach of adolescent athletes.
42
REFERENCES
1.
Yates B, White S. The incidence and risk factors in
the development of medial tibial stress syndrome among
naval recruits. Am J Sports Med. 2004;32(3):772-780.
2.
Mubarak S, Gould R, Lee Y. The medial tibial stress
syndrome. Am J Sports Med. 1988;10:201-205.
3.
Galbraith RM, Lavallee ME. Medial tibial stress
syndromes: conservative treatment options. Curr Rev
Musculoskelet Med. 2009;2:127-133.
4.
McLeod TCV, Decoster LC, Loud KJ, Micheli LJ, Parker
JT, Sandrey MA, White C. National Athletic Trainers’
Association Position Statement: prevention of
pediatric overuse injuries. J Athl Training.
2011;46(2):206-220.
5.
Baron MJ, Powell JW, Ewing ME, Nogle SE, Branta CF.
First aid and injury prevention knowledge of youth
basketball, football and soccer coaches. Intl J
Coaching Science. 2009;3(1):55-67.
6.
Iversen MD, Friden C. Pilot study of female high
school basketball players’ anterior cruciate ligament
injury knowledge, attitudes and practices. Scand J Med
Sci Sports. 2009;19:595-602.
7.
O’Donoghue EM, Onate JA, Van Lunen B, Peterson CL.
Assessment of high school coaches’ knowledge of sportrelated concussion. Athletic Training and Sports
Health Care Journal. 2009;1(3):120-132.
8.
Cross PS, Karges JR, Adamson AJ, Arnold MR, Meier CM,
Hood JE. Assessing the need for knowledge on injury
management among high school athletic coaches in South
Dakota. J South Dakota Medicine. 2010: 241-245.
9.
Ward CW. Teens’ knowledge of risk factors for sports
injuries. J School Nursing. 2004;20(4):216-220.
43
APPENDICES
44
APPENDIX A
Review of Literature
45
REVIEW OF LITERATURE
Medial tibial stress syndrome (MTSS), often referred
to as “shin splints,” is an overuse injury referred to as a
continuum of injuries often associated with athletes
participating in endurance sports at the high school,
college, and professional levels.1-4 Although the certified
athletic trainers (ATCs) dealing with these injured
athletes are familiar with MTSS, oftentimes the parents and
coaches of the athletes experiencing it are uneducated on
the subject. This lack of knowledge could potentially lead
to improper management and possibly even make these
athletes’ symptoms worse.
The purpose of this review is to examine MTSS
including current recommendations for best practices
related to prevention, management and treatment. This
review will have five separate sections: 1) The definition
and incidence of MTSS, 2) The functional anatomy associated
with MTSS found upon examination of the athlete with MTSS
and associated risk factors, 3) Diagnostic testing used in
conjunction to the evaluation of the injured athlete, 4)
Management of MTSS, and finally, 5) The overall knowledge
of parents and coaches of athletes of injuries sustained by
46
the adolescent athlete.
A summary of the literature will
be provided at the end of this literature review.
Definition and Incidence
Medial tibial stress syndrome (MTSS) is defined as the
most common overuse injury seen in the running and active
population.5,6 Although it is very common, the definition is
often inconsistent throughout the literature.
Additionally, the incidence of MTSS throughout the
literature is often inconsistent as well.
Definition
Yates and White studied the incidence of medial tibial
stress syndrome among naval recruits.5 In their literature
review, they reference Murbarak et al’s characterization of
MTSS, stated as “a symptom complex seen in athletes who
complain of exercise induced pain along the posteriormedial
border of the tibia.”5,7
Drawing information from several
sources, Yates et al5 expanded on this generic definition to
dismiss the previous assumptions that MTSS is merely an
inflammatory response process.
Instead, Yates and White
presented that MTSS is a “a bone stress reaction that
becomes painful,” citing metabolic changes in the bone due
47
to exercise as well as an increase in osteoclastic activity
on the posteriormedial border; often from compression of
the bone. This increase in osteoclastic activity coupled
with the bone’s inability to replace the broken down tissue
fast enough, leads to increasingly porous bone tissue.
As
the bone is able to be broken down more easily, the athlete
begins to feel pain as the bone is subjected to
microtraumas which can ultimately result in a stress
fracture of the tibia.
Though a good definition is crucial
to its correct diagnosis, knowing its incidence among the
active population is equally helpful in coming to the
correct conclusion and identifying potential athletes who
could be predisposed to MTSS and other overuse injuries.
Incidence
As previously referenced, Yates and White5 examined the
incidence of medial tibial stress syndrome in a population
of 124 naval recruits, aged 17 to 35 with a mean age of
21.06 years (mean age=20.95 years in MTSS group), by way of
entrance and exit interviews during their ten week training
program. The authors began by taking a baseline history,
anthropometric and biomechanical data on each subject and
monitored the subjects throughout their training regime.
They defined MTSS based on each subject’s pain history,
48
location of pain and positive palpation of pain on the
posterior-medial boarder of the tibia.
They found that
forty of the recruits, 35%, developed MTSS.
The authors
also reported that female recruits were significantly more
prone to developing MTSS (52.9% of female recruits versus
28.2% of male recruits; p=0.012).
They concluded that
controlling foot pronation and enabling male and female
recruits to train separately could potentially decrease the
incidence of MTSS in their sample.5
Furthermore, Yates et al stated that MTSS accounts for
anywhere between 13.2% to 17.3% of all running injuries.5
Though this number is quite low, Orava et al’s findings
were quite different.6
Orava and Puranen6 examined the overall occurrence and
frequency of medial tibial stress syndrome, as well as
several other overuse conditions in the lower leg, in 2750
athletes in Finland, 73% of their subjects falling within
the 16 to 29 year old population.
MTSS was the most common
of the injuries, accounting for 60 percent of all the
cases, and when combined with tibial stress fractures, it
accounted for 75% of all injuries and the authors noted
that both occurred typically at the same site with the same
symptoms.
The authors of this article also examined the
49
underlying causes of MTSS and noted that pain was most
often elicited by exertional ischemia.
As Orava et al’s study involving a sample size of over
2,000 individuals showed that incidence can be as high as
60 percent of injuries,6 diagnosis of MTSS early is
critical.
Using an array of devices and methods during
evaluation for diagnosis can give the clinician the edge
against this syndrome and help catch it before it becomes
severe.
Functional Anatomy and Risk Factors
The anatomy associated with medial tibial stress
syndrome (MTSS) is typically consistent throughout the
literature. Repetitive microtrauma and chronic overuse
were outlined in the sources as the main causes of MTSS
with secondary causes consisting of the culmination of
several other injuries to the lower leg.5,6 This section
will examine; 1) the functional anatomy associated with
MTSS as well as the examination and physical findings of
MTSS, and 2) the risk factors often predisposing athletes
to MTSS.
50
Functional Anatomy and Physical Findings
A study by Cosca et al1 examined the causes of common
overuse injuries including MTSS through an anatomy
overview. The authors outlined basic causes, linking MTSS
as being a part of a continuum of stress injuries and
microtraumas to the posteriomedial tibia. The main cause
noted was hyperpronation.1 The authors additionally examined
the common sign of “shin splints” with regard to pain
patterns associated with the relative severity of MTSS. The
occurrence of more anterior focal tenderness was more
indicative of a stress fracture than more generalized
tenderness showed.1
Similar to Cosca, Reinking et al2 examined the anatomic
and physiologic aspects of exercise related leg pain.
Their study outlined concurrent issues often associated
with MTSS such as chronic exertion compartment syndrome,
tendinopathies of the lower extremity, tibial and peroneal
nerve entrapment and stress fractures of the tibia and
fibula.
They further examined the anatomy associated with
MTSS as well as the typical epidemiology and pathology
behind it.
More specifically, the authors noted that the
cause of MTSS is typically more lateral than the pain
presents with the anatomical sources of the medial leg pain
associated with MTSS as the tibialis posterior muscle,
51
flexor digitorum longus, soleus, and the deep crural fascia
of the shank.
Reinking et al also noted that external risk
factors such as training volume, surfaces and shoes
contributed to MTSS.
Additionally, it examined intrinsic
factors such as fore-foot and rear-foot pronation and
navicular drop as other key anatomic factors contributing
to MTSS.2
A retrospective study performed by Lau et al3 examined
pediatric patients, mean age 11.5 years, diagnosed with
overuse injuries.
The authors studied 506 cases of overuse
injuries in the pediatric population. Seventy-three percent
of the patients in this study were male and findings stated
that the knee and lower leg were the most common part of
the body for an overuse injury to occur. The authors went
on to examine the differences in functional anatomy between
the adolescent and adult athlete citing open and closed
epiphyseal plates as one the main difference. The authors
concluded that there must be caution taken when diagnosing
the pediatric patient as to not overlook issues only seen
in adults, most commonly the higher occurrence of avulsions
with muscular injuries in children.
Bates,4 in similar methodology to Lau’s retrospective
study3 of the pediatric patient, examined the signs and
symptoms, incidence, pertinent anatomy and diagnostic
52
procedures behind MTSS in the form of a literature review.
The symptoms included pain during walking and, in more
severe cases, at rest as well as tenderness at the sight of
pain, typically over the same anatomical landmarks as found
by Reinking et al2. Additionally, the review stated that the
athlete may present with compartment syndrome of the lower
leg. The author found that “shin splints” accounted for up
to 15% of all running injures and up to 60% of all lesions
in the lower leg.4
In the same vein, Stauch aimed to
examine shin pain in the athletic population.
Strauch et al8 provided an in-depth analysis on the
evaluation methods of shin pain in the athletic patient,
most specifically, the runner. They noted that palpation,
especially along the medial boarder of the distal third of
the fibula is key to the diagnosis of MTSS.
In an exploratory surgery case study by Percy,9 the
author presented a case study in which an adolescent male
presents with persistent discomfort in the right lower leg,
categorized as shin splints, with a metatarsal fracture in
the ipsilateral foot.
The patient’s pain persisted for
eight months without reduction in symptoms following
treatment of rest and ice.
The symptoms continued to
persist and the author hypothesized that exploratory
surgery to solve the problem.
During the surgery, unlike
53
the previous studies1-5, Percy found the athlete’s lower leg
musculature to be anomalous and continued to decompress the
sheath around the muscle with a biopsy revealing a
significant difference in muscle physiologic make-up than
that of the un-injured leg.
This difference showed atrophy
on the injured side with increased fibrosis within the
tissues, linking this early article to the more current
diagnosis of MTSS.6
Though many of the studies reviewed have listed their
own approach to diagnosing MTSS, Edwards et al10 found a
more standardized approach to diagnosing chronic leg pain
in the athletic population. The conditions each case had to
meet to be included under the blanket of “chronic leg pain”
included medial tibial stress syndrome, stress fractures,
chronic exertional compartment syndrome, nerve entrapment
and popliteal artery entrapment syndrome. For each
condition, the authors created an algorithm to be used in
differential diagnosis these conditions and provided a
short summary of any confounds between the diagnoses. The
authors concluded that this could help differentiate
between several of the chronic conditions in the event that
the symptoms were masked or common between several overuse
syndromes.
54
Identifying the anatomic structures involved is just
one of the pieces to the puzzle of diagnosing and
eventually treating MTSS.
However, diagnosis can be
simplified greatly if the ATC is able to identify certain
factors putting their athletes at risk.
Risk Factors
In addition to anatomical and physical findings
present in patients with MTSS, multiple risk factors were
identified in several studies as contributors and the
incidence of MTSS in the athletic population.4-6,8
In their review, Bates4 examined the biomechanical risk
factors, including running gait, with regard to foot
rigidity in the supinated position during heel strike. The
author stated rigidity during heel strike in conjunction
with overpronation and/or tibial varum could influence the
incidence of MTSS.
They concluded that this was one of the
underlying causes of MTSS.
Similar to Bates,4 Rassi et al11 looked at the
relationship between alignment of the lower extremity and
MTSS with regard to navicular drop, Q-angle, Achilles
angle, tibial angle and intermalleolar and intercondylar
distances in the non-professional athlete. Additionally,
the subjects had their Body Mass Index (BMI) and history
55
taken prior and were observed over 17 weeks. Overall, the
results showed that navicular drop was the only significant
variable that could predict the occurrence of MTSS.
However, regarding the authors additional findings (Qangle, Achilles angle, tibial angle and intermalleolar and
intercondylar distances), Rassi et al concluded that these
did not apply to their population of non-professional
athletes, as they were not statistically significant.8
As Bates4 looked at static, measured risk factors, in a
study examining ballet dancers, Gans12 examined more dynamic
risk factors in the ballet dancer.
In their study, Gans
looked at eight dancers with a history of previous MTSS and
eight without with regard to heel contact during the ascent
and descent of jumps and if it contributed to their
developing MTSS. The author examined the dancers from the
push-off to the landing phase of their jumps to determine
any abnormalities contributing to MTSS. The author found no
significant evidence in the single heel strike, however
there was significance in the double heel strike. Though
there were significant findings, Gans concluded that there
could be confounding issues with Achilles tendon tightness,
however they did note that heel strike could contribute to
MTSS.
56
Similar to Rassi’s lower leg study11, Barnes et al13
examined the association between foot type and medial
tibial stress syndrome by way of systematic review of the
literature. The foot types examined included pes cavus, pes
planus and the “normal” arch. The authors concluded that
there was no significant relationship between foot type and
the incidence of medial tibial stress syndrome.
An accurate evaluation of the athlete and paying
attention to important functional anatomy are key to
correctly diagnosing MTSS. Though the evaluation of MTSS is
critical, it is equally as important to know the definition
and incidence of medial tibial stress syndrome to aid in
the care of the athletic population.
Diagnostic Testing
Although a thorough evaluation of the associated
anatomic structures of the patient experiencing symptoms is
important, diagnostic testing is an important step in the
diagnosis, prevention and treatment of MTSS.
This section
will outline and examine some of the diagnostic imaging
procedures used in the diagnosis of MTSS.
Gaeta et al14 examined the use of CT scans in on
runners with MTSS.
The purpose of their study was to
57
determine if runners who were asymptomatic would have
abnormalities on CT scans of their tibias as well as
determine how accurately the CT scan is in diagnosing
medial tibial stress syndrome.
They did this by performing
CT scans on 20 asymptomatic runners and 21 runners who had
either uni- or bilateral tibial pain.
The study found that
of the painful tibias, 14, all of them showed CT
abnormalities and the testing’s specificity, sensitivity,
positive predictive value and negative predictive value
were all very high as well and concluded that high
resolution CT scanning is clinically accurate in indicating
MTSS.
In a similar study by Holder et al15, the authors
examined scintigraphic patterns of MTSS in 10 patients.
The patient population consisted of 5 male and 5 female
athletes who were clinically diagnosed with “shin splints”
or MTSS.
The patients were subjected to three-phase
scintigraphy to help diagnose medial tibial stress
syndrome.
The typical findings that the authors found were
longitudinally oriented lesions on the posterior tibia,
involving about one third of the bone.
The authors
concluded that this indicated soleus involvement and that
these scintigraphic findings were significant in their
58
ability to help in the determining of medial tibial stress
syndrome from stress fractures and reactions.
In another study examining bone scans and MTSS,
Spencer et al16 described the use of bone scan to determine
abnormalities in patients with medial tibial stress
syndrome, described in this article as “shin splints.”
The
subjects, all young athletes, had previously had
radiographs taken on their lower legs, all of which came
back displaying no abnormalities.
In each of the patients,
there was a significantly noticeable lesion on both tibias
and, in one case, on the tarsal bones.
The author noted
that this further supported the evidence that bone scans
can be a very crucial step in the diagnosis of medial
tibial stress syndrome.
Though the Holder et al and Spencer et al studies15,16
showed the efficacy of bone scans, they can be very
expensive.
Samsi et al17 chose to look at the more cost
efficient x-ray imagining method as a means for diagnosing
MTSS.
The authors examined the efficacy of x-rays and bone
scans in the diagnosis of medial tibial stress syndrome.
The study used a total of twenty patients, the majority
with tibial pain in the middle or lower 1/3 of the bone,
however 3 patients had tenderness over their fibula.
In
the x-ray films, all the films appeared normal with the
59
exception of one patient with significant stress fractures,
while the bone scan revealed an abnormality in twelve of
the twenty patients.
The authors concluded that bone
scanning is indicated for the diagnosis of medial tibial
stress syndrome because of its high sensitivity and
specificity after x-rays were performed.
Similarly, Kijowski et al18 found that x-rays were
ineffective of diagnosing MTSS.
However, in their study,
the authors examined the correlation of x-ray/radiographic
imaging with magnetic resonance imaging in patients who
were previously diagnosed with medial tibial stress
syndrome and were either currently receiving treatment or
had just recently returned to participation in their given
activity.
Their 80 subjects each had underwent MRI and
radiographic imaging.
The study concluded that there was a
strong association between the reaction on the radiographs
at the site of the patients’ symptoms and the MRI findings.
Although MRI and bone scan findings were found
significant in diagnosing MTSS14-18, Magnusson et al19 looked
at the bone mineral density to find a link.
In their
study, the authors examined the radiographic data from 14
adult male athletes who had been previously been diagnosed
or were currently receiving treatment for medial tibial
stress syndrome.
The subjects’ bone mineral density was
60
measured at a baseline and then between 4 and 8 years later
to record the difference.
The study found that in the
regions where the pain was palpated, the bone mineral
density was significantly lower in the baseline test and
returned to normal at the final measurement.
The authors
concluded that although MTSS causes low bone mineral
density while its symptoms are present, post-recovery, the
athlete regains normal bone mineral density following an
increased uptake.
Moen et al’s20 critical review examined the different
methods of diagnosing medial tibial stress syndrome.
Unlike previous studies, the authors found that x-ray
absorptiometry was an effective imaging method for
detecting MTSS.
The authors concluded that though imaging
techniques are useful in diagnosing MTSS, they must be used
with caution.
Medial tibial stress syndrome, though somewhat of an
enigma at times, can be easily diagnosed if the correct
imagine procedure is utilized.14-19
Though the use of X-rays
has not been shown to have positive results,17,18 the
efficacy of MRI’s, CT scans, bone scans and bone mineral
density measurements have all been proven in the diagnosis
of MTSS.
14-16,18-20
61
Management of MTSS
Once an athlete has undergone an evaluation by their
athletic trainer, physical therapist or orthopedic
physician and have been formally diagnosed with MTSS, the
next step is to get them back to competition pain-free.
This involves not only a rehabilitation and management
program, but also a separate program to help prevent MTSS
from reoccurring.
Yates and White5 found a recurrence rate
of 28%, with a relative risk of 1.52, showing statistical
significance that an athlete will be more prone to
developing MTSS if he/she has been previously diagnosed.
Statistical significance in perspective, this section will
examine the management approaches with regard to
rehabilitation of the athlete with MTSS as well as the
prevention strategies implemented in the literature for
preventing MTSS in the future.
Rehabilitation and Treatment
The athlete suffering from MTSS may or may not undergo
rehabilitation.
Though this may seem like an inappropriate
management strategy to some, much of the literature
emphasizes rest as the main tool for helping recover from
MTSS.13,20-25
62
Orava and Puranen’s6 study mentioned earlier in the
definition and incidence section5,6 went further to state
that the only treatment examined which was noted to
decrease symptoms in both the fascial compartment as well
as at the site of MTSS was rest.
The authors concluded
that if rest was ineffective, a surgical intervention in
the form of a fasciotomy is recommended to alleviate
symptoms.6
Galbraith et al21 also examined the management of MTSS
by way of a systematic review.
Their review reinforced
several factors already mentioned by the authors in the
Functional Anatomy and Risk Factors section that contribute
to MTSS such as navicular drop, footwear, running distance
and intensity.
The main focus; however, was to delve into
some conservative treatment approaches taken to expedite
the process of returning the athlete to play after they
have been diagnosed with MTSS.
The authors concluded that
there are in fact several factors that can be classified as
both prevention and rehabilitation.
These factors, which
can also aid in the recovery process, included relative
rest such as cross training or implementing low-impact
exercises into the a modified training routine.
Additionally, the use of cryotherapy and electrical
stimulation with soft tissue mobilization and whirlpool
63
baths were also indicated for both the acute and subacute
phases.
In a case study using a less traditional approach than
that of Galbraith et al,21 Krenner22 examined a chiropractic
approach to managing medial tibial stress syndrome.
The
treatment consisted of breaking up of adhesions via muscle
stripping and massage.
Acupuncture was also utilized and
additionally, chiropractic manual adjustive techniques to
help restore normal biomechanical function bilaterally.
This continued 5 times over 10 days until the symptoms were
alleviated.
decreased.
Additionally, patient’s activity was sharply
Krenner concluded that treatment of MTSS must
be a multi-faceted process that not only alleviates pain
but also restores biomechanical function.
Strauch and Slomiany23 took a more traditional approach
to their study and examined the causes, treatments and
rehabilitation for patients with medial tibial stress
syndrome.
In the treatment phase of management, the
authors identified rest as the main treatment method
utilized; however, they noted that pool workouts were
effective in maintaining the athlete’s level of fitness.
Acute treatment for pain modulation consisted of NSAIDS,
ice massage, iontophoresis and compression to the area by
way of a neoprene sleeve worn on the lower leg.
64
Similar to the other authors,20-23 in an article from
the Journal of Athletic Training, Shaffer24 provided an in
depth look into the prevention and treatment of stress
fractures.
This article was an update to a previous
article by the same authors.
They updated their findings
from their initial study to include that pneumatic bracing
of the tibia, which used in conjunction with immobilization
and rest, aided in reducing the recovery period in the
athlete with stress reactions, stress fractures and MTSS.
Though there are many articles concerned with the
treatment of MTSS, very few of the articles surveyed
implement these methods into a high quality study testing a
larger sample size.
In a randomized controlled trial
however, Johnston et al25 examined the treatment of medial
tibial stress syndrome in 2700 navy recruits, which was
finally narrowed down to 25 subjects in their experimental
group following the exclusion of subjects who progressed to
stress fractures or concurrent lower extremity pathologies.
Their two treatment methods consisted of traditional
conservative treatment involving typical cyrotherapy
methods, a stretching and strengthening program, NSAIDs for
pain modulation, modification of training routines and
relative rest with the other group received pneumatic leg
brace orthoses.
Though the orthoses did aid in the
65
soldiers’ recovery, the authors weren’t able to draw any
conclusions from their findings and stated that more
research would be needed to verify if the orthoses are
effective in the prevention and treatment of medial tibial
stress syndrome.
Although many of the authors suggested different
methods such as leg orthoses,23,25 and traditional modality
use for pain modulation,21,22 the one thing that remained
consistent was the need of rest for the injury.
Whether it
was termed “relative” or “modified,” rest was the one true
generally accepted treatment option for the athlete
suffering from MTSS.6,20-23,25 However, once the athlete who
was suffering from MTSS is returned to participation, the
focus must now be changed from treating the syndrome to
preventing it.
Prevention
Once the athlete has completed resting and their
rehabilitation program for MTSS and has returned to
competition, the focus must shift from treating MTSS to
preventing it from occurring again.
Strauch and Slomiany23 noted that prevention can be
made considerably easier with the implementation of a
strength and conditioning program, even after the athlete
66
has fully recovered.
The program, the authors suggested,
should include flexibility exercises as well as
strengthening exercises, emphasizing the calves, hamstrings
and quadriceps.
Adverse to Strauch and Slomiany,23 Shaffer’s24 review
also examined two studies which integrated only a
stretching program to aid, but found that both were
ineffective in preventing MTSS.
The authors concluded that
evidence for preventing MTSS and tibial stress fractures is
generally lacking concrete strategies for effective
prevention.
Essentially, the prevention of MTSS must be a
multifaceted approach.
Examining MTSS on a larger scale, Rome et al26 created
a Cochran review examining the common techniques for
preventing stress fractures and reactions in young
athletes.
The authors went on to review 13 trials of
military recruits enrolled in MTSS prevention programs and
3 trials of treatment programs.
In the 10 trials involving
orthoses, data suggested that the interventions did
significantly prevent MTSS when compared to the nonorthoses groups.
Two trials concluded that muscle
stretching did not help prevent injuries when performed
prior to exercises, much like Shaffer.24
67
Similarly, a review by Craig27 examined the literature
on the prevention of MTSS.
The author examined studies in
which there was a controlled trial of an evidence based
prevention method for MTSS including insoles, stretching
programs, footwear and graduated running programs.
However, like previous literature,23,24 Craig concluded that
none of the studies of MTSS prevention had statistically
significant evidence that their respective prevention
method was effective, however, there was promise for shock
absorbing insoles from one of the studies reviewed.25
An NATA position statement by McLeod et al28 examined
the prevention of overuse injuries in the pediatric
population, including MTSS.
The statement highlights some
of the profiles of both male and female athletes that may
predispose athletes to overuse injuries such as tall
stature, more explosive strength, large Q angles, increased
muscle tightness and decreased muscle flexibility.
The
authors also stated that a decrease in the overall fitness
level in the general population means that training
routines must be more gradually introduced to help prevent
overuse injuries.
They concluded that the athletic trainer
must be able to identify risk factors associated with
overuse injuries as well as taking the appropriate steps as
to help prevent these injuries.
68
Similar to previous articles,23-25 A prospective
controlled study was conducted by Gardner et al29 to examine
the effect of shock absorbent insoles in the prevention of
stress fractures and other overuse injuries.
The authors
studied a group of 3,025 marine recruits over a period of
12 weeks and systematically issued elastic polymer insoles
to even and odd numbered platoons. After a period of time,
the authors found that the insoles did not prevent stress
reactions in the tibias.
They also included a control
group of those recruits who were wearing running sneakers
as opposed to boots during their workouts for about an hour
and a half a day, examining the age of the shoe relative to
the incidence of shin pain.
They found that though there
was a trend that the age of the shoe had somewhat an
effect, it was not large enough to be significant in
preventing stress reactions.
They concluded that neither
the shock absorbent insoles nor the age of sneakers of the
control group was significant in preventing lower extremity
stress reactions their subject pool.
Tolbert and Brinkley30 examined several articles on the
incidence of MTSS in athletics and created a program to
help counteract the underlying causes they found in a
review of the literature.
Including a warm up for 5 to 10
minutes greatly increased the efficacy of the program.
The
69
program also included hamstring stretching, soleus
stretching, gastrocnemius stretching and ice massage for
pain modulation.
The authors concluded that though rest is
the only treatment, by integrating a stretching and
strengthening program such as this, the athletic training
and strengthening and conditioning staff can greatly reduce
the incidence of MTSS.
Similar to Shaffer24 and Craig27 however, Brushoj et
al’s31 randomized controlled trial examined an exercise
program to aid in the prevention of MTSS and other overuse
injuries of the lower extremity.
The subjects were either
given an prevention program consisting of squats, lunges,
hip abduction and external rotation exercises, forefoot
lifts, coordination drills and quadriceps stretching or a
placebo program of abdominal curls, back extensions, biceps
and triceps towel curls and pectoral stretches.
The
authors found that the program did not help prevent the
incidence of MTSS in the recruits; however, it did increase
the recruits’ 12-minute maximal running test distance when
compared to the placebo group.
The authors concluded that
this may be caused by the lack of knowledge of all the risk
factors behind overuse injuries.
Though very few of the authors found any significant
evidence on the effective prevention of MTSS, making sure
70
to only gradually increase activity was shown to help
prevent MTSS.
Additionally, the integration of a warm-up
into a training routine can also decrease the incidence of
MTSS.
Knowledge of Athletic Injuries
Prevention, assessment and management of the athlete
with MTSS is built into the proficiency assessment of
athletic trainers as they complete their undergraduate or
entry-level masters’ programs.
On the other end of the
spectrum, however, the same cannot be said for the parents
and coaches of these athletes as they are not as versed in
these areas.
Injuries, generally, are easily recognized by
coaches, parents and other athletes, who typically possess
a basic understanding of the care and prevention aspects.
Several recent studies have been conducted looking at the
knowledge level of these three populations that are the
frontline in dealing with athletic injuries.
O’Donoghue et al32 conducted a study in the form of a
survey examining the knowledge of high school coaches with
regard to sport-related concussions. Looking at their
subjects’ knowledge, the authors split their survey into
prevention, management and recognition sections.
71
Additionally, the subjects were split into groups according
to sex and whether or not they had attended a concussion
workshop or not.
The authors found that overall, the
coaches’ scored best in the area of recognition and worst
in management and that male coaches, regardless of the sex
of their athletes or their sport, were more knowledgeable
than females.
In a more focalized study by Cross et al,33 the authors
examined only the state of South Dakota’s high school
coaching population’s knowledge of injury management.
The
population included 1050 coaches from 14 sports, the
majority of which indicated that they were in charge of the
initial evaluation of athletic injuries for their athletes.
The study found that less than 50 percent of the coaches
surveyed had current CPR or first aid certifications and,
overall, the coaches’ knowledge of the management of acute
athletic injuries was lacking.
Similar to O’Donoghue et al’s32 study, Baron et al34
conducted a smaller, but similar survey-based study with
regard to injury prevention and first aid knowledge of high
school coaches in the mid-Michigan area.
The results,
however; unlike O’Donoghue’s32 study, showed that only
fifteen out of the 290 coaches earned a passing score on
the Revised First-Aid Assessment Survey, suggesting that
72
overall, the population who was surveyed had insufficient
knowledge in the realm of first aid and injury prevention.
While many of these studies have examined the
knowledge of coaches,32-34 Iversen and Friden35 examined the
knowledge of female high school basketball players’
knowledge of anterior cruciate ligament injures with regard
to knowledge attitudes and practices associated with ACL
injuries.
The authors examined 113 players and 12 coaches
in these knowledge areas with 86 (74 players, 12 coaches)
completing the study.
The authors concluded that even
after the trial, there were no significant findings with
regard to any of the areas beings assessed.
Very much in the same context of Iversen and Friden’s
study,35 Ward36 also examined teens’ knowledge of the risk
factors associated with common sports injuries in the area
of prevention of athletic injuries.
In their study, the
author administered a survey during a physical education
class to students testing the subjects’ knowledge of
athletic injury prevention.
Ward concluded that the
subjects not only had a high level of athletic
participation, but they concurrently had a high level of
knowledge with regard to common injury prevention practices
and the equipment often utilized.
73
Although coaches are often the first responders to
their athletes when an acute trauma occurs, they are not
always as knowledgeable as many would like them to be.32-34
Although two of the studies surveyed looked at the
knowledge of athletes of injury prevention and
management,35,36 the athlete who is injured will not be the
first responder to their own ankle sprain, torn labrum or
other trauma, nor should they be expected to be.
Additionally, few studies have examined the knowledge level
of the parents of the athletes who are suffering these
injuries.
Because of this lack of knowledge, the athletes
can often be at risk and this can create a problem.
Summary
Medial tibial stress syndrome is a continuum of lower
leg traumas associated with overuse in athletics and other
physical activity.5-7 Though the evaluation of the
functional anatomy and risk factors associated with it are
very well defined, and all but set in stone,1-10 the
diagnostic testing for MTSS has been somewhat controversial
and, as far as the literature is concerned, very
indeterminate.14-19,24
74
The athletic trainer must recognize these risk factors
and be able to integrate prevention programs and educate
their athletes on the proper prevention techniques to help
them avoid MTSS and keep them in the game.22-29 Additionally,
when an adolescent athlete does end up with MTSS, rest and
a proper rehabilitation and management program is critical
in the athlete’s return to play.5,6,20-25
Although the athletic trainer is often very
knowledgeable on MTSS, the integration of these prevention
and management strategies can be difficult if the parents,
coaches and athletes they are working with are ignorant on
the subject.
As shown in the literature, coaches and
athletes are oftentimes well below the adequate knowledge
level in regard to athletic injury management and
prevention in general and the literature of the knowledge
of parents is all but non-existent.32-36
This can create an
issue for the Athletic Trainer during the management of the
athlete with MTSS.
75
APPENDIX B
The Problem
76
STATEMENT OF THE PROBLEM
The purpose of the study was to examine the knowledge
of parents and coaches with regard to medial tibial stress
syndrome.
If we, as athletic trainers, are able to
identify problem areas and gaps in knowledge bases and
educate those with this lack of knowledge, the overall care
of the athlete suffering from medial tibial stress syndrome
may be better. As MTSS is a continuum of overuse trauma to
the lower leg, the overall management of it can be
considerably difficult as everyone involved in the
prevention, management and treatment must take a
multifaceted approach.
The athletic trainer and coaches
are typically on the front lines of the prevention aspect
in the adolescent athlete. These are the individuals
typically responsible for the conditioning prior to the
season and training program throughout the season.
The
parents become much more involved when the athlete sustains
MTSS as they must try to help their children manage the
problem.
Since the parents and coaches are such a large
part in the prevention and management aspects of MTSS,
their knowledge of the prevention and treatment must be to
a certain level as to not mismanage or further injure the
athlete.
77
Definition of Terms
The following definitions of terms were defined for
this study:
1) Medial tibial stress syndrome (MTSS) - A continuum of
overuse injuries to the lower leg resulting in a loss
of function.
2) Adolescent Athlete- Any high school-aged person
competing in high school athletics.
Basic Assumptions
The following are basic assumptions of this study:
1)
The subjects will be honest when they complete their
demographic sheets.
2)
The subjects will answer the survey to the best of
their ability.
3)
Subjects will be representative of high school coaches
and parents in their knowledge of MTSS.
Limitations of the Study
The following are possible limitations of the study:
1)
The knowledge of MTSS in the populations being
surveyed may be skewed by overall education of the
community surveyed.
78
2)
Coaches and Parents may provide inconsistent
responses.
3)
The validity of the survey has not been established.
4)
There is no current research specifically regarding
this topic.
5)
The distribution method to both the parents and
coaches was indirect, which could account for the low
response rate.
Significance of the Study
This study will be significant as it will provide
feedback to the knowledge base of parents and coaches with
regard to medial tibial stress syndrome.
This can aid in
the care of the athlete suffering from MTSS by having the
athlete’s parents and coaches be able to potentially
identify signs and symptoms and refer their athlete to
their athletic trainer or doctor, potentially decreasing
recovery time.
With this knowledge, communication between
the athletic trainer, parents and coaches will be made
easier as all three will be greater informed.
Additionally, the risk of MTSS being mismanaged in the
adolescent athlete can be minimized as both the coaches
would be less likely to have the athlete “walk it off,”
79
and, similarly, parents will be less likely to push their
children through the pain.
80
APPENDIX C
Additional Methods
81
APPENDIX C1
MTSS Knowledge Survey
82
83
84
85
86
87
88
89
90
91
92
93
APPENDIX C2
Institutional Review Board –
California University of Pennsylvania
94
95
96
97
98
99
100
101
102
103
104
105
The following changes were submitted to the IRB and
accepted. They can be found in this email approval from
the IRB:
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair
Dear Joseph McShane:
Please consider this email as official notification that the modifications
(listed below) to your previously-approved study (#11-036 “Knowledge of
Medial Tibial Stress Syndrome of Parents and Coaches of Adolescent
Athletes") have been approved by the California University of Pennsylvania
Institutional Review Board.
-Modify methods to include online survey distribution (e.g. SurveyMonkey)
in addition to the pen and paper method already in place
NOTE: the cover letter/consent form must appear on the online site prior to
any survey questions.
-Addition of McDowell High School as a data collection site
(1)
(2)
(3)
(4)
This modification is effective 2-21-2012. The expiration date is the same as
for the original approval (2-19-2013). These dates must appear on the
consent form.
Please note that Federal Policy requires that you notify the IRB promptly
regarding any of the following:
Any additions or changes in procedures you might wish for your study
(additions or changes must be approved by the IRB before they are
implemented)
Any events that affect the safety or well-being of subjects
Any modifications of your study or other responses that are necessitated
by any events reported in (2).
To continue your research beyond the approval expiration date of 2-192013 you must file additional information to be considered for continuing
review. Please contact instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board
106
APPENDIX C3
Letter to Panel of Experts
107
November 28, 2011
Dear Athletic Training Colleague,
I am a graduate student at California University of Pennsylvania pursing a Master of Science
Degree in Athletic Training. I am conducting survey research to add to the bank of knowledge
within the Athletic Training profession. The objective of my study is to test the knowledge level
of my subjects with regard to medial tibial stress syndrome. The subjects for this study will
include parents and coaches of high school athletes. The participants will be contacted by their
children’s athletic directors and all information will be kept confidential.
I am the primary researcher and have developed the questionnaire to be used in this study. You
have been chosen to be an expert on this panel to assist in the validation of my study, due to
your expertise and experience. Your feedback is very important to the success of this study and I
greatly appreciate any suggestions you have. Any comments or suggestions you submit will be
used to revise and make the questionnaire more valid for use in this study.
Any additional comments about the survey would be appreciated. Please note this survey will be
delivered to the subjects via paper survey and not as a word document. I have given you the
word document version in order that you may make comments. Please return this document to
me with any comments you may have by December 1, 2011. If you have any questions do not
hesitate to contact me via email or phone at mcs4257@calu.edu or (814) 403-8266.
After completing and reviewing the survey, please answer the following questions:
1) Are the questions direct and understandable?
2) Are there any questions that are not coherent or should be excluded from the research?
3) Are there any questions that should be added to questionnaire that would aid in the
research?
Thank you in advance for your time, efforts, and consideration in helping me with my research.
Sincerely,
Joseph McShane, ATC
California University of PA
108
APPDENDIX C4
Cover Letter for Survey
109
110
APPENDIX C5
Letter to Athletic Directors
111
February 8, 2012
Dear Athletic Director:
My name is Joseph McShane and I am a Graduate Athletic Trainer at California University of
Pennsylvania seeking my Masters of Science degree in Athletic Training. A requirement for this
degree is the completion of a research based thesis project; my study’s title is “The Knowledge
of Medial Tibial Stress Syndrome (Shin Splints) of Parents and Coaches of Adolescent Athletes.”
Students participating in high school athletics are subjected to the rigors of not only training, but
competition as well. As their training regimes grow ever more intense to compete at a higher
level and beat their competition, the risk for injuries increases. Although many coaches and
parents think of an athletic injury consisting of a sprained ankle or a separated shoulder, many
are unaware of the injuries caused by overtraining and overuse; termed “overuse injuries.”
Medial tibial stress syndrome (MTSS), often referred to as “Shin Splints,” is one of these injuries
often seen in the pediatric population. Though its incidence is quite common, its management
for the children who are without the supervision of an athletic trainer at their high school is
often left up to their parents and coaches. A lack of knowledge of the proper management of
this injury can lead to more serious injuries such as stress fractures or neural damage from
compartment syndrome of the lower leg. My study is aiming to test the knowledge level of
these parents and coaches to see how knowledgeable they really are.
I am asking that the parents of athletes and coaches fill out a survey on their own time. This
survey will ask 30 questions regarding medial tibial stress syndrome and take about twenty
minutes. In addition to the knowledge questions, the subjects will be asked demographic
questions such as “are you a parent or a coach” and “what sport does your child participate in?”
Once the surveys are completed, they will be returned by each subject in a provided postage
paid envelope.
I am writing to seek your approval to use your High School athletes’ parents and coaches for
participation in my study.
In conclusion, I would like to thank you for your time, cooperation, and consideration with this
matter.
Sincerely,
Joseph McShane
California University of Pennsylvania
Graduate Assistant Athletic Trainer
112
REFERENCES
1.
Cosca DD, Navazio F. Common problems in endurance
athletes. Am Family Phys. 2007;76(2):237-244.
2.
Reinking MF. Literature Review: Exercise Related Leg
Pain (ERLP): A Review of the Literature. North
American Journal of Sports Physical Therapy. 2007;
2(3):170-181.
3.
Lau LL, Mahadev A, Hui JHP. Common lower limb sportsrelated overuse injuries in young athletes. Ann Acad
Med Signapore. 2008;37(4):315-319.
4.
Bates P. Shin splints- a literature review.
Sports Med. 1985;19(3):132-137.
5.
Yates B, White S. The incidence and risk factors in
the development of medial tibial stress syndrome among
naval recruits. Am J Sports Med. 2004; 32(3):772-780.
6.
Orava S, Puranen J. Athletes’ leg pains.
Sports Med. 1979;13:92-97.
7.
Mubarak S, Gould R, Lee Y. The medial tibial stress
syndrome. Am J Sports Med. 1988;10:201-205.
8.
Strauch WB, Slomiany WP. Evaluating shin pain in
active patients. J Musculoskeletal Medicine.
2008;25(3):138-140,144-146,148.
9.
Percy ECC. Case report: an epiphyseal stress fracture
of the foot and shin splint in an anomalous calf
muscle in a runner. Brit J Sports Med.
1980;14(2,3):110-113.
10.
Edwards PH, Wright ML, Hartman JF. A practical
approach for the differential diagnosis of chronic leg
pain in the athlete. Am J Sports Med.
2005;33(8):1241-1249.
11.
Raissi GRD, Cherati ADS, Mansoori KD, Razi MD. The
relationship between lower extremity alignment and
medial tibial stress syndrome among non-professional
athletes. Sports Medicine, Arthroscopy,
Rehabilitation, Therapy and Technology. 2009(1:11).
Brit J
Brit J
113
12.
Gans A. The relationship of heel contact in asscent
and descent from jumps to the incidence of shin
splints in ballet dancers. Physical Therapy.
1985;65(8):1192-1196.
13.
Barnes A, Wheat J, Milner C. Association between foot
type and tibial stress injuries: a systematic review.
Br J Sports Med. 2008;42:93-98.
14.
Gaeta M, Minutoli F, Vinci S, Salamone I, D’Andrea L,
Bitto L, Magaudda L, Alfredo B. High-Resolution CT
grading of tibial stress reactions in distance
runners. Am J Roentgen. 2006;187: 789-793.
15.
Holder LE, Michael RH. The specific scintigraphic
pattern of “shin splints in the lower leg”: concise
communication. J Nucl Med. 1984;25:865-869.
16.
Spencer RP, Levinson ED, Baldwin RD, Sziklas JJ, Witek
JT, Rosenberg R. Diverse bone scan abnormalities in
“shin splints.” J Nucl Med. 1979;20:1271-1272.
17.
Samsi AB, Tilve GH, Shikare S. Bone imaging in sports
medicine. J Postgraduate Medicine. 1997;43(3):71-72.
18.
Kijowski R, Choi J, Mukharjee R. Significance of
radiographic abnomalities in patients with tibial
stress injuries: correlation with magnetic resonance
imaging. Skeletal Radiol. 2007;36:633-640.
19.
Magnusson HI, Ahlborg HG, Karlsson C, Nyquist F,
Karlsson MK. Low regional tibial bone density in
athletes with medial tibial stress syndrome normalizes
after recovery from symptoms. Am J Sports Med.
2003;31:596-600.
20.
Moen MH, Tol JL, Weir A, Steunebrink M, De Winter TC.
Medial tibial stress syndrome: A critical review. J
Sports Med. 2009;39(7):523-546.
21.
Galbraith RM, Lavallee ME. Medial tibial stress
syndroms: conservative treatment options. Curr Rev
Musculoskelet Med. 2009;2:127-133.
22.
Krenner BJ. Case report: comprehensive management of
medial tibial stress syndrome. J Chiropractic
Medicine. 2002;3(1):122-124.
114
23.
Strauch WB, Slomiany WP. Shin pain treatments get
active patients back on track. Biomechanics.
2008;15(4):31-38.
24.
Shaffer SW, Uhl TL. Preventing and treating lower
extremity stress reactions and fractures in adults. J
Athletic Training. 2006;41(4):466-469.
25.
Johnston E, Flynn T, Bean M, Breton M, Scherer M,
Dreltzler G, Thomas D. A randomized controlled trial
of a leg orthosis versus traditional treatment for
soldiers with shin splints: a pilot study. Military
Medicine. 2006;171(1):40-44.
26.
Rome K, Handoll HHG, Ashford RL. Interventions for
preventing and treating stress fractures and stress
reactions of bone of the lower limbs in young adults
(Review). The Cochrane Library. 2009(1).
27.
Craig DI. Medial tibial stress syndrome: Evidencebased prevention. J Athl Training. 2008;43(3):316-318.
28.
McLeod TCV, Decoster LC, Loud KJ, Micheli LJ, Parker
JT, Sandrey MA, White C. National athletic trainers’
association position statement: prevention of
pediatric overuse injuries. J Athletic Training.
2011;46(2):206-220.
29.
Gardner LI. Dziados JE, Jones BH, Brundage JF, Harris
JM, Sullivan R, Gill P. Prevention of lower extremity
stress fractures: a controlled trial of a shock
absorbent insole. APJH. 1988;78(12):1563-1568.
30.
Tolbert TA, Binkley HM. Treatment and prevention of
shin splints. Strength and Conditioning Journal.
2009;31(5):69-72.
31.
Brushoj C, Larsen K, Albrecht-Beste E, Nielsen MB,
Loye F, Holmich P. Prevention of overuse injuries by
a concurrent exercise program in subjects exposed to
an increase in training load: a randomized controlled
trial of 1020 army recruits. Am J Sports Med.
2008;36(4):663-670.
32.
O’Donoghue EM, Onate JA, Van Lunen B, Peterson CL.
Assessment of high school coaches’ knowledge of sportrelated concussion. Athletic Training and Sports
Health Care Journal. 2009;1(3): 120-132.
115
33.
Cross PS, Karges JR, Adamson AJ, Arnold MR, Meier CM,
Hood JE. Assessing the need for knowledge on injury
management among high school athletic coaches in South
Dakota. J South Dakota Medicine. June 2010; 241-245.
34.
Baron MJ, Powell JW, Ewing ME, Nogle SE, Branta CF.
First aid and injury prevention knowledge of youth
basketball, football and soccer coaches. Intl J
Coaching Science. 2009;3(1):55-67.
35.
Iversen MD, Friden C. Pilot study of female high
school basketball players’ anterior cruciate ligament
injury knowledge, attitudes and practices. Scand J Med
Sci Sports. 2009;19: 595-602.
36.
Ward CW. Teens’ knowledge of risk factors for sports
injuries. J School Nursing. 2004;20(4): 216-220.
116
ABSTRACT
Title:
THE KNOWLEDGE OF MEDIAL TIBIAL STRESS
SYNDROME OF PARENTS AND COACHES OF
ADOLESCENT ATHLETES
Researcher:
Joseph J. McShane
Advisor:
Dr. Ellen J. West
Date:
May 2012
Research Type: Master’s Thesis
Context:
This study evaluated the knowledge of
parents and coaches of adolescent athletes
of medial tibial stress syndrome with regard
to different areas of knowledge associated
with athletic injuries within the scope of
practice of athletic trainers.
Objective:
The purpose of this study was to examine the
knowledge of parents and coaches of medial
tibial stress syndrome in the adolescent
athlete.
Design:
Descriptive research study
Setting:
The researcher distributed a cover letter
containing a link to the Internet based
survey to athletic directors at the high
schools to be surveyed. The athletic
directors then distributed the letter to the
parents and coaches at their respective
schools.
Subjects:
Parents and coaches of the six western
Pennsylvania high schools’ athletes
surveyed.
Interventions: The independent variables in the study were
the subjects tested (either parents or
coaches). The dependent variable was the
subjects’ score as measured by the MTSS
knowledge survey (r = 0.374), each question
being worth one point. The survey was
created by the researcher and administered
117
via a cover letter given to the athletic
directors at the high schools to be surveyed
who then distributed the cover letter to the
parents and coaches at their school. The
data was analyzed using SPSS at a
significance level at α ≤ 0.05.
Measurements:
All data analyzed at a significance level at
α ≤ 0.05 for all hypotheses. H1: an
independent samples t-test was used to
compare mean prevention knowledge scores
between parents and coaches. H2: an
independent samples t-test was used to
compare mean rehabilitation and treatment
knowledge scores between parents and
coaches. H3: an independent samples t-test
was used to compare mean overall knowledge
scores between parents and coaches.
Results:
Hypothesis 1 had findings that were not
significant. H1: (t(59) = .200, p > 0.05).
Hypotheses 2 and 3 had findings that were
significant. H2: (t(59) = -2.754, p <
0.05). H3: (t(59) = -2.382, p < 0.05).
Conclusion:
The study revealed that coaches of
adolescent athletes have a significantly
greater level of knowledge of the
rehabilitation and treatment of medial
tibial stress syndrome than parents of
adolescent athletes. Coaches also have a
significantly greater overall level of
knowledge of medial tibial stress syndrome.