Prolonged stress may generate a periosteal reaction detectable as a “rough” or “bumpy” feel upon palpation. Pain that persists more than five minutes post-activity carries a higher suspicion of stress fracture.Ĭlinical evaluation demonstrates diffuse tenderness over the posteromedial tibial border. Initially, symptoms may subside during training, but as the condition progresses (toward stress fracture), symptoms may linger throughout activity or even at rest. Symptoms are often worse with exertion – particularly at the beginning of a workout. The clinical presentation of MTSS includes vague, diffuse pain over the middle to distal posteromedial tibia. Prolonged insult may lead to a tibial stress fracture, and many authors now believe that MTSS and stress fracture represent two different points along a continuum of bony stress reaction. Stress reactions occur when the normal adaptive remodeling response cannot keep pace with excessive training loads, i.e., high demands with inadequate recovery times. Healthy bone responds to this stress by remodeling itself more densely. The stress of exercise can temporarily weaken bone. Research suggests that traction periostitis may be an inflammatory precursor to a tibial stress fracture. Early etiological theories focused on myofascial strain, but current evidence shows that a bony stress reaction is the most likely cause of MTSS.
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