Successful Treatment of Medial Tibial Stress Syndrome with Interosseous Membrane Acupuncture: A Case Series

Abstract

Background: Medial tibial stress syndrome (MTSS), otherwise known as shin splints, frequently causes pain and disability in the physically active population and can be recalcitrant to treatment. Interventional and alternative therapies, specifically acupuncture, for treatment of MTSS have been poorly described in the literature. The aim of this case series is to describe an acupuncture technique for the treatment of MTSS.

Cases: Patients who received the diagnosis of MTSS were treated in an outpatient military treatment facility. One Hwato^® 0.30 mm × 75 mm needle was placed 1 cun distal and 1 cun lateral to the tibial tuberosity of the affected leg and was inserted deeply through the plane of the interosseous membrane. A second needle was then placed 2 cun distal to the first needle in the same trajectory and at the same depth. Needles were then irregularly stimulated for 5 minutes before needle removal. After treatment, the patient vigorously moved the affected leg before reassessing pain.

Results: Both patients noted a clinically significant decrease in pain immediately after intervention, which lasted for 4 weeks.

Conclusions: Interosseous membrane acupuncture is a clinically significant, effective means to decrease MTSS-associated pain in physically active adults. This case series demonstrates a technique to augment conservative therapy of patients with MTSS.

Introduction

Medial tibial stress syndrome (MTSS), otherwise referred to as “shin splints,” affects up to 35% of the physically active population, with higher prevalence in subjects who endure repetitive stress on their lower extremities, such as runners, dancers, and military personnel.^1,2 Risk factors include female gender, pronated foot type, higher body mass index, and previous history of MTSS.^3,4 MTSS is an overuse injury of the lower extremity suspected to be caused by repetitive muscle traction, leading to tibial periostitis and cortical microtrauma.⁵ Current therapy relies upon conservative modalities, such as relative rest, ice, compression, elevation, physical therapy/home exercise programs, and gradual return to activity.⁶ Furthermore, there exists no high-quality evidence to support any intervention, to include acupuncture, as being effective in the treatment of MTSS.⁷

For centuries, Traditional Chinese acupuncture has been used as treatment for musculoskeletal complaints.⁸ In modern times, studies have shown promise for the use of Western medical acupuncture in MTSS, although these lack a universal protocol.^3,9 The Western medical technique described in the 2 cases presented hereunder joins Traditional Chinese acupuncture points with Western medical techniques of interosseous membrane needling in a succinct and successful protocol for lasting treatment of MTSS-associated pain.

Methods

One Hwato^® 0.30 mm × 75 mm needle was placed 1 cun distal and 1 cun lateral to the tibial tuberosity of the affected leg and was inserted deeply through the plane of the interosseous membrane. The depth of the intraosseous membrane varied between patients, but there was a noticeable loss of resistance upon passing through the interosseous membrane. No patient response was necessary, although the patient was aware when the intraosseous membrane was accessed. A second needle was then placed 2 cun distal to the first needle in the same trajectory and at the same depth, which is shown in Figure 1. The needles were both irregularly strummed and stimulated by moving the acupuncturist's fingernail vertically on the needle's handle for 5 minutes before needle removal. After treatment, the patient vigorously moved the affected leg for 30 seconds before reassessing pain.

FIG. 1.

Second Hwato^® 0.30 mm × 75 mm needle placed 2 cun distal to the first needle in the same trajectory inserted deeply through the plane of the interosseous membrane.

Treatment consisted of 1 session in an outpatient clinic setting performed by an acupuncturist formally trained in medical acupuncture. Treatment did not involve any associated interventions other than the aforementioned protocol. Patients were given a basic explanation on the theory behind acupuncture before receiving their verbal and written consent to proceed with treatment.

Cases

Case #1

A 27-year-old female uniformed service member presented to an outpatient military treatment facility with a 4-month history of MTSS. She had previously trialed conservative therapy that consisted of a home exercise program, nonsteroidal anti-inflammatory medication, ice, and massage without significant relief. Her level of activity at time of presentation included high-intensity interval training and running. She underwent 1 interosseous acupuncture treatment that reduced her pain from a 7/10 to a 3/10 on a standard 11-point numeric pain rating scale (NPRS). Follow-up occurred in person at 6 months after initial therapy during which the patient denied any negative outcome of treatment. The patient reported her pain was stable at a 3/10 and noted an increase in functionality, with the ability to perform activities such as high-intensity interval training and running without being limited by pain.

Case #2

A 43-year-old female presented to an outpatient military treatment facility with a 6-month history of MTSS. She had also previously trialed conservative therapy that consisted of a home exercise program, nonsteroidal anti-inflammatory medication, ice, and a meridian-based acupuncture technique without significant relief. Her level of activity at time of presentation included only running. She underwent the same interosseous acupuncture treatment that reduced her pain from a 5/10 to a 1/10 on a standard 11-point NPRS. Follow-up occurred in person at 4 weeks after initial therapy during which the patient similarly denied any negative outcome of treatment. The patient reported her pain was stable at 1/10 and correspondingly noted an increase in functionality, with the ability to run without being limited by pain. The pretreatment and post-treatment NPRS for each patient is shown in Figure 2.

FIG. 2.

Pretreatment and post-treatment numeric pain rating scores.

Discussion

MTSS plagues much of the physically active population. Current therapy often requires cessation of physical activity and simultaneously does not allow for prompt recovery. This simple single treatment was successful in delivering both immediate and lasting pain reduction with subjective improvement in function. Unlike current recommendations to cease and modify physical activities for several weeks, this treatment allowed for quick return to normal activities. This protocol is easily replicated, showed no adverse outcomes in either patient, and produced a lasting pain reduction by 50% in each patient. Each patient also showed an absolute pain reduction of 4 on the NPRS, which indicates a clinically significant reduction in pain.¹⁰

Conclusions

This case series demonstrated that interosseous membrane acupuncture provided a clinically significant reduction in MTSS-associated pain in physically active adults at 1 military treatment facility. This technique shows promise in becoming the solitary effective intervention in addition to conservative management in the treatment of MTSS.

Further studies are required to reproduce these results and to investigate whether interosseous membrane acupuncture is an effective method for decreasing pain and improving physical function in a generalized adult population with MTSS. Pain and functional status measurements using validated pain and disability questionnaires should be implemented over preset time intervals to determine the significance of this technique as the sole intervention for the treatment of MTSS.

Disclaimer

This information was presented in poster format at the American Academy of Pain Medicine 2020 Annual Meeting in National Harbor, MD, and at the Tri-Service Southeast Regional Family Medicine Residency Scholarship Symposium in Fort Walton Beach, FL. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. Government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.