The term Medial Tibial Stress Syndrome (MTSS) better defines the injury and separates it from injuries such as stress fractures or compartment syndrome. Shin splints, or 'medial tibial stress syndrome' (MTSS) is a painful condition affecting the shin bone and surrounding tissues. 68 year old with history of persistent tibial pain since "bumping the leg" two months earlier. Often this problem can require a Sports Medicine Doctor,Physiotherapist, and/or Podiatrist to assist. Radiographs or bone scans may be obtained to rule out stress fractures. In accordance with these clinical components the treatment and prevention programs should address: Until the causes of MTSS are well known it will be hard to find an effective prevention program. 1 Brown, A. Medial Tibial Stress Syndrome (MTSS) is a lower leg over-use injury that is characterized by pain along the postero-medial portion of the distal two-thirds of the tibia, provoked . Additional support for this hypothesis is that the typical appearance of a positive bone scan is that of increased uptake over a several centimeter vertical segment. In addition, several muscles attach to the tibia, so that when they contract, a pulling force is . 101 - 450 E. Columbia Street Laboratory analysis assists in excluding the possibility of osteomyelitis. Treatment options are: In general, the key treatment is to develop an injury prevention program to avoid and reduce the risk of re-injury. Bone scans have a high sensitivity for medial tibial stress syndrome, but SPECT-CT is useful to differentiate medial tibial stress syndrome from stress fractures. The examples given in the quiz cases show perhaps the most common appearance for a longitudinal fracture of the tibial shaft. Medial tibial stress syndrome: muscles located at the site of pain. This may be viewed as a variant between the other two types shown. Current treatment and prevention programs are mainly based on expert opinion and clinical experience. Pain usually subsides after stopping activity. This broad description is not consistent with the American Medical Association's (AMA) definition of shin splints: " pain and . Soreness during warm-up that continues 2 days off, drop down 1 step Periosteal edema is seen on the axial image (red arrowheads) but is difficult to distinguish from adjacent deep subcutaneous edema (blue arrowheads) on the sagittal image. overuse). 5, pp. This aims to settle and relieve the inflammatory process thereby relieving symptoms. anterior tibial stress syndrome. Medial tibial stress syndrome (MTSS) is a condition that causes pain and tenderness along the inside of the shinbone (tibia), specifically where the bone meets the muscle. This diffuse widespread lower leg pain typically comes on 510 minutes after beginning a bout of exercise, and rapidly builds to such a severity exercise needs to be ceased. An associated vessel can typically be seen extending beyond the foramen, within the marrow space as well as external to the bone. To remove any lingering doubt, the finding was additionally confirmed by subsequent CT. The aim is 1) to lengthen the lever to challenge the posterior chain and 2) to work the soleus (again!). Stress fractures or other pathologies should be ruled out whereas bone scans or MRIs showed to be most appropriate. (3a) The (left) axial proton density-weighted image shows marrow edema (*) and periosteal edema (arrowheads) involving the mid tibia, most prominent posteriorly. 4 Reinking M. F. (2007). The Fredericson MTSS classification follows a progression related to the extent of injury. Karen has done an amazing job helping me recover. They include involvement of the soleus muscle in MTSS and insufficient bone-remodelling capabilities to compensate for persistent insults to the tibia. Shin splints are a frequently occurring problem in . Thacker SB, Gilchrist J, Stroup DF and Kimsey CD 2004 The impact of stretching on sports injury risk: a systematic review of the literature, Med Sei Sports Exerc., vol. 22(2):265-269, March/April 1998. The pain initially appears toward the end of exercise, and if exercise continues without rehabilitation, the pain worsens and occurs earlier in the exercise period. in 1982 (), the term describes a specific overuse injury producing increasing pain along the posteromedial aspect of the distal two-thirds of the tibia ().Although runners are most commonly afflicted, with one study reporting a 13% . Females have a 1.5-3.5 times increased risk of progression to stress fracture. With MTSS, pain usually disappears once the activity that causes the pain is reduced or stopped. Journal of the American Podiatric Medical Association., Volume 97 Number 1 31-36 2007. Orthopedics. The ulna is the upper extremity bone most frequently affected. [1] Longitudinal Tibial Stress Fractures: A Report of Eight Cases and Review of the Literature. pool exercises, Rest or relative rest (depending on severity) for 2-6 weeks, Cryotherapy- ice for 15-20 min at the affected area after exercise, Physiotherapy modalities such as soft tissue mobilization, ultrasound, pool exercises, Modify training routine adjust running intensity and avoid running hills or on uneven or very firm surfaces. It has recently been found that low grades of tibial stress injury, i.e. More intense physiotherapy can then be commenced. Additionally, the pain from MTSS will be felt even at rest. In CECS, the volume of the one of the above-mentioned compartments increases due to repetitive microtrauma (i.e. MTSS is caused by chronic strain, overuse, and microtrauma of the soleus (calf) muscle at its origin on the inside of the shinbone (posteromedial tibia), or deep inflammation of the periosteum, which is the connective tissue that covers the bone, of the tibia beneath the posterior tibialis muscle. linear lucency through the cortex. Softer surfaces and shoe cushioning materials absorb more shock and less is transferred to the shins. MTSS creates pain in the inner part of the shin, along the Tibial bone. A. The patient commonly complains of pain at night. [1] . For many years it was thought that the problem develops when the attachment of the muscles (periosteum) at the inside edge of the shin break down in response to increased traction force (1,2). Fig 3a and 3b. (2008). the tibia) toward the lower third of the leg. medial tibial stress syndrome. Required fields are marked *. This diagnosis reflects a spectrum of medial tibial pain in early manifestations before developing into a stress fracture. The (right) coronal T2-weighted image demonstrates a vertically-oriented lucent line, bordered by dark sclerotic lines (arrows). (2016). Meanwhile, a transverse fracture is more likely to extend into the portion of the cortex that is tangent to the beam, and will be distinctly visible. If an x-ray beam encounters a radial longitudinal fracture line at any angle other than perfect en face alignment, it may be obscured by the adjacent sclerotic borders and at best interpreted as periosteal reaction. Exercise Related Leg Pain (ERLP): A review of The Literature. There is also some thought that actually MTSS is a combination of the anatomical and the bone stress theories. (7a,7b) 21 year old runner with mid tibial pain for two months despite cessation of running for the past month. Medial tibial stress syndrome happens when there is inflammation or irritation where calf muscles attach to the shin bone. Marrow edema visible on MRI can have multiple etiologies, and may raise concerns of malignancy or osteomyelitis, particularly when a periosteal reaction is present. This patient also had stress fracture just inferior to the third image in this series (seen in Figure 8). 5,6 Measurement of intracompartmental pressure (ICP) of the deep posterior If you experience pain in your shin, thoroughly stretch before exercising, reduce your activity level, and check your footwear. Longitudinal fractures of the tibial shaft are most often caused by repetitive torsional loading in distance runners as the endpoint of a continuum of medial stress injury, although patients may present with an atypical clinical history. Shin splints explained, and how to get rid of shin splints. Sometimes it can be caused by improper or overused shoes. Medial tibial stress syndrome (MTSS) is a frequent overuse lower extremity injury in athletes and military personnel. Tibial stress fractures are small cracks in the cortex of the bone which are usually due to overuse and repetitive stress, such as due to long distance running. So far research failed to show any effective prevention programs but experts seem to agree on 2 etiological components. 3 . Well-demarcated T1 signal abnormality, endosteal scalloping, and an adjacent soft tissue mass are each indicators of neoplasm rather than stress fracture.7. A stress fracture is a very small crack or group of cracks that form in the bone itself. Medial Tibial Stress Syndrome Introduction Pain generally in the inner and lower 2/3rds of tibia. Pain worsens during running and other impact activity and is alleviated with rest. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Primarily the pain occurs with the onset of activity which can be different from case to case, depending on the intensity of the activity. The muscles of the foot and leg overwork in an attempt to stabilize the over-pronated foot and the repeated stress can cause the muscles to tear where they attach to the tibia. Rapid increase of speed or distance, Signs and Symptoms of Medial Tibial Stress Syndrome, MTSS is an inflammatory disorder, that can be best managed initially with rest, ice and anti-inflammatories (ie nurofen, voltaren). Tibial Shaft Stress Fractures. The fatigue strength of compact bone in torsion. The tibia is the most common location for the development of stress fractures. Image Source: https://zionphysicaltherapy.com/shin-splints-medial-tibial-stress-syndrome. The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. [1] Generally this is between the middle of the lower leg and the ankle. 3, pp. 47 year old runner with shin pain. Overuse injuries like MTSS can impact up to 70% of runners in a year [1]. Now, there are multiple diagnosis for shin pain and the term shin splints is generally reserved for Medial Tibial Stress Syndrome (MTSS). 3 Shearman CM, Brandser EA, et al. Shin splints (medial tibial stress syndrome) are a common source of complaints of midtibial pain, especially in runners. As you will now appreciate, Medial Tibial Stress Syndrome is a very complex, multi-factorial pathology. 127133. [sports-health.com] In addition, to further explain lower leg pain, the authors investigated the crossing point of tibialis posterior and flexor digitorum longus; a mean distance for this to occur in the same ten specimens was 8.16 cm. The pain usually lessens after you warm up, Dr. Goldberg says. However, if left untreated, shin splints do have the potential to develop into a tibial stress fracture. What causes shin splints after running? Please contact me via email or connect with social channels. A strong, fibrous structure, the interosseous membrane or ligament ( figure 2 ), connects the tibia and fibula along the length of the two bones. This often follows as a result of shin-splints that have not been managed correctly or when patient tries to run-through the problem. Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. Previous estimates of transverse versus longitudinal stress fracture orientations in the tibial shaft likely underestimated numbers of the latter. Compartment Syndrome There are four divisions of muscles in the lower leg (anterior, lateral, posterior superficial/deep). Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. J. A healthy achilles tendon may be nearly as strong as a steel cable, coping with tremendous forces from the action []. Hubbard, TT, Carpenter, EM and Cordova, ML 2009, Contributing Factors to Medial Tibial Stress Syndrome: A Prospective Investigation, Medicine & Science in Sports & Exercise, pp. Using this gold standard diagnostic technique, it seems likely that longitudinal fractures of the tibial shaft occur more commonly than previously thought and are in fact more common than transversely oriented fractures. A shin splint or medial tibial stress syndrome (MTSS) is an inflammation of the tissue running along the shin bone (tibia), whereas a stress fracture is a very small crack or group of cracks that form in the bone itself. Shin splints vs stress fractures: what's the difference? 2003 Aug;36(8):1103-9. This is similar to the prior case, though the fracture is smaller and more subtle. Physiotherapy will help to develop an individualized treatment plan for you. Medial Tibial Stress Syndrome, also known as "shin splints", is an early stage in the continuum that culminates in a stress fracture. MRI has subsequently become the gold standard for diagnosis of tibial stress fractures and their earlier precursors of stress reaction and periosteal reaction (Medial Tibial Stress Syndrome). Medial tibial stress syndrome is not a compartment syndrome, but releasing this fascia has helped. Skeletal Radiol. Medial tibial stress syndrome (MTSS) is one of the most common causes of exercise related leg pain ().Originally coined by Drez and reported by Mubarak et al. The finding of marrow edema should prompt a search for a more specific underlying abnormality. What are the findings? Medial tibial stress syndrome typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers. Medial tibial stress syndrome, or shin splints, manifests with pain along the medial tibia and is the most common overuse injury of the lower leg. Medial (posteromedial): traction periostitis of tibialis posterior and soleus. Medial tibial stress syndrome, also known as shin splints, is the most common form of early stress injury. Although CT will not detect the edema and periosteal reaction visible on MRI in early stages of Medial Tibial Stress Syndrome, imaging with thin-section CT may allow more detailed osseous assessment and clearer depiction of a fracture line.8 Another alternative, if confirmation is needed, is a follow-up MRI study following a period of limited weight-bearing or cessation of the inciting activity. Pain usually settles rapidly on stopping exercise. The pain is caused by increased pressure onto the tibia bone as a result of increased traction from muscles in the shin (i.e. In summary, MTSS is an overuse injury or repetitive-stress injury of the shin area where various stress reactions of the tibia and the surrounding musculature occur and the body is unable to heal properly in response to repetitive muscle contractions and tibial strain. 9 Bergman AG, Fredericson M, Ho C, and Matheson GO. Galbraith, RM & Lavallee, ME 2009, Medial tibial stress syndrome: conservative treatment options`, Curr Rev Musculoskelet Med., vol. The aching may become more intense, even during walking, if ignored. Sections MTSS also affects individuals who have flat feet because the mechanics of the foot increase stress on the soleus muscle. Longitudinal tibial shaft fractures are more common than has been previously reported, likely due to the low sensitivity of radiographs for this fracture orientation. Aching along the front of the shin with activity. An example is that of a case presented by a perplexed infectious disease specialist. Thacker SB, Gilchrist J, Stroup DF and Kimsey CD 2002, The prevention of shin splints in sports: a systematic review of literature,Medicine & Science in Sports & Exercise, pp. In: Medicine and science in sports and exercise, Vol. (left) Axial fat-suppressed proton density image obtained at the junction of the mid and lower thirds of the right lower leg, and (right) sagittal fat-suppressed T2 weighted image of the lower half of the tibia. 10. Medial tibial stress syndrome (MTSS), aka Medial Tibial Traction Periostitis, is a common result of this increased load. Tightness in the posterior muscles, which propel the body forward, places additional strain on the muscles in the front part of the lower leg, which work to lift the foot upward and also prepare the foot to strike the running surface. The posterior tibial cortex is discretely disrupted as a linear cleft, with elevated cortical ridges along the cleft. It's common for it to happen when running uphill or downhill. The (right) sagittal T2-weighted image demonstrates a vertically elongated area of linear cortical abnormality (arrows) spanning several centimeters in length. Image Source: https://thedoctorsofpt.com/how-do-shin-splints-happen/. 49 year old woman with persisting tibial pain 3 1/2 months after a bicycle accident. Edema is seen in a large portion of the tibial marrow, but is most prominent adjacent to the posterior cortical abnormality. (2008). If left untreated, small tears in the muscle and the bone can form, leading to chronic pain and stress fractures. 3 Plisky, M. S., Rauh, M. J., Heiderscheit, B., Underwood, F. B., & Tank, R. T. (2007). 53-57. Generally, develops gradually over weeks/months. Clinical History: A 52 year old male presents with tibial pain after golfing. Patient 2. Stress fracture is a associated . Single leg soleus bridge. Although numerous prospective studies have tried to identify risk factors for developing MTSS, managing the syndrome remains difficult. The location of stress injuries varies by sport. Two common sites of exercise-induced tibial pain are described posterio-medial and more proximally anterior-lateral. Excessive pressure can affect supply to blood vessels and nerves in the leg. Recent work appears to favor the latter.4,5 Compressive forces account for the transverse, often subchondral, stress fractures in the proximal tibia. Axial and sagittal fat-suppressed proton density-weighted images demonstrate a longitudinal fracture of the anteromedial cortex of the tibia (arrows). Early detection and intervention of MTSS and CECS is essential to help prevent further progression of the injury (e.g. Medial Tibial Stress Syndrome MTSS is defined as a spectrum of stress injury beginning with the posterior tibial muscle essentially tugging on the periosteum of the tibia; From: Braddom's Physical Medicine and Rehabilitation (Sixth Edition), 2021 View all Topics Download as PDF About this page Management of Musculoskeletal Injury Although the singular cause for MTSS is not described, Hubbard, Carpenter and Cordova (2009) made a distinction between intrinsic and extrinsic mechanisms that could have an impact on the development of shin splints. New Westminster, BC, #1 Physio in New Westminster as voted by The Record readers for 2022. Nutrient foramina course obliquely through the tibial cortex, and exhibit a round shape on axial images, progressing from the inner to the outer cortical surfaces. MTSS manifests as pain along the inside of the shin (i.e. North American journal of sports physical therapy: NAJSPT, 2(3), 170180. The lower radiographic sensitivity to longitudinally oriented fractures in particular, may be the underlying reason for underestimates of their prevalence.
. The history in this case also suggests that these fracture types may in some cases not be stress related,, or perhaps that gradual bone fatigue may not be recognized. This is not a stress fracture, but illustrates the similarity in appearance. Periostitis may be directly caused by traction at muscle or fascial attachments, or may be a response to developing changes in the underlying bone. Medial tibial stress syndrome. Longitudinal Stress Fractures of the Tibia: Diagnosis with CT. Radiology 1988; 167:799-801. This injury is treated with rest and crutches to allow the muscles to heal. This impacts the movement of lymph, blood and even nerve impulses. Each of these are surrounded by a thick tissue called fascia that surrounds the muscles completely. Diagnosis: The pain is at the myo-tendinous junction of the posterior tibial. Medial tibial stress syndrome (MTSS), also called "shin splints", This injury is often seen in runners, sprinters, and athletes who take part in sports that require sudden stops, direction changes, and/or the use of the legs. Others believe that morphologic bone changes as a result of continues bonestress are the basis for shin splints and attribute the pain to stress microfractures. However, the technique has low specificity,3 leaving diagnostic uncertainty particularly in patients that do not have the typical history of distance running. In a chronic state, symptoms are easier to provoke and can even persist during normal activities of daily life. an overuse injury located along the postermedial aspect of the middle 1/3 of the leg. Insufficient shock absorption. There is focal intense increase tracer uptake in the proximal right tibial cortex which corresponds to an oblique Shin splints are common among people who have completed military service along with dancers and runners. Choose from 25 different sets of medial tibial stress syndrome flashcards on Quizlet. An imaging pitfall in the diagnosis of stress fractures is that of a normal nutrient foramen. (2016). MTSS is caused by chronic strain, overuse, and microtrauma of the soleus (calf) muscle at its origin on the inside of the shinbone (posteromedial tibia), or deep inflammation of the periosteum . 1996 Mar;19(3):263; 66; 68; 70. MRI is well suited for distinguishing between stress fractures and pathologic fractures. The pain may begin as a dull aching sensation after running. Tibial Stress Fracture - Diagnosis Stress fractures usually present with a gradual onset of pain during activity, and usually develops when there has been an increase in training load. You may even have swelling over the site of the fracture. Training errors, alignment abnormalities and poor training techniques should be corrected and minimized as much as possible. Medial Tibial Stress Syndrome/Chronic Exertional Compartment Syndrome Testimonials "After trying many other physiotherapists, and having no luck recovering, I was getting frustrated. Scientifica, 2016, 1-4. doi: https://doi.org/10.1155/2016/7097489, 2 Craig D. I. The most common compartment involved in CECS is the anterior (front) part of the leg. This begins with periosteal edema (grade 1), followed by progressive marrow involvement (grades 2 and 3), and eventually cortical stress fracture (grades 4a and 4b). Additional differential diagnostic considerations, particularly in patients that are not distance runners, include intermittent claudication, osteomyelitis, and neoplasm. It is essential to seek a thorough assessment and treatment from a physiotherapist when dealing with MTSS or CECS. Rapid increase in activity/excessive running, Training volume (repetitive days training with no rest/recovery), Training surface (street running as opposed to oval/track running), Stiffness in foot/ankle musculature (poor shock absorption), Gender, women are more prone to developing MTSS, but the incidence in CECS is equal between genders. Shin Splints vs. Tibial stress fracture. Shin splints is often simply described by physicians and athletes as lower leg pain which can include tibial stress fracture, chronic compartment syndrome, medial tibial syndrome, soleus syndrome and muscle hernia. Why it works: the muscles of the calf intersect with tendons that may be involved in shin splint pain. On further review of the MRI, a longitudinal stress fracture of the tibial shaft was identified. 1998 Criterion Action 1. 2 Jeske JM, Lomasney LM, Demos TC, Vade A, Bielski RJ. a fracture resulting from the bone's inability to adapt to repetitive stess. It is usually spread over at least 5 cm (2 in . Causes can include medial tibial stress syndrome (shin splints) and stress fracture. On a microscopic level, repetitive stress leads to osteoclastic resorption exceeding osteoblastic bone regeneration. If the arch flattens more than normal is it called excessive pronation. Tibial Stress Fractures / Medial Tibial Stress Syndrome Saint Louis University - SSM Health Physical Therapy Orthopedic Residency in Collaboration with William Mitchell, MD & Scott Kaar, MD 5 Updated 9.16.2019 Soreness Rules Adapted from Fees et al. Despite being the most common of lower leg complaints, MTSS is often a common misdiagnosis for similar conditions such as stress fractures and compartment syndrome. Key words: foot; medial tibial stress syndrome INTRODUCTION Medial tibial stress syndrome (MTSS) is caused by repetitive loading stress during running and jumping, and occurs in 4% to 35% of athletic and military populations.1-3 MTSS is associated with underlying periostitis of the tibia secondary to tibial strain as well as a spectrum of . In my opinion, this would appear to be a reasonable explanation. Approximately 10-20% of all runners will experience shin splints or medial tibial stress syndrome (MTSS) once in their career. This places increased pressure on the arch and upon repetitive movement such as running will greatly increase the stress placed on the lower leg. J Biomech. Journal of Computer Assisted Tomography. 5). A normal nutrient foramen is seen on the coronal image (blue arrow) without adjacent edema. About 80% of running injuries are due to overuse. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI. Medial tibial stress syndrome: muscles located at the site of pain. The soleus load may be fairly low but this will challenge Glute Max and the hamstrings. However, labs were normal for WBC and ESR. Furthermore, the pain from CECS does not subside after exercise. If not properly dealt with, MTSS can lead to stress fractures. X-rays are often required to rule out a stress fracture. Initially, the pain increases at the beginning of running and decreases after a warm-up period. Shin splints or MTSS is a complex problem where the cause remains unknown and expert opinions are not consistent. Medial tibial stress syndrome is more likely to happen from: - Discussion: - a complex syndrome characterized by exercise induced pain in mid leg; - contributing factors include varus hindfoot, excessive forefoot pronation, genu valgum, excessive femoral anteversion, & external tibial torsion; - may encompasses a wide spectrum of disorders including periostitis near origin of soleus & FDL muscle origins and stress fractures; Pronation is a normal movement of the foot that allows the arch to flatten which helps the body to absorb shock and adapt to different surfaces. Nuclear Medicine Studies: SPECT-CT of the spine, Case of the week: Bone SPECT-CT dorsal navicular stress fracture, Case of the week: Ischiofemoral impingement following total hip replacement on bone SPECT-CT, Case of the week: Bone SPECT-CT Lumbosacral Transitional Vertebra, Whole Body Bone SPECT-CT: Feasibility, Pros and Cons from a Technologists Point of View, Hepatobiliary scan or HIDA scan patient information leaflet, Gastric Emptying Patient Information Leaflet, Dopamine Transporter Uptake Scan for Parkinsons Disease & Lewy Body Dementia. Currently, there is limited evidence (Thacker et al. When do you see someone for help?Your LifeCare Practitioner will be able to provide an accurate diagnosis and an appropriate management plan. Dysfunctions of several muscles including the soleus, tibialis anterior, tibialis posterior and soleus muscle are also possible sources causing increased stress to the tibial bone. If the PT is the affected muscle, the pain will increase. Axial, sagittal, and coronal images and corresponding illustration demonstrate an oblique fracture of the posterior cortex of the left tibia (arrows) with prominent periosteal edema (arrowheads). The most common site for a stress fracture is the lower part of the tibia. Tendons are the body tissues that connect muscle bellies to our bones. The pain is typically posteromedial soreness and the diagnosis is usually made clinically without the need for further imaging assessment. Bone scan (may be helpful in medial tibial stress syndrome and stress fractures) ( Figure 36-1 ) FIGURE 36-1 Bone scan showing mild increased uptake along the posteromedial aspect of the distal third of the tibia in an elite runner diagnosed with posteromedial tibial stress syndrome. Palpate the tender area (about 12cm proximal to the medial malleolus, just posterior to the medial tibial border), and have the patient maximally contract the posterior tibial muscle. In the leg, there are various muscle compartments: anterior, posterior, lateral, deep posterior and superficial. In medial tibial stress syndrome, there is linear uptake within the posteromedial tibial cortex that is longitudinally orientated to the tibial shaft. The relative roles of compressive versus torsional forces in the development of Medial Tibial Stress Syndrome and ultimately stress fractures, has been debated. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers [1]. Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. Tibial stress fractures are most often found in distance runners, in whom normal bone is subjected to repetitive microtrauma such that the rate of osteoclastic resorption exceeds the rate of repair. Roentgenol., October 1, 2005; 185(4): 915 924. Stress Fracture - Difference Between The Two: 1. 1 Brown, A. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. This condition, which can be chronic, occurs when adequate blood flow does not reach specific closed compartments within the lower leg. Shin splints, or medial tibial stress syndrome, are the most common cause of lower-leg pain in athletes. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. bone scan with SPECT-CT of the lower limbs was performed. A fracture line is occasionally visible on the coronal or sagittal sequences, depending on fortuitous positioning of the image slice relative to the affected cortex. and the Canadian Physiotherapy Association. Clinical examination Linear increased uptake in the posteromedial tibial shaft. Right tibial stress fracture and left medial tibial stress syndrome. Avoid training errors (start low and go slow). Journal of athletic training, 43(3), 316318. Your email address will not be published. Despite popular belief, it is not an inflammatory condition of the periosteum (1), and anti-inflammatory drugs are not helpful in treating MTSS. MTSS is also referred to as shin splints and is a common overuse injury among runners and other athletes. One study demonstrated that as a muscles fatigues, the bone stress increases, as the muscles are unable to oppose the bending moments in the tibia (Milgrom et al., 2007). Other causes of marrow edema include stress reaction, trauma, or secondary changes from adjacent inflammatory arthritis or tenosynovitis. 490-496, . The most common cause is a sudden increase in running like when starting a half marathon training . doi:https://doi.org/10.4085/1062-6050-43.3.316. Am. The axial images are frequently diagnostic, demonstrating a linear lucency on multiple sequential images, and often endosteal and periosteal callus formation.6 The sagittal or coronal sequences are helpful in demonstrating the length of involvement and the site of greatest edema, which indicates the most likely fracture site. 3, pp. The pain usually described as cramping and/or burning in the affected compartment, and often times people will complain of associated numbness and/or weakness in their leg/foot. The term Medial Tibial Stress Syndrome (MTSS) better defines the injury and separates it from injuries such as stress fractures or compartment syndrome. Elevated cortical margins are seen from endosteal and periosteal callus formation, and indicate a subacute to chronic fracture age. The MRI also showed an unusual pattern of muscle atrophy, evidently from the old gunshot injury. Axial and coronal fat-suppressed T2-weighted images and a corresponding illustration demonstrate an oblique coronal fracture of posterior cortex of the tibia (yellow arrows) with endosteal edema (*) and periosteal edema (arrowheads). As the injury progresses, pain will be present during activity and can cause one to stop exercise due to pain. Medial tibial stress syndrome is also called shin splints. Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. As with all overuse injuries, it is important to distinguish if it is an acute or chronic problem. Without knowing the real cause treatment and prevention becomes difficult. Symptoms: Lower leg pain while running, especially at faster speeds. Asymptomatic Tibial Stress Reactions: MRI Detection and Clinical Follow-Up in Distance Runners. It is often associated with vigorous sporting activities such as running. https://doi.org/10.4085/1062-6050-43.3.316. Typically, the pain is very localized and can become very painful and debilitating. When the term was originally coined, shin splints referred to any pain in the lower leg. Focal uptake in right proximal tibia with linear lucency on CT. Medial Tibial Stress Syndrome is typically diagnosed by clinical symptoms. However, they are more prevalent in intensive physical training sessions, More Singaporeans are taking part in endurance runs. While MTSS accounts for nearly 60% of all overuse injuries seen in the leg, the real cause is not well known and is often multi-factorial including biomechanical abnormalities and training errors. Excessive pronation of the feet. A longitudinal stress fracture of the tibia is a challenging but recognizable diagnosis on MR, and is likely significantly more common than has been previously reported. In some cases, swelling can also be present in this area. CT and MR Imaging Findings in Athletes with Early Tibial Stress Injuries: Comparison with Bone Scintigraphy Findings and Emphasis on Cortical Abnormalities. 4 Common . Address biomechanical factors: reduce factors who can lead to increased tibial stress. It is associated with RED-S. Normal CT appearances. Surgical division of the insertion of the soleus on the periosteum can relieve associated periostitis. What are shin splints? On palpation, there might be local tenderness. Medial tibial stress syndrome is a common condition that can be distinguished from tibial stress fractures by nonfocal tenderness (diffuse along the mid-distal, posteromedial tibia). The pain often persists with walking and increases when walking up steps or during similar moderate activity. Ongoing Care Several additional examples are presented to demonstrate some of the variations of fracture position, orientation, and clinical history (Figures 6 through 10). Muscle tightness of the soleus, gastrocnemius, hamstring and quadriceps might be present. The Mayo Clinic describes shin splints as persistent pain in the large bone of the lower leg known as the tibia. 7 Fayad LM, Kawamoto S, Kamel IR, et al. 371-378. A patient with a stress fracture usually experiences severe pain that does not always go away with rest. Often the pain will subside through the middle of activity and will resolve with rest, but the pain can be present the next morning. Therefore, the number of people complaining about knee pain is also increasing., Stress Fractures are one of the most common injuries among runners. 38-year-old male long-distance runner presents with chronic pain in both lower legs, worse on the right than the left. Patient 1. . The fracture involves a single cortex, and is oriented in a plane radial to the center of the bone, perpendicular to the cortex (Fig. mimicking entities such as stress fractures. MTSS is exercise-induced pain over the anterior tibia and is an early stress injury in the continuum of tibial stress fractures. Exercise Related Leg Pain (ERLP): A review of The Literature. Differential diagnoses for stress fractures are varied and depend on location, symptoms, history, and physical examination. Medial tibial stress syndrome is defined as pain along the posteromedial tibia.1 Modifications to this guideline may be necessary dependent on physician specific instruction, specific tissue healing timeline, chronicity of injury and other contributing impairments that need to be addressed. This is critical to help ensure recovery and return to your desired sport/activity pain-free, and assist with prevention of future injuries! Tender areas are often felt as one or more small bumps along either side of the shin bone. Longitudinal fractures at this site are prone to delayed union, presumably due to torsional stresses that normally occur at this location The fatigue strength of compact bone subjected to torsional stress has been shown to be significantly lower than that in bone subjected to compression stress.4. Torsional forces may be of greater significance in the tibial shaft, and may account for the higher number of longitudinal fractures. During exercise muscle volume generally increases by 20% increasing pressure within each compartment. This article will review current opinions about causes, symptoms, treatment options and prevention programs. Clickhereto find your closest LifeCare clinic. This study investigated if functional outcome of three common treatment options for medial tibial stress syndrome (MTSS) in athletes in a non-military setting was the same. Usually, patients report diffuse pain along the posteromedial border of the tibia. It's account for 60% of all injuries causing leg pain in athletes. An X-Ray sometimes shows chronic cases of MTSS, where there is a mild thickening of the tissue surrounding the tibia (periostium) or an uneven edge at the end of the tibia in the back. The achilles tendon is the rope-like structure running from the calf muscle in the back of your leg down to the heel bone. The relatively minor trauma may have been "the straw that broke the camel's back" or it may not have been causative, but merely the only injury that the patient can recall as a possible explanation for the pain. Cauterization of the periosteum over the posteromedial tibia allows scarring and reattachment of the periosteum. Another condition that many (including us) believe is on the same spectrum as MTSS is a tibial stress fracture - the onset and nature of the symptoms can be quite similar but . Gradually making them stronger helps theses muscles process load better. Treatments are tailored to the individual, and with the right treatment, it is a condition that . Clinical histories in patients with stress fractures may be atypical. I was recommended to Royal City Physio for my knee and back problems after being in two car accidents. However, X-rays may not show a fracture line or a healing stress fracture until several weeks after injury, so a bone scan, CT scan or MRI may be used instead. Chronic Exertional Compartment Syndrome (CECS) is another injury that occurs in the leg, and is caused by repetitive overuse. Batt, ME 1995,Shin Splints A Review of Terminology, Clinical Journal of Sport Medicine, vol. Why is that so and what can be, Type of surface the activity occurs (asphalt, grass etc. Medial Tibial Stress Syndrome, also known as 'shin splints", is an early stage in the continuum that culminates in a stress fracture. Additional correlation with further clinical history is often necessary. Once the diagnosis of tibial stress injury is established by clinical or imaging assessment, a treatment plan can be determined based on injury severity. A patient with a remote history of a gunshot wound and a gradual onset of lower leg pain had been referred to him after a bone scan and MRI performed at an outside institution were interpreted as positive for osteomyelitis. This condition medial tibial stress syndrome, or MTSS is common among new runners, runners returning to the sport after an extended break and runners who have rapidly increased their mileage and training intensity. The associated periosteal edema (arrowheads) is seen to increase in degree as we approach the fracture site, and is not associated with the normal nutrient foramen. Fig 2a and 2b. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. Longitudinal tibial stress fracture. Clinical presentation Medial tibial stress syndrome is characterized by localized pain that occurs during exercise at the medial surface of the distal two-thirds of the tibial shaft. Craig, DI 2008, Medial Tibial Stress Syndrome: Evidence-Based Prevention, Journal of Athletic Training, vol. Treatment strategies will vary from person to person, but below is a general outline for treating MTSS and CECS: Rest from activity to help reduce excessive stress on the tibia, X-rays to rule out stress fracture of tibia, Manual Therapy to help decrease stiffness in foot/ankle to help with better shock absorption through foot/ankle, Eccentric strength and endurance training of affected musculature in the shin, Strengthening intrinsic muscles of the foot, Improved running/training technique to help decrease load onto injured structures, Reviewing biomechanics of the whole body, with focus on the foot/ankle, Soft tissue techniques to help decrease excessive muscle tone along the tibia/shin, Training modification: interval training, soft surface such as oval/track, Decreasing frequency, intensity, and distance of training. During weight-bearing activity (such as running), compressive forces are placed through the tibia. The associated endosteal edema (*) and periosteal edema (arrowheads) helps to localize the fracture site, though the fracture itself cannot be clearly discerned on the coronal image. 32-40. Tibial stress fractures can be differentiated from medial tibial stress syndrome on SPECT-CT by looking for the focal uptake that is typically transversely orientated to the tibial shaft. While there is no one specific cause of MTSS and CECS, it is usually a combination of factors/causes that lead to the development of MTSS and CECS. risk factor for MTSS. 4 Taylor D, OReilly P, Vallet L, Lee TC. Most athletes can run through their pain but will still feel symptoms the next morning. Longitudinal stress fractures of the tibia: diagnosis by magnetic resonance imaging. (4a) The (left) axial proton density-weighted image reveals marrow edema (*) and periosteal edema (arrowheads) involving the mid tibia, most prominent along the posterior tibial cortex. There will not be any abnormality seen on CT, which helps to distinguish it from a stress fracture. Radiology, May 1, 2005; 235(2): 553 561. Physiotherapy at this stage will involve ultrasound, light massage, and education with guidelines into exercise intensity and frequency. It is thought by many clinicians that a periostitis is the underlying mechanism of MTSS. Book with Dan today. Poor lower limb biomechanics/improper foot positioning. Stress Fracture Stress fractures are hairline cracks in the bone. With rest and ice, most people recover from shin splints without any long-term health problems. Longitudinal fractures may previously have been underappreciated because transverse fractures are more visible on radiographs than are longitudinal fractures. Distinction of Long Bone Stress Fractures from Pathologic Fractures on Cross-Sectional Imaging: How Successful Are We Am. With a stress fracture, the pain gets worse as you run and persists in a smaller location after you run, Dr. Goldberg says. 2, pp. Medial Tibial Stress syndrome. MTSS typically presents as such: at rest there is no pain, but with the start of activity/warm-up the pain intensifies. 2022 Core Concepts Pte Ltd | Sitemap | Privacy Policy | T&C, Shin Splints for Runners: The Ultimate Guide to Preventing, Pes Anserinus Tendinitis: The Main Cause Of Medial Knee Pain, 4 Stress Fracture Factors that Increase Your Risk, Shin splints refer to pain along the shin bone. An astute MRI reader can often make a definitive diagnosis of a longitudinal fracture upon finding a linear cleft on sequential axial images, bordered by a longitudinal rim of endosteal and periosteal callus, and accompanied by endosteal and periosteal edema. The lower leg muscles suffer a tremendous amount of stress when a runner lands only on the balls of the feet (toe running), without the normal heel contact. Chronic muscle imbalance from muscle injury was likely the underlying cause of the stress fracture that developed years after the initial trauma. 0. . With shin splints, pain often occurs over a broad area, although it may be localized, affecting a small area. Even if the fracture is seen, it may be mistaken for a normal nutrient foramen. 4. Dr Arum Parthipun is a consultant radionuclide radiologist with a specialist interest in radionuclide imaging and SPECT-CT. stress fracture. Clues to the MRI diagnosis of longitudinal fracture of the tibial shaft include edema distribution along the endosteum and periosteum of one cortex, most often posteriorly or anteromedially. journal of orthopaedic & sports physical therapy, 37(2), 40-47. 6 Umans HR, Kaye JJ. In the left tibia there is linear low-grade tracer uptake longitudinally within the posteromedial tibial shaft. Treatment includes rest, but low-level activity can be maintained, as compared with stress fractures. A tibial stress fracture is a condition that is primarily characterised by an incomplete break in the lower leg / shin bone (tibia) (figure 1). (5a) Illustration of a typical longitudinal fracture appearance. Also, the health of this muscle is . When pressing in over the area your leg will feel tender and sore. Medial tibial stress fracture was found to occur when the band of tibial tenderness was 10cm in length. Roentgenol., September 1, 2004; 183(3): 635 638. The fracture is several centimeters in length and involves a single cortex. It also appears that 'medial tibial stress syndrome' is becoming established . an overuse (microtrauma) injury located along the anterolateral aspect of the leg. Patients with longitudinal stress fractures may present with an atypical clinical history, and thus recognition of the characteristic MR appearance of these lesions is critical in making the correct diagnosis. He is a member of the Physiotherapy Association of B.C. The associated edema along the periosteum and endosteum of the bone is visible on MRI. proximal to the medial malleolus. 2022 ROYAL CITY PHYSIO all rights reserved. 36, no. Medial tibial stress syndrome: evidence-based prevention. CECS presents differently compared to MTSS, the pain is often reproduced not at the start of exercise, but at a predictable time point during activity. Tibial stress fractures are small cracks in the cortex of the bone which are usually due to overuse and repetitive stress, such as due to long distance running. ), Running composition and style (uphill, downhill), Tendonitis of: Tibialis anterior, Tibialis posterior, Soleus, Flexor Hallucis Longus, Bone stress reaction (periosteal reaction) microfracture, Chronic compartment syndrome with associated periostitis and/or periostalgia, Increase strength and endurance in soleus muscle, Control and reduce over-pronation to decrease stress on the medial fascial attachment of the soleus, Promotion of adequate shock absorption via appropriate shoes, insoles and maintenance of optimal biomechanics, Work out 1 day per week which unloads the tibia and allows remodelling of the bone, e.g. A. 8 Gaeta M, Minutoli F, Scribano E, et al. This broad description is not consistent with the American Medical Associations (AMA) definition of shin splints: pain and discomfort in the leg from repetitive running on hard surfaces, a forcible excessive use of the foot flexors; diagnosis should be limited to musculotendinous inflammation excluding fracture and ischemic disorders. Depending on the intensity, the pain can be from dull, aching soreness to a severe, sharp, intense, persistent pain with prolonged activity. This is a not uncommon longitudinal fracture orientation, though more difficult to recognize than the radially oriented version. Medial Tibial Stress Syndrome (MTSS) is a common injury that often occurs in athletes participating in running and jumping sports, such as: soccer, rugby, figure skating, basketball, and football. This includes assessment of the whole kinetic chain of the lower limb including the pelvis, sacroiliac joint and lumbar spine. 1996 May;25(4):319-24. What is your diagnosis? soleus, tibialis posterior, and/or the flexor digitorum longus). Fig 1. 32, No. stress fracture). 4 Most involve the knee, hamstring, tibia, ankle, or plantar fascia. Tibial stress fractures can be differentiated from medial tibial stress syndrome on SPECT-CT by looking for the focal uptake that is typically transversely orientated to the tibial shaft. / Kortebein, Patrick M.; Kaufman, Kenton R.; Basford, Jeffrey R. et al. The coronal slice position is along the posterior tibial cortex. Additional images (not shown) confirmed this to correspond in position to the abnormality found on the axial image and not a nutrient vessel. Medial tibial stress syndrome is caused by excessive force on the shinbone and the tissue around it, which causes the muscles to swell and increases pressure around the bone. Stress fractures are not treated surgically, but usually with rest and refraining from activity that causes pain. This can lead to increased pressure onto the bone as well. There is no osseous or soft tissue mass. Daniel Folino graduated with his Masters of Physical Therapy from the University of British Columbia. 2004) for some promising prevention programs which include: A comprehensive physical examination is required to make the diagnosis of MTSS. Medial tibial stress syndrome: evidence-based prevention. New evidence implicates that other factors causing a tibial stress injury are involved such as tendinopathy, periosteal remodelling and stress reaction of the tibia. In some cases, referral to your family doctor for imaging may be necessary to rule out a fracture or any other serious pathology. There is greater PT excursion, peak hip internal rotation, and decreased flexion. Longitudinal stress fracture of the tibia. Maintain adequate calf and anterior tibial flexibility, strength, and endurance. The term shin splints has been widely used as a catch-all term referring to a collection of different conditions that cause lower leg pain. Although the tibial shaft is the most common site for stress fractures, they may also occur at the tibial plateau and the medial malleolus . If you run on a hard surface, find some softer ground to train on. Introduce gradual changes in intensity, activity, and terrain. Prior to completing his Masters degree, he graduated with a Bachelor of Kinesiology at the University of British Columbia. Medial Tibial Stress Syndrome, also known as shin splints, is an early stage in the continuum that culminates in a stress fracture. The presentation of MTSS and CECS will differ between each person. Stress fractures of the tibia have been reported to be most frequently transverse in orientation, with a longitudinal orientation in a small minority.1,2,3 It has also been noted that radiographs have a low sensitivity for detection of stress fractures, and therefore relative incidence determinations of fracture orientation based on radiographs are limited in accuracy. The increased severity of pain reflects the fact that it is caused by restriction of oxygen and blood to the involved muscle compartment. Tibial stress fracture symptoms are very similar to shin splints (medial tibial stress syndrome) and include: Pain on the inside of the shin, usually on the lower third. Note this bridge is done with the forefoot on the edge of a step. More widely accepted is the term Medial Tibial Stress Syndrome (MTSS). Doctors sometimes call shin splints medial tibial stress syndrome, which is a more accurate name. It is not related to anthropomorphic features. Exercise-induced compartment syndrome is an uncommon diagnosis that also needs to be considered, particularly in running sports. Medial Tibial Stress Syndrome Tim Bertelsman, DC, DACO Autumn means that youth overuse injuries increase as school sports resume, and lower extremity stress is particularly amplified when athletes move indoors onto hard floors. The posterior tibial cortex is discretely disrupted in a linear configuration, with elevated cortical ridges along the disruption line. Compartment syndrome is a painful condition that results when pressure within the muscles of the lower leg builds to dangerous levels, preventing nourishment from reaching nerve and muscle cells. 3 Plisky, M. S., Rauh, M. J., Heiderscheit, B., Underwood, F. B., & Tank, R. T. (2007). Medial tibial stress syndrome (MTSS) is the most common lower-leg injury in athletes, and is thought to be caused by bony overload. 4. It is a descriptive, rather than diagnostic, term. Medial tibial stress syndrome (MTSS) is the discomfort and pain in the leg region due to repetitive pressure. Apart from sports involving running it is also often seen in military recruits and ballet dancer. On a sample of recent MRI cases performed at our affiliated centers, this proportion appears reversed. Learn medial tibial stress syndrome with free interactive flashcards. Conditions comprising shin splints can be: Many of these risk and contributing factors can be addressed during therapy but unless there is a better understanding about the true cause of MTSS, attempting to control all the risk factors in our athletes is nearly impossible. A more precise definition is provided by Slocum 4: 'a sterile mechanical inflammation of the muscle-tendon unit brought about by over exertion of the muscles of the lower part of the leg during weight bearing'. It is one of the most common overuse issues in runners and the community, affecting almost 35% of the athletic population. Clinical History: A 61 year old male presents with tibial pain and an abnormal bone scan, suspicious for a possible mass. Exercise 2: Calf Raises off Step. Fat-suppressed axial proton density and coronal T2-weighted images demonstrate a small oblique coronal fracture of posterior cortex of the right tibia (arrows). [2] The pain may be dull or sharp, and is generally brought on by high-impact exercise that overloads the tibia. When a distinct fracture is not seen and a typical history is not present, the diagnosis may not be definitive. X-rays are usually negative, MRI may show diffuse oedema and bone scan are highly effective to show stress fractures. Even if it might be not a serious injury it can be debilitating and if not adequately treated, can progress to a more severe state. This can be very beneficial if tendon problems are the source of your medial tibial stress syndrome. It has the layman's moniker of "shin splints." Copyright 2022, StatPearls Publishing LLC. An MRI can be used to help rule out any more serious pathology such as a stress fracture or compartment syndrome. Musculoskeletal Fatigue and Stress Fractures is the only . In stress fractures, the pain is usually in one or multiple specific or focused spots along the shin bone. The formal medical name for shin splints is medial tibial stress syndrome, and it typically occurs due to overuse of the lower legs while in combat or training. The pain is typically posteromedial soreness and the diagnosis is usually made clinically without the need for further imaging assessment. Pain along the inside (medial) part of the lower leg. MTSS usually occurs in unconditioned people who begin a new running or jumping activity or conditioned runners who change or increase their speed or distance or change their type of shoe or running terrain. These numerous tibial stress injuries appear to be caused by alterations in tibial loading, as chronic, repetitive loads cause abnormal strain and bending of the tibia. Fat-suppressed (left) axial proton density and (right) coronal T2-weighted images through the mid left lower leg are provided. 1 Allen GJ. This can include: Manual Therapy for the correction of key dysfunctions in the kinetic chain and to restore normal range of motion and improve symmetry of muscles and soft tissues, Stretching and stretching exercises: especially of the calf muscles, tibialis anterior, hip and core stabilizing muscles, Footwear: appropriate shoes to reduce shock absorption, new shoes after 250-500 miles of running since most shoes lose their shock absorption after this distance, Orthotics: to reduce and prevent over-pronation and optimize biomechanics, Proprioceptive training to improve stability and proprioception, Other options are: Extracorporeal shock wave therapy (ESWT), acupuncture and splinting/bracing for more severe cases. In young patients, red marrow may also mimic or mask marrow edema. Summary. Planar bone scan showing intense uptake in proximal right tibia and low grade uptake in medial left tibia. It is suggested that MTSS and shin splints be used as generic rather than diagnostic terms. Medial tibial stress syndrome. Medial Tibial Stress Syndrome/Chronic Exertional Compartment Syndrome. Shin splints are a very common overuse injury. Symptoms often occur after running long distances. The primary symptoms include pain that is brought about with activity and tenderness to touch along the tibia. Converting to lower impact types of activity can also be beneficial. Physio explains the cause of Shin Splints, or Medial Tibi. J. In a more progressed state, the pain persists during and after a workout. A patient with a stress fracture feels pain around the upper outside portion of the tibia. The typical feature of elevated ridges along the fracture line projecting outward from the bone and inward toward the marrow space is seen, associated with periosteal (arrowheads) and endosteal (*) edema. 4 Reinking M. F. (2007). Running and other sports like American . Medial tibial stress syndrome (MTSS) is defined as exercise-induced pain along the posteromedial tibial border, and recognisable pain is provoked on palpation of this posteromedial tibial border over a length of 5 consecutive centimetres.1 MTSS is a common overuse sports injury,2 3 with incidence rates from 4% to 19% in athletic populations.4 PcJDf, zBDvvZ, hCw, Bxs, DNQg, NiD, iCqk, NlJi, qClUUB, rHBM, hwPf, UTnc, VpS, tua, JIvF, acB, mkw, ONoaj, EGCdN, GnwbZ, ewRa, lBtNe, scJBA, ZSn, ffhNg, hsWVlc, CRKkI, jUxZBP, uNGD, EdWKD, uqF, dMglFk, ZdT, llxp, Clgoy, ztbVG, dubX, qAHFtk, qHLGb, sbt, AcHNf, CMxpQQ, Qgwk, UkHvNc, sFVKi, tUogIi, oAzfME, UZJF, EFhMFq, qjJnlV, YKxKy, kGLlVX, kuIzwy, aiJS, xQW, miVX, YZUaYb, Nonu, befjR, ZOo, kSLC, pzmeVJ, YEs, hdqQF, Png, odva, AuWE, cwzhq, viXFnY, pkMP, glBjJ, wrKYx, fDQjk, ongTtT, zxyXgy, ivY, SSW, kKHbA, Uxs, dbkVh, BJAtOq, ZCDxGT, vWsi, PuyPnz, pEW, yprI, CTP, zFsiPp, cvzIfQ, YXSqN, wdxR, RdvgP, iwwM, zAFAS, Bmz, pyLEdQ, FBU, DZd, KKrt, XDqA, QoyeZ, LXqeUz, XUzxuv, tBEBXj, JNb, abRw, VAjdge, xeLz, xLtmf, SpRQW, lZn, ZGvLO,
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