It is defined as exercise-induced pain along the distal posteromedial border of /Name /Im0 WebDoctors sometimes call shin splints medial tibial stress syndrome, which is a more accurate name. Franklyn M, Oakes B. Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. For 17 years, we've helped hard-working physiotherapists and sports professionals like you, overwhelmed by the vast amount of new research, bring science to their treatment. Nuclear bone scans or magnetic resonance imaging findings need to be considered in conjunction While these studies have provided information on the stress or strain experienced by the tibia under different types of impact exercise, in all these studies, the subjects had no pathology, and the stress or strain experienced by the tibia is likely to differ between these non-injured subjects and individuals with MTSS or a TSF. This month, get insight and expertise on: Practical injury prevention advice, diagnostic tips, the latest treatment approaches, rehabilitation exercises, and recovery programmes to help your clients and your practice. Characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, in most cases it is also an injury involving underlying cortical bone microtrauma, although it is not clear if the soft tissue or cortical bone reaction occurs first. PROTECTthe area from further injury (i.e. Deep posterior compartment : this part have the flexor digitorum longus, the tibialis posterior and the flexor hallucis longus musles. A bilateral Zanca view maydemonstrate that the distal clavicle is slightly elevated, but the CCinterspace is the same in both the injured and uninjured shoulders. All occur by an overuse mechanism. Would you like email updates of new search results? A full strength/power assessment of all the muscles of the leg should be performed as well as a full vascular and neural exam. Chronic Exertional Compartmental Syndrome, Nerve entrapment (common/superficial peroneus and saphenous), Pain while performing activities of daily living, Limitations in Day to day activity or sports activities. Shalby Hospital, near Fortune Circle, Ahmedabad, Gujarat 382330, Your email address will not be published. Adequate warm-up, including stretching, before soccer practice and games. Shin splints are a very common overuse injury. This clearly requires further examination. Marrow oedema on T1 and STIR-T2-weighted images, Requires less firm palpation and may have linear tenderness as above, May have subcutaneous anteromedial tibial oedema, Periosteal oedema: moderate to severe on T2-weighted images. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. The authors would like to gratefully acknowledge Mr Jeff Copeland for compiling and formatting the references and photographing the MRI images. REST does not imply halting all soccer activity, and your injured athlete can be running in deep water, cycling, etc. MTSS is an overuse fatigue injury involving tibial periostitis in conjunction with cortical bone oedema and microtrauma, although the cortical bone response may not occur in all individuals. Physicians will often prescribe anti-inflammatory medication and therapists can apply various electrical modalities that will assist in controlling inflammation and returning the area back to optimal function. Gradually making them stronger helps theses muscles process load better. There are many different opinions as to the specific cause of tibial stress, including: P.R.I.C.E. /BitsPerComponent 8 The https:// ensures that you are connecting to the MRI exams now demonstrate excellent anatomical resolution of both bone and soft tissue. Thus, while nuclear bone scanning is an important diagnostic tool, the results need to be considered in conjunction with the patients clinical symptoms for a correct interpretation of the findings. physiotherapy clinic bapunagar In a subsequent study, the authors found that after recovery from the injury, the BMD returns to normal[32]. However, This disease are often not serious, if treated properly, it can be quite disabling and progress to more serious complications. /Type /XObject Superficial posterior Compartment : this is the gastrocnemius and soleus muscles are strongly plantar flexors of the ankle.Lateral compartment : this compartment have the peroneus brevis and peroneus longus muscles, mainly work as a foot evertors. However, cortical bone geometry and BMD also differs between TSF and MTSS patients[33,38], indicating there may be different specific biomechanism involved in each case. >> 2016 Mar;50(5):273-80 WebMedial tibial stress syndrome (MTSS - commonly known as shin splints) is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes and other active individuals. The leg should also be examined for any subcutaneous oedema, which indicates periostitis is present and probable associated microfractures. No palpabledisplacement of the joint itself. In addition, the loading conditions on the model can easily be altered so the direct relationship between applied load and stress or strain in the bone can be determined, and the model geometry can also be changed. Bookshelf Clipboard, Search History, and several other advanced features are temporarily unavailable. Reviewers were blinded to the authors' names and affiliations but not the results. It was also found that the tensile failure will occur first, before any compressive failure occurs[16], which differs from most engineering materials, where cyclic loading results only in tensile failure. ? We use cookies so we can provide you with the best online experience. Sciatica This site needs JavaScript to work properly. These injuries present as a more severe type III injury withmore pain and a greater amount of displacement at the AC joint. What grade of pain would the patient be assigned? One of the current authors (Oakes[24]) first proposed this in 1988, where, based on the bone fatigue studies which had been conducted at the time and his own extensive clinical observations, MTSS could be classified into two main categories, where the first type was associated with external cortical bone microfractures, and both types may also be seen together to form a third type of MTSS. However, not all cases of MTSS lead to a TSF; if they were one injury on a continuum, all MTSS patients would eventually sustain a TSF with continued exposure to the same impact forces, yet this does not occur. We strip away the scientific jargon and deliver you easy-to-follow training exercises, nutrition tips, psychological strategies and recovery programmes and exercises in plain English. Type V injuries represent a greater degree of soft tissue damage withthe deltotrapezial fascia being stripped off the acromion and theclavicle. Foot pronation, indicating weak invertors, may signify an alignment problem associated with a TSF or MTSS. Strznickel J, Jandl NM, Delsmann MM, von Vopelius E, Barvencik F, Amling M, Ueblacker P, Rolvien T, Oheim R. Knee Surg Sports Traumatol Arthrosc. /Count 0 Epub 2016 Dec 5. HHS Vulnerability Disclosure, Help The prevention of shin splints in sports: a systematic review of literature. Br J Sports Med. Contemporary accurate diagnosis of either MTSS or a TSF includes a thorough clinical examination to identify signs of bone stress injury and to exclude other pathologies. The tibialis posterior plantar flexes and inverts the foot. Bethesda, MD 20894, Web Policies They therefore concluded that the tibialis posterior may be the cause the type of MTSS which occurs in the lower third of the tibia, since this muscle correlates to the location of the symptoms. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD. Johnell et al[13] first demonstrated microtrauma was a cause of MTSS from bone biopsies obtained from chronic MTSS patients undergoing fasciotomy after failing to respond to conservative treatment, and bone biopsies from control subjects at autopsy or who were undergoing surgery for other injuries. Running on a hard or uneven surface and poor running shoes (like a bad shock absorbing capacity). Bramsche, Germany: Rasch Druckerei; 2012, British Journal of Sports Medicine. Treatment includes resting the bone, anti-inflammatories, physical therapy, and sometimes surgery. The pain may be dull or sharp, and is generally brought on by high-impact exercise that overloads the tibia. official website and that any information you provide is encrypted This overview article provides an evidence update on the diagnosis and management of athletes with medial tibial stress syndrome. Based on their MRI study of 14 patients with 18 symptomatic legs, Fredericson et al[12] postulated that periosteal oedema occurs prior to the formation of cortical bone microcracks, as only periosteal oedema was detected in their patients with the mild injuries, or the MTSS, while those with more severe injuries had both periosteal oedema and either a partial fracture, or marrow oedema indicating bone microtrauma. In the second case, muscle fibre traction is postulated to cause periostitis which may or may not lead to cortical bone microcracks. All multiple focal areas of signal abnormality in grade 4a stress injuries were located in the anterior and posterior tibial cortex (Figs. If warranted, selected diagnostic tests may be ordered such as X-rays, bone scans, etc. The advent of MRI and developments in this imaging modality over the last 10-15 years has given the treating physician an alternative option involving no ionising radiation. Minimal to moderate tenderness andswelling over the AC joint. The distalend of the clavicle may be palpated to be slightly superior to theacromion and shoulder motion produces more pain at the AC joint. The above research on cortical bone cyclic testing, both in vitro and in vivo studies, provided invaluable data on the development of fatigue injury in cortical bone. Control Abuse. It is important, as with all overuse injuries, that a correct diagnosis be determined before the cycle of pain becomes established. In another BMD study on MTSS patients, Ozgrbz et al[34] found that the BMD did not differ between MTSS patients and aerobic controls in several different bones, including the tibia at three different sites. Keywords: Each study was evaluated independently for methodologic quality using a 100-point checklist. An official website of the United States government. CT imaging could be used in conjunction with radiography and a nuclear bone scan for cases where a TSF was suspected, as small overt fractures could often be observed, such as small fracture in the navicular, other tarsal bones, the carpals and the sesamoids of the foot, and avascular necrosis of these bones could also be identified. Physicians could use it to follow patients at various points in time, and it was particularly useful for clinical trials, as the long-term response of bone and soft tissues to both normal and excess loading conditions could be determined. Keep up to date with the science and best practice in managing sports injuries. Physiotherapy Exercise No current evidence supports any single prevention method for MTSS. 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. The MTSS score mainly measures pain over the shin and limitations of activity due to shin pain. This work has involved either BMD measurements or detailed tibial cortical bone geometry studies. The MTSS patients were diagnosed both clinically and by a nuclear bone scan, and all had medial diffuse pain at the junction of the middle and distal thirds of the tibia (it was not stated if all patients had posteromedial pain, although this was implied in their introductory discussion). A sport medicine practitioner will take a history of the injury, conduct a physical examination of the injured area, and undertake a biomechanical assessment of the soccer player's lower extremity (looking for anatomical abnormalities). P- Reviewer: Ohishi T, Zak L S- Editor: Ji FF L- Editor: A E- Editor: Jiao XK, BPG is committed to discovery and dissemination of knowledge, Sep 18, 2015 (publication date) through Dec 11, 2022, Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA, Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. Epub 2018 Mar 24. WebOne of the most common shin conditions is Medial Tibial Stress syndrome, an overuse injury usually caused by kicking and running. Both MTSS and TSFs occur from microcracks developing in cortical bone as the anterior cortex of the tibia cycles from overt compression loading on heel-strike to tension loading at push-off, and both injuries involve an alteration in cortical bone geometry[38] and BMD[31-33]. Conducting this type of experimental work on injured subjects would provide invaluable data pertaining to the injured tibia; however, there are obviously ethical and other considerations in performing this type of analysis which may preclude this type of study from being conducted, especially on subjects who are injured. w !1AQaq"2B #3Rbr Nuclear bone scans and magnetic resonance imaging (MRI) can both be used for the diagnosis of MTSS, but the patients history and clinical symptoms need to be considered in conjunction with the imaging findings for a correct interpretation of the results, as both imaging modalities have demonstrated positive findings in the absence of injury. 2015. /Height 2240 Low Back Pain Performing strain gauge experiments on MTSS patients may provide a critical insight into the strain experienced by the tibia when injured; however, there are obviously ethical considerations in surgically bonding strain gauges to the bone of injured individuals. government site. 2000;32(3 suppl):S27S33, Phys Med Rehabil Clin N Am. Physiotherapist also checked Aggravating factors and relieving factors are noted and explain to you. The cause of the injury should be established and addressed in order to facilitate healing and prevent future re-occurrence. Developing collective mental resilience to manage competition demands, State of mind: Understanding cognitive load in performance and injury rehabilitation. Knee Surg Sports Traumatol Arthrosc. In summary, previous studies on BMD and cortical bone geometric parameters demonstrate that patients with MTSS have lower BMD and lower values of various cortical bone geometric factors than aerobic control subjects. It is characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, most often on the medial border near the junction of the mid and distal thirds of the tibia[1]. Unlike the studies on cortical bone specimens, these in vivo tests may account for adaptive remodelling in living cortical bone. The extensor digitorum longus extends the other toes and assists in eversion with the the peroneus tertius muscle. Accessibility Plain radiographs were often normal in the early stages of a suspected TSF (e.g., 3-4 wk post-symptoms or 4-6 wk post-injury), but a nuclear bone scan may be positive, demonstrating early uptake of radionuclide in the region of increased vascularity of the overt fracture not readily seen on plain radiographs, such as a fractured navicular in a running athlete or a fractured scaphoid in a gymnast. Accuracies of 75% or greater have been found for nuclear bone scans[10,26,27], although it has been criticised for resulting in false positives: it has been argued that increased radionuclide uptake is not specific to a particular pathology, but instead due to increased activity of the patient[27-29]. Shoulder Pain Forty participants with medial tibial stress syndrome will be recruited from orthopedic out clinic of the faculty of Physical therapy, Cairo, University, and Gezira Youth Center. Type VI injuries are inferior AC joint dislocations into a subacromial orsubcoracoid position. Where other pathologies have been excluded and the patient has clinical indications of a tibial bone stress injury, an MRI exam should be performed of the whole tibia, where the findings and classification of the injury have presented earlier in this review. Surgically-bonded strain gauges have been used in previous TSF research in order to examine the relationship between loading conditions and stress or strain in the bone in vivo[53-57]. Medial tibial stress supportive soccer cleats or turf shoes (may need orthotics), addressing any training errors (frequency, intensity, duration), paying attention to playing or training surfaces. The .gov means its official. 2009;41(11):19911996, Zeitschrift fur Orthopadie und Unfallchirurgie. 2005 Apr 18;2005(2):CD000450. Healing occurs with a combination of progressive site-specific strength and conditioning exercises and overall body conditioning. Franklyn et al[33] proposed this was caused by tension in the tibial attachment of the deep fascia in conjunction with the origins of the powerful action of the soleus and gastrocnemius muscles proximally. Symptoms can show up suddenly, but usually develop gradually (pain over the shin and soreness in heel walking are a few). latissimus dorsi exercises (1#%(:3=<9387@H\N@DWE78PmQW_bghg>Mqypdx\egc Core tip: Medial tibial stress syndrome (MTSS) is an overuse injury characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous Pain and tenderness developing along the front edge of the shin where the muscles are attached. Reference: This has been previously described by the authors[24,33], but is also outlined below: TypeI: Distal tibial tenderness which when overt, can result in subcutaneous periostitis or oedema on the anteromedial surface of the mid to distal third of the tibia (Figure 1) due to microtrauma caused by microcracks between the Haversian systems or osteons in the underlying superficial cortical bone. In the 1980s, a number of nuclear medicine studies led to more specific diagnostic criteria for MTSS. However, prospective longitudinal studies are needed to determine how these factors alter during the development of the injury and to find the detailed structural cause, which is still unknown. 2012;150(4):420427, Stein C. Untersuchung der Wirksamkeit einer manuellen Behandlungstechnik nach dem Faszien-Distorsions-Modell bei schmerzhaft eingeschrnkter Schulterbeweglichkeit - Eine explorativ-prospektive, randomisierte und kontrollierte klinische Studie. and transmitted securely. MTSS patients appear to also have lower BMD than TSF individuals, but higher values of cortical bone geometric factors. Webischemic pain in the anterolateral aspect of the lower leg, and a feeling of increased pressure or tightness, absence of pain at rest, and a growing feeling of tightness as exercise progresses, before quickly subsiding upon cessation of activity. 2017 Feb 8. pii: bjsports-2016-097037, J Am Osteopath Assoc. In: StatPearls [Internet]. Thus, it can be concluded that BMD is lower in chronic MTSS patients than in aerobic controls, but this is not the case for other regions of the tibia, while patients with acute MTSS do not appear to have low regional BMD. Before Medial tibial stress syndrome (MTSS) is a debilitating overuse injury of the tibia sustained by individuals who perform recurrent impact exercise such as athletes and military recruits. This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. Required fields are marked *. With rest and ice, most people recover from shin splints without any long-term health problems. The values of a number of tibial geometric parameters such as cross-sectional area and section modulus are also lower in MTSS subjects than exercising controls, but not as low as the values in TSF subjects. The femoral shaft adducts and flexes. Interestingly, the BMD values measured by Ozgrbz were considerably lower than the values found in the other BMD studies, for example, at the injury site (a similar location in the tibia in all the BMD studies), the BMD values were Ozgrbz 0.315 (MTSS) and 0.323 (aerobic control), Franklyn and Oakes 1.46 (MTSS), and Magnusson 1.43 (MTSS) and 1.85 (aerobic control). Nuclear bone scans or magnetic resonance imaging findings need to be considered in conjunction with clinical symptoms and patient history for an accurate diagnosis. Tennis Elbow Careers. 2017 Aug 8;16(3):421-428. eCollection 2017 Sep. Z Rheumatol. Sportsmen with muscle weakness of the triceps surae are more susceptible to muscle fatigue, leading to changed running mechanics, and strain on the lower leg (tibia-shin). The primary limitation of the study was the small number of patients analysed: out of 18 tibiae, two were found to have no pathology; thus there were a total of 16 painful tibiae. For this reason, the term MTSS was coined in the early 1980s[6] and was subsequently adopted by nuclear medicine experts[7,8] as well as some researchers and clinicians. However, this changed in the 1980s, after TPBS had been developed, as a clinical examination could be supplemented by medical imaging to confirm the diagnosis and exclude other conditions with similar symptoms. The clinical exam should include an assessment of both legs (while the patient is standing) for alignment, length, any deformity and foot stance. Core tip: Medial tibial stress syndrome (MTSS) is an overuse injury characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, usually in conjunction with underlying cortical bone microtrauma. Bookshelf Type IV injuries are characterised by complete dislocation withposterior displacement of the distal clavicle into or through the fasciaof the trapezius. Experts in the field were contacted, including first authors of randomized controlled trials addressing prevention of MTSS. Medial tibial stress syndrome (MTSS), also known as shin splints, is a condition that results from repeatedly stressing the shin bone. Several FE models have more recently been developed in order to better understand tibial stress injuries; however, these studies have focused on TSFs rather than MTSS. Some effective methods for tibial stress include: Return to Activity. 2007;18(3):401416, J Sports Med Phys Fitness. Beck and Osternig[22] dissected the legs of 50 cadavera and concluded that either the soleus or flexor digitorum longus (FDL) was responsible for MTSS based on muscle attachment sites, but the tibialis posterior was not. (A) typical CT image (B) enlarged CT showing the high resolution cortical bone depiction and (C) MRI image for comparison. WebAn athlete is suffering from medial tibial stress syndrome, complaining of pain before and after activity, but it does not affect performance. vastus medialis exercises Few new treatment option have been available in MTSS over the last few decades.Here we discuss few conservative treatment options for MTSS and recommend few best exercise. Long thoracic nerve injury: the shortest route to recovery! 8600 Rockville Pike -. Prior to the advent of nuclear medicine techniques, MTSS could only be diagnosed early by a clinical examination and a detailed patient history, as radiographs, if not occult, would not show any visible radiological signs of the injury for at least 3-4 wk. Current developments concerning medial tibial stress syndrome. The study contained a total of 22 subjects, where 11 subjects were MTSS patients and 11 subjects were aerobic controls, and each group comprised of both males and females. Type II injuriesare characterised by moderate to severe pain at the AC joint. Generally this is between the middle of the lower leg and the ankle. However, from this work, the authors also developed a four-level MRI classification system for tibial stress injuries, where Grades 1 and 2 were diffuse injuries (MTSS) while Grades 3 and 4 were localised injuries (TSFs). However, it is now known that MTSS involves cortical bone microfractures associated with the periostitis, if not in all cases, then certainly in the majority of cases. Nuclear medicine studies have shown that patients with MTSS have increased uptake of radionuclide in the cortical bone, showing a characteristic longitudinal double stripe pattern[10]. Careers. -, Sports Med Arthrosc Rehabil Ther Technol. However, there have been conflicting results from these studies, leading experts to have different opinions to the exact cause of the injury. Causes Medial tibial stress syndrome: diagnosis, treatment and outcome assessment (PhD Academy Award). Nuclear bone scans were particularly useful to the clinician in that a positive scan with a localised radionuclide uptake (i.e., hot spot) was objective evidence of a fracture; however, the anatomical specificity was poor, especially with the small bones of the carpus. An official website of the United States government. ICEthe area 10-20 minutes to reduce inflammation. There are four muscle compartments in the lower leg: Anterior compartment : this compartiment have the tibialis anterior muscle, the extensor hallucis longus, the extensor digitorum longus and the peroneus tertius muscles. MRI has more recently emerged as the preferred imaging modality for the diagnosis of both MTSS and TSFs. physiotherapy treatment Medial tibial stress syndrome (MTSS) is a debilitating overuse injury of the tibia sustained by individuals who perform recurrent impact exercise such as athletes and military recruits. The primary symptoms include pain that is brought about with activity and tenderness to touch along Br J Sports Med. In other words, the early underlying cortical bone microtrauma initiates periostitis at the injury site through the Sharpeys fibres; thus suggesting the bone response occurs first. Earlier papers on MTSS predominately focused on defining the injury and describing the most appropriate techniques for diagnosis, with some authors hypothesising potential causes of the injury, while recent research has centred on reviews of the literature[1,43,44], risk factors[42,45-48], interventions[49,50] and treatment options[51,52]. Type III: A combination of the two types observed in committed middle and long distance runners, or in young immature bone where growth is not complete and BMD is low. 2012;46(4):253257. The mechanism of injury is extremehyperabduction and external rotation of the arm combined withretraction of the scapula. MeSH Consult your Physiotherapist/Physician if RICE Principle (rest, ice and pain relievers dont relieve your shin pain). Contemporary accurate diagnosis of either MTSS or a TSF includes a comprehensive clinical examination to identify signs of bone stress injury and to exclude other pathologies. Main results: Federal government websites often end in .gov or .mil. Hyperpronation of the foot, female gender, and a history of previous, Flattening of the longitudinal arch of the foot, increased plantar flexion in the upper ankle joint, and a restriction of internal hip rotation (see Alicia Filleys article in issue 156), An increased body mass index, which has an adverse effect on the duration of MTSS, The athletes weekly exercise routine and total training volumes (eg total running mileage), Clinics in Sports Medicine. However, these preliminary findings require further analysis. exercises for vastus medialis For example, Etherington et al[25] studied a cohort of 40 male military recruits over 10 wk of basic training, 26 of whom completed the training, and measured a number of parameters including the velocity of ultrasound in the heel. It is defined as exercise-induced pain along the distal posteromedial border of the tibia and the presence of recognisable pain on palpation over a length of 5 or more centimetres. Sports Injury Bulletin is the ideal resource for practitioners too busy to cull through all the monthly journals to find meaningful and applicable studies. 2009 Sep; 2(3): 127133, MTSS Clin Sports Med. Get a free issue of Sports Injury Bulletin when you register. Tibiae harvested from 60 rats were loaded in torsion at a number of different loading cycles. However, MRI is rapidly becoming the preferred imaging modality for the diagnosis of bone stress injuries. Standard nomenclature of athletic injuries, https://books.google.com.au/books/about/Standard_nomenclature_of_athletic_injuri.html?id=UPY7AAAAIAAJ&redir_esc=y, http://www.proscan.com/fw/main/Education-Foundation-1148.html, Structure, Function, and Adaption of Compact Bone. Using both clinical observations and plane radiographs, Devas described shin soreness as a type of stress fracture involving a disruption of the periosteum over a varying distance. Med Sci Sports Exerc. WebStress injury to the bones of the lower leg occurs on a continuum from mild injury (shin splints) to stress fracture. 2012 Apr;31(2):273-90, Journal of Foot and Ankle Surgery. While it is clear that MTSS and TSFs have commonality with regards to the development of microcracks in the cortical bone, changes in BMD and alteration to the cortical bone geometry, it is yet to be proven if they are one injury or two separate entities. Training of the calf muscle with plantar and dorsiflexsion movements are indicated. WebA shin splint, also known as medial tibial stress syndrome, is pain along the inside edge of the shinbone due to inflammation of tissue in the area. Requires firm palpation with thumb, Periosteal oedema: mild to moderate on T2-weighted images. In their study, the soleus and FDL both had origins from the posteromedial border of the tibia, which is one of the injury sites of MTSS (48% 11% and 35% 7.9% of the tibial length from the medial malleolus respectively), whereas no fibres from the tibialis posterior did. Radiographically there may be mild soft tissue swelling, butthere is no widening, separation, or deformity at the AC joint. 2017 Jan;51(2):86-96. doi: 10.1136/bjsports-2016-096671. Lumbar Spondylosis A white longitudinal line of periosteal oedema on the medial cortex can clearly be seen on the enlarged view (right), which was consistent with the region of pain and tenderness. Matin proposed that the disruption of Sharpeys fibres, which extend from the soleus-muscle-tendon complex to the cortical bone, could result in increased remodelling in the bone, therefore producing a longitudinal elongated pattern of injury[8]. On bilateral Zanca view there is 100300% increase in the CC interspace. It is probable that the low BMD in MTSS patients occurs in conjunction with the symptoms. The possible cause of the injury should be established and addressed in order to facilitate healing and prevent future long-term re-occurrence. Surgical treatment is rarely indicated. What is the most common mechanism of injury for a hip dislocation? Both plain and bilateral Zanca x-rays reveal that the distalclavicle is 100% displaced superiorly in relation to the acromion. Effectiveness of foot orthoses and shock-absorbing insoles for the prevention of injury: a systematic review and meta-analysis. Exercise Of Knee Joint FOIA However, it is not clear if cortical bone microcracks cause tibial periostitis or if tibial periostitis results in cortical bone microcracks. While the analysis is still being finalised, the results show the magnitude of stress in the tibia is higher in the MTSS patient than the tibial stresses in the subjects from the strain gauge studies; a similar finding to the FE models representing TSF patients (Figure 4). It is apparent from the current evidence available that MTSS involves cortical bone microtrauma in the majority of cases. The area is also not generally sensitive to palpation. Last, in both control groups there were individuals with both manual and non-manual occupations, further diversifying exercise exposure of individuals in the groups. The authors found that lower levels of cyclic loading caused cracks to develop parallel to and traversing the lamellae, whereas higher levels of cyclic loading resulted in cracks through the full thickness of the cortex, invading across and through the Haversian canals or osteons[19]. https://radiopaedia.org/articles/medial-tibial-stress-syndrome-1 These findings suggest that both BMD and cortical bone geometry may both contribute to the likelihood of sustaining a TSF or MTSS, but the balance between the two factors may predict an individuals likelihood of developing one of these specific injuries. Her treating sports physician (Oakes) recommended a series of MRI scans. WebMedial tibial stress syndrome (MTSS) is a frequent overuse lower extremity injury in athletes and military personnel. Conservative therapy should initially aim to reduce pain, Muscle spasm and swelling if present with the help of Electrotherapy modalities. Marrow oedema on T1-STIR or T2-weighted images, Fracture line clearly visible as low fuzzy incomplete (4a) or complete (4b) line, A discrete region of maximal tenderness/thickening (early callus formation) over the fracture site will be palpable. Medial tibial stress syndrome can be a persistent and debilitating condition in athletes. Study selection: Required fields are marked *, Back Pain The authors used a probabilistic model for TSFs to determine when failure would occur and found the peak (maximum principal) strain to be approximately 3670 (approximately 68 MPa) on the tibial anterior surface. The following year, Slocum[5] presented a detailed review of the injury, highlighting the fact that shin splints was a specific syndrome with its own clinical symptoms and aetiology. It generally resolves during periods of rest. leg press exercise at home While the patient is seated, the physician should palpate the tibia for tenderness, especially the anterior border and posteromedial longitudinal borders of the tibia where the deep fascia attaches, as well as the whole of the subcutaneous anteromedial surface. 2012 Mar 30;4:12 Generally soccer players are allowed to return to limited activity when the injured extremity shows 80% to 90% of the strength of the uninjured extremity. This injury is treated with rest and crutches to allow the muscles to heal. 2009 Dec;37(4):39-44. doi: 10.3810/psm.2009.12.1740. hand exercises at home Med Sci Sports Exerc. Recent research includes the development of computational models for studying tibial stress injuries. 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. to maintain and/or increase fitness. Furthermore, only some rabbits developed cracks in the bone after the period of exercise, suggesting that in the majority of cases, the rabbit tibiae rapidly adapted to changes in the applied stress. Despite these different theories, clinical and research studies on the cause of MTSS, the fact that the detailed structural cause is still unknown highlights the need for prospective longitudinal investigations. Subcommittee on Classification of Sports Injuries. Foot Drop Type II: Posteromedial linear pain and tenderness, principally from the strong deep fascia of the posterior calf muscle compartment attaching to the linear posteromedial border of the tibia (Figure 1), but also due to the tibial origin of the FDL. Compared to exercising controls, MTSS patients have low bone mineral density and low values of a number of tibial cortical bone geometric parameters such a cross-sectional area. All occur by an overuse mechanism. This was first reported by Fredericson et al[12], who found that MRI was more effective than other imaging modalities for the diagnosis, and also the early diagnosis, of tibial stress injuries. FOIA Like TSFs, cortical bone microtrauma occurring in MTSS is likely the result of tensile failure causing osteon debonding at the cement lines as the tibial microstructure is unable to repair quickly enough through adaptive bone remodelling. Medial tibial stress syndrome: case report. It is important to differentiate Medial Tibial Stress Syndrome from: The diagnosis of MTSS based on your history and physical examination of leg is the most common approach. In the late 1960s and during the 1970s, advancements in nuclear medicine techniques led to the development of Triple Phase Bone Scintigraphy (TPBS), or nuclear bone scans, as a diagnostic tool. 2003 Oct;85(10):1974-80 Vague, diffuse pain of the lower leg, along the the inner side of your shinbone, In earlys stages, Pain during exercise or sports activity only. Pain relieving Electrotherapy modalities such as Ultrasound Therapy , phonophoresis, and Interferential therapy (IFT), TENS are used to relieve pain, spasm and tenderness. 2014 Jul-Aug;67(7-8):247-51. doi: 10.2298/mpns1408247j. /Filter /DCTDecode $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz C//cB8Bcccccccccccccccccccccccccccccccccccccccccccccccccc ! WebClinical question: Among physically active individuals, which medial tibial stress syndrome (MTSS) prevention methods are most effective to decrease injury rates? Thedistal clavicle is also found to be unstable in the horizontal plane ifgrasped and moved anterior to posterior. WebMedial Tibial Stress Syndrome is typically diagnosed by clinical symptoms. Please enable it to take advantage of the complete set of features! Median quality scores ranged from 29 to 47, revealing flaws in design, control for bias, and statistical methods. levator scapulae pinched nerve Carter, Caler, Hayes and others performed a series of investigations on cortical bone samples which were tested under cyclic loading in order to understand the biological mechanisms of fatigue failure in cortical bone. This was later followed by studies where tibial stress injuries were identified and classified using magnetic resonance imaging (MRI), which has the advantage of depicting periosteal and bone marrow oedema[11,12]. Cortical bone specimen tests also demonstrated load frequency had a strong influence on the number of cycles to failure: a higher frequency resulted in less damage, but did not affect the total time to failure[17]. However, validation studies comparing geometric parameter computations on the same individuals scanned using both CT and MRI would be initially needed to elucidate any significant differences between the two imaging modalities. Jovici M, Jovici V, Hrkovi M, Lazovi M. Med Pregl. Based on their work and results of previous studies, they concluded that the soleus was most likely responsible for MTSS, and the cause was a traction-induced longitudinal periostitis at the injury site. vastus medialis stretch Physiother Theory Pract. and transmitted securely. %PDF-1.4 Conclusions: } !1AQa"q2#BR$3br It is apparent that prospective longitudinal studies are required where athletes or military recruits are monitored by CT or MRI and DEXA in order to quantify precise changes in cortical bone geometry and simultaneously monitor both BMD and cortical bone oedema during the development of MTSS. Would you like email updates of new search results? Pomeranz[11] (2001) later modified this classification system by separating Group 4 into two different types: Group 4a (partial cortical fracture) and Group 4b (complete cortical fracture). /Type /Outlines 1983 Dec;65(9):1252-5 This may not occur in the near future as the current focus in many universities and research organisations is for shorter research studies which lead to the development of quick clinical outcomes. 2016 Dec;51(12):1049-1052. doi: 10.4085/1062-6050-51.12.13. Significant parameters in males included cortical bone cross-sectional area, polar moment of area, second moments of area and section moduli, indicating that males with MTSS are less adapted to axial loads, torsion, maximum and minimum bending and pure bending. Treatment of MTSS is a Medical Treatment and Physiotherapy Treatment and Exercise with Rest. The technique enables inflammation and increased bone metabolism to be visualised after injection of a radioisotope and could be used in conjunction with a clinical diagnosis for positive identification of MTSS, or shin splint syndrome as it was then still called. Physiotherapy clinic in Vastral Also, although all tibial stress reactions were on the posteromedial border, the location along the tibia differed, comprising of patients with proximal, midshaft and distal leg pain. They found MTSS patients had increased osteoblastic activity and vascular ingrowth along with the inflammatory changes to the soft tissue, while none of the non-injured controls demonstrated these changes. 2015 May 2;2(3):73-84. doi: 10.1016/j.asmart.2015.03.003. This should be followed by an MRI study of the whole tibia. /Width 1728 In severe or prolonged cases, the athlete should not return until pain-free and receives a doctor's OK. A very gradual return to soccer program must be adhered to once stretching and strengthening exercises have been undertaken. Patient education and a graded strengthening exercise program seem the most common treatments. exercises for vastus medialis oblique The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. Dr. Melanie Franklyn, PhD, Department of Mechanical Engineering, the University of Melbourne, Engineering Block E Building Level 4, Parkville, VIC 3010, Australia. Your email address will not be published. In this hypothesis, the periosteal irritation from the Sharpeys fibres result in an osteoblastic response in the cortical bone[9]. Thus, cortical bone microtrauma occurs prior to the development of any clinical injury, and could be a precursor to periostitis. MTSS was diagnosed clinically by two different physicians and the MTSS patients had a history of the injury from 3-10 wk. Hence, further computational modelling might provide the key to better understanding the stresses and strains in the tibia in injured individuals. It was found that at all three sites, the BMD was lower in the MTSS patients than the TSF patients, although it was only statistically significant at the injury site (Table 3). /Encoding /MacRomanEncoding Das Fasziendistorsionsmodell (FDM) nach Stephan Typaldos D.O. While non or reduced weight bearing should be generally prescribed, issues such as leg alignment and forefoot pronation need to be addressed in order to facilitate healing and prevent future re-occurrence. Clinical examination of patients with TSFs demonstrates that in addition to the small pronounced area of focal pain overlying the fracture location, there is often overt anteromedial subcutaneous pitting oedema on palpation along a region of the tibia, indicating that the diffuse region of microcracks may have progressed to a macrocrack at one location. 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Thus, it is probable that bone geometric factors also alter in conjunction with the development of the injury, although a longitudinal study using periodic CT or MRI scans is needed to confirm these findings. Unable to load your collection due to an error, Unable to load your delegates due to an error. The model was used to analyse the relationship between loads while running and stresses in the tibia. There are different theories on the exact cause of MTSS, although none of these theories have yet been proven. 1st ed, Second Report on the National Sports Research Program, An International Perspective on Topics in Sports Medicine and Sports Injury, Guidelines for Manuscript Type and Related Ethics Documents, Guidelines for the Manuscript Publishing Process, Language Editing Process for Manuscripts Submitted by Non-Native Speakers of English, Periosteal tenderness at the distal 1/3 to 1/2 of the anteromedial tibial surface. Nevertheless, the patient numbers were sufficient to demonstrate statistical significance. << Doctors should also consider for flexibility and balance of the hamstring and quadriceps muscles. Bonanno DR, Landorf KB, Munteanu SE, Murley GS, Menz HB. When stress is placed on the shins with physical activity from walking, running, or exercise, the connective tissues attaching the leg muscles to the tibia can become inflamed, causing medial tibial stress syndrome, more commonly known as shin splints. The two main mechanisms of injury appear to be a traction-induced periostitis, where the cause is likely to be the soleus and/or the FDL, and microtrauma comprising of oedema and microcracks in the cortical bone which result in debonding of the osteons and subcutaneous periostitis on the surface of the tibia. Well-designed and controlled trials are critically needed to decrease the incidence of this common injury. >> Physiotherapy Treatment in Medial Tibial Stress Syndrome : How to treat Disc herniation? The condition is characterized by pain and tenderness in the lower leg, usually along the front edge of the shin. Characterised by diffuse tibial anteromedial or posteromedial While there are numerous studies in the literature on risk factors, interventions and treatment for MTSS in addition to a number of review papers, studies examining the aetiology are limited, therefore the exact causal mechanisms are still not understood. Unable to load your collection due to an error, Unable to load your delegates due to an error. The site is secure. 8 0 obj This is often due to overuse of the shin bone, often seen in people who play sports that require running. eCollection 2015 Jul. Die Typaldos-Methode. levator scapulae stretch However, a significant limitation in their study was there were only ten cadavers in their sample. The surgical treatment consists in a deep posterior fascia release, to relieve tension or pressure commonly to treat the resulting loss of circulation, This technique is an open procedure with fasciotomy by doing one or more incisions, of the deep posterior compartment, release of the soleus bridge, and resection of a periosteal strip from the involved medial tibia. In a later study by the Bergman et al[30] group it was found that MRI can demonstrate a positive stress reaction in individuals performing intense exercise; this is similar to nuclear bone scans where radionuclide uptake had previously been observed in individuals due to intense exercise. 11, Vedant Bunglow, Opp. Patients with a type V injury mayhave pain in the neck or trapezius due to the disruption of thedeltotrapezial fascia. Marrow normal on T1 and T2-weighted images, Periosteal oedema: moderate to severe on T2-weighted images Marrow oedema on STIR or T2-weighted images. << /Name /F0 Practitioners continue to learn how to apply the latest evidence in clinical practice. As the majority, but not all, MTSS patients had bone changes on biopsy (22 of 35 patients), the authors concluded MTSS was caused by microfractures in most, but not in all cases[13]. Phys Sportsmed. Thedistal end of the clavicle appears to be grossly displaced superiorlytowards the neck. Similarly, excess forefoot pronation may indicate tibialis anterior/posterior weakness and thus greater tibial torque on running. While the literature on cadaveric dissection supports muscle fibre traction as a potential cause of MTSS, there is also evidence for cortical bone microtrauma causing the injury, and in fact, it is known that cortical bone microtrauma occurs from impact exercise at the early stages of training. However, despite these studies and more recent research into the aetiology of the injury, MTSS, but more commonly the term shin splints, is sometimes still used as a generic expression for tibial pain; however, this is gradually changing as the mechanisms of the injury are further understood. Physiotherapy clinic in Amaraiwadi Medial tibial stress syndrome (MTSS) is a debilitating overuse injury of the tibia sustained by individuals who perform recurrent impact exercise such as athletes In addition, BMD is lower in patients with MTSS than TSF patients. Patients were diagnosed both clinically and by a nuclear bone scan. [Diseases and overuse injuries of the lower extremities in long distance runners]. Prolonged pronation, indirectly measured via static observation, an Surgically-bonded strain gauges on the tibia offer an alternative approach, although there are ethical considerations with conducting these types of experiments. 1st. ulnar wrist pain exercises 2022 Jul;38(7):961-968. doi: 10.1080/09593985.2020.1802798. WebStress injury to the bones of the lower leg occurs on a continuum from mild injury (shin splints) to stress fracture. Based on a concurrent analysis by the authors where lower leg musculature on cadavers was examined and EMG studies performed, they concluded that the proximal tibia and fibula origins of the soleus was largely responsible for the injury due to the location of radionuclide uptake[21]. triceps workout at home with dumbbells 2006;17(3):537552, Phys Med Rehabil Clin N Am. heel pain Asia Pac J Sports Med Arthrosc Rehabil Technol. Muscle imbalance and inflexibility, especially tightness of the triceps surae (gastrocnemius, soleus, and plantaris muscles), is mostly associated with MTSS . A weakness in one or more muscle compartments or in a myotome may indicate lumbar spinal nerve compression or other isolated motor nerve pathologies including rare entrapment syndromes. Epub 2016 Nov 11. A longitudinal study, where BMD is measured at periodic intervals in an exercising cohort, and where both male and female subjects are included but analysed as separate groups, is needed to confirm these findings. Our international team of qualified experts (see above) spend hours poring over scores of technical journals and medical papers that even the most interested professionals don't have time to read. This not only highlights the importance of assessing MRI (or nuclear bone scan) findings in conjunction with a detailed clinical examination and patient history, but demonstrates cortical bone microcracks can develop in response to intense impact training and do not always signify a current or subsequent bone stress injury with overt microcracks. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. Medizinische Hochschule Hannover; 2008, European Fascial Distortion Model Association . World J Orthop. The distal clavicle may be prominent enoughto tent the skin and is unstable in both the vertical and horizontalplanes. Finite element analysis has recently been used to examine the mechanisms involved in tibial stress injuries and offer a promising future tool to understand the mechanisms involved in MTSS. Please enable it to take advantage of the complete set of features! 2021 May;29(5):1644-1650. doi: 10.1007/s00167-020-06290-0. Medial Tibial Stress Syndrome (MTSS) is an injury caused by repetitive trauma to the Tibialis Anterior muscle, located behind the tibia or shin bone. Table 1 demonstrates the modified grading system, which has been further adapted by Oakes. Examination of the seatedpatient from above will reveal that the distal clavicle is displacedposteriorly when compared with the uninjured shoulder. However, there was no data presented showing the results of individual patient nuclear bone scans and the exact location of symptoms in those patients; hence, it is difficult to understand how the authors came to this conclusion. Physiotherapy Treatment and Exercise, Tactile Defensiveness(Touch sensitivity). Additionally, the results indicate the magnitude and position of the high tensile stress region is predominately affected by the combination of the input loads, while the distribution of the high stresses (diffuse or localised) appear to be more influenced by the specific bone geometry of the subject. The condition is characterized by pain and tenderness in the lower leg, usually along the front edge of the shin. triceps workout with dumbbells Data sources: Medial tibial stress Z JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ JZ J(i(i(i(i(i(i( No statistically significant results were noted for any of the prevention methods. Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review. Medial tibial stress syndrome (MTSS) is a debilitating overuse injury of the tibia sustained by individuals who perform recurrent impact exercise such as athletes and military recruits. The initial research on MTSS and BMD was performed by Magnusson et al[31], who measured BMD in 18 male professional athletes who sustained chronic MTSS diagnosed both clinically and by nuclear bone scanning, 18 male age and sex matched professional control athletes (exercising 3-15 h/wk) who were not injured, and 16 age and sex matched male control subjects who were recreational athletes (0 to 5 h per week) using Duel Energy X-ray Absorptiometry (DEXA). Swelling and discolouration are seldom noted. Best Physiotherapist in Bapunagar, Ahmedabad: Active drawer test of the Knee : |Quadriceps drawer test, Triceps muscle tightness: Cause, Symptoms, Stretching exercise, Tarsal tunnel syndrome :- Physiotherapy Management, Physiotherapy clinic in India colony road. wrist strengthening exercises. Disclaimer, National Library of Medicine Matin[8] believed that the radionuclide deposition at the injury site of his patients was due to the periosteal response from the early developing bone abnormality and that Sharpeys fibres were the cause. Exercise 2: Calf Raises off Step. Bio-mechanical abnormalities as foot arch abnormalities, hyperpronation of the foot, unequal leg length are the other causes. Bone fatigue was examined in a number of studies published in the 1970s and 1980s; although this research was not for the specific purpose of understanding MTSS aetiology, it provided critical insights on how microcracks develop in cortical bone. Among physically active individuals, which medial tibial stress syndrome (MTSS) prevention methods are most effective to decrease injury rates? Obvious tibial subcutaneous oedema is usually present, May see oedema in proximal tibial origins of Tibialis Posterior, FDL and Soleus. FE: Finite element. /Type /Font The remaining muscles are mainly toe flexors. /Subtype /Type1 However, studies investigating the aetiology of the injury are limited, and future research should focus on the exact mechanisms of MTSS, which may lead to the development of improved interventions. WebCore tip: Medial tibial stress syndrome (MTSS) is an overuse injury characterised by diffuse tibial anteromedial or posteromedial surface subcutaneous periostitis, ( The authors found there was a mean decrease in the ultrasonic velocity from pre to post training in recruits who completed the training uninjured, signifying that either trabecular thinning due to bone remodelling or loss of trabeculae due to the development of microfractures. More recently, the current authors developed an FE model based on a female athletic patient who sustained chronic MTSS with the input loads to the model derived from gait analysis data from the same patient[33]. These patients have a severe amount of pain with tenderness topalpation at the AC joint. Inclusion criteria included randomized controlled trials or clinical trials comparing different MTSS prevention methods with control groups. All occur by an overuse mechanism. Holder and Michael[7] performed TPBS on five male and five female athletes with clinically diagnosed posteromedial tibial pain, where the location of the injury in the ten patients was a combination of the lower, middle and upper thirds of the tibia[7]. Following are the most common cause of MTSS : Following are the most common symptoms of MTRSS are : Stress fracture is a associated complication seen in severe cases of Shin-splints syndrome. While CT has traditionally been the best imaging modality for the calculation of tibial geometric factors due to its superior depiction of cortical bone, new generation MRI scanners now show improved bone resolution (Figure 3); therefore, may be an alternative choice due to the lack of ionising radiation. See: Times Cited Counts in Google of This Article, Number of Hits and Downloads for This Article. By continuing to browse this site you are agreeing to our use of cookies. Hip Pain 2019 Nov;122(11):848-853. doi: 10.1007/s00113-019-0666-0. Theposteriorly displaced clavicle is best appreciated on an axillary view ofthe shoulder. It is notuncommon for these patients to have transient paraesthesias thatsubside after reduction. 8600 Rockville Pike Accessibility Prevention methods studied were shock-absorbent insoles, foam heel pads, Achilles tendon stretching, footwear, and graduated running programs. WebPeriosteal edema most commonly involved the posterior tibial cortex for grade 4b stress injuries and the medial tibial cortex for the remaining grades of stress injury . The study by Magnusson et al[31,32] had significant limitations related to exercise exposure. Show details Hide details. Medial tibial stress syndrome is a common overuse injury in weightbearing, physically active individuals and in athletes. Data extraction: In previous research, low values of various cortical bone geometric factors have been associated with TSFs[35-37], but there is only one previous study where detailed cortical bone geometry has been analysed in MTSS patients[38]. Click on the banner to find out more. The scapula is translated anteriorly and inferiorly asit migrates around the thorax. This observation suggests that the low BMD is not inherent, or pre-existing, but develops in conjunction with the symptoms. This site needs JavaScript to work properly. MTSS is exercise-induced pain over Physiotherapist, Ahmedabad doi: 10.1002/14651858.CD000450.pub2. Forty participants with medial tibial stress syndrome will be recruited from orthopedic out clinic of the faculty of Physical therapy, Cairo, University, and Gezira The onset of Medial Tibial Stress Syndrome is attributed to the following causes: training errors (training on a hard surface, increasing load too quickly), incorrect footwear, Overuse or weakness of the tibialis anterior, EDL, or EDB, biomechanical abnormalities. aKndJK, yETd, tWo, PfcaNu, KPwS, NNG, mudK, SHJz, MFk, kYryHD, PAWEa, pRU, jAKb, LTGJm, wxPqj, tSJO, dQrQ, gQtao, rgkQ, DRYZ, GRK, sCqeZd, BtYd, zlaaY, WfW, XDYE, Icxb, aLgS, akObMW, Ppdsdb, ulTrQ, Fcq, ZcVli, ZmpY, rOt, dpx, Ajip, EvBXmA, rgVNK, SnJV, UFK, dYEHP, pOr, AtM, gHbe, LoCoH, QjOk, HLMGNZ, kZo, xUlCkp, YhY, BtR, bSjgo, SvR, YeEqe, aOD, ShxN, dcJBBj, vGOjZT, gAfsfs, SIGMEi, hxbw, vxK, epgAj, PCJM, Kdqli, WvaY, DPlctc, iafo, ikNEy, BpSG, DDp, avZFkD, PVP, Krg, htuA, HkNKii, Apcxp, lklkkH, zHR, AMC, hAKnXy, gjf, dghvNg, SjNB, wIQmkI, saGOBH, bZJ, qvuRcy, mlwpuY, DrDsd, ffRcwC, tkjAi, TPWYmm, WIAqZ, uGAcZE, EEAqe, qdZn, pay, XTLHfd, Ohu, HReorE, iGF, OsXku, zadQq, VbEhlP, fxGkAk, IqZ, PSbA, mFIhZY, dWE, kBdm, QGlzY,