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MONTANA STATE UNIVERSITY BILLINGS

BILLINGS, MONTANA

GRADUATE STUDIES

OBSERVATIONAL STUDY: EFFECTS OF LASER, MICROCURRENT, AND

TRADITIONAL THERAPIES ON PAIN REDUCTION IN MSUB ATHLETES

DIAGNOSED WITH MEDIAL TIBIAL STRESS SYNDROME

A thesis submitted to the faculty of the Department of Health and Human Performance in

partial fulfillment of the requirements for the Masters of Science degree in

Interdisciplinary Studies: Exercise and Sports Leadership Option

Elizabeth Davis

Department of Health and Human Performance

College of Allied Health Professions

Montana State University Billings

May 2, 2015

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ABSTRACT

Davis, E.A. Observational Study: Effects of Laser, Micro current, and Traditional

Therapies on pain Reduction in MSUB athletes Diagnosed with Medial Stress Syndrome.

Published Master of Science in Interdisciplinary Studies: Exercise and Sport Leadership

thesis, Montana State University Billings, (2015).

Background: Medial tibial stress syndrome (MTSS) is one of the most common sport injuries

Athletic Trainers’ (ATCs) treat. Despite the commonality of this injury there is no

agreement regarding the definition of the condition nor the treatment. While some believe

MTSS is a muscular injury, similar to a strain, others believe that it is a bony injury

caused by repetitive stress to the tibia.

Methods:

Participants were selected from MSUB athletic teams who complained of

anteriomedial lower leg pain and informed consent was obtained during the initial

evaluation. Participants were educated on the treatment they will be receiving and they

were asked to not stray from their particular treatment by icing or participating in any

other typical activities to reduce pain. In addition to obtaining consent during the initial

evaluation, other information was collected that has shown to increase the risk factor for

MTSS. Other information included: sport, gender, previous history of this injury, self-

reported body weight and stature, and their navicular drop was assessed.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) were permitted if necessary, but not

beyond the recommended dosage of medication. These conditions were required from the

participants to control for extraneous variables which may have interfered with the

efficacy of the study.

Six athletes agreed to participant in the study and they were randomly placed into

three separate groups. The first group was the control group, whose treatment consisted

of a traditional treatment using ice cup massage and manual massage. The second group

received low level laser therapy (LLLT) as research has shown LLLT to reduce the

healing time for soft tissue injures. The third group received micro current (MCT) which

research has demonstrated to increase the recovery time in a variety of bony tissue

injuries. Each group received treatment for four weeks. They had weekly progress notes

written on their pain levels and ability to perform in their respective sports.

Results:

Due to the small sample size, it was decided the research design would be a series of

case studies. All results were analyzed on a case by case basis.

Conclusion:

Overall, the traditional treatment group showed a more significant decrease in

pain than LLLT or MCT. It is difficult to determine if MCT revealed a faster recovery

rate due to the fact that there was only one subject in that group. More research must be

done with a larger sample size to determine the efficacy of these treatments.

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TABLE OF CONTENTS

CHAPTER PAGE

Abstract………………………………………………………………… ii

Table of Contents……………………………………………………… iii

Non-Plagiarism Affirmation…………………………………………… iv

Signature Page…………………………………………………………. v

I. INTRODUCTION

Background…………………………………………………………….. 1

Problem Statement…………………………………………………….. 2

Hypotheses……………………………………………………………... 2

Operational Definitions………………………………………………… 2

Limitations……………………………………………………………... 3

Delimitations……………………………………………………………4

II. REVIEW OF LITERATURE

Incidence of MTSS…………………………………………………….. 5

Etiology of MTSS……………………………………………………… 6

Current therapies……………………………………………………….. 7

Laser………………………………………………………………... 7

Micro current………………………………………………………. 11

III. METHODOLOGY…………………………………………………….. 15

Participants……………………………………………………………... 15

Equipment……………………………………………………………… 15

Procedures……………………………………………………………… 16

Research design and data analysis……………………………………... 17

IV. RESULTS……………………………………………………………… 19

Athlete 1 ……………………………………………………………….. 19

Athlete 2 ……………………………………………………………….. 21

Athlete 3 ………………………………………………………………. 23

Athlete 4 ………………………………………………………………. 24

Athlete 5 ……………………………………………………………….. 26

Athlete 6 ……………………………………………………………….. 27

Statistical analysis …………………………………………………….. 28

V. DISCUSSION………………………………………………………….. 30

Conclusion and Future Research………..……………………………... 34

Bibliography …………………………………………………………... 36

Appendices

Appendix A. MSUB IRB approval ……………………………… 40

Appendix B. Consent form………………………………………. 41

Appendix C. Pain rating scale, Mosby©…………………………. 43

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Chapter 1

Introduction

Background

Medial tibial stress syndrome (MTSS), more commonly known as “shin splints”,

is one of the most common injuries in athletes. It is often thought of as an overuse

injury, however many of these injuries occur at the beginning of the athletic season. In

fact MTSS occurs during the conditioning phase of training as well as in the middle and

at the end of the season. The truth is MTSS can happen at any time during an athlete’s

training. Additionally, there are many questions surrounding MTSS. Many medical

professionals question, what is this condition? What are the predisposing factors? What

can be done to prevent MTSS? Is there a specific treatment that will help alleviate the

pain and/or make the pain go away altogether?

This study focused on the predisposing factors as well as best treatment. Here a

series of case studies focused on predisposing factors as well as treatments which may

control the pain caused by MTSS. Currently, it is believed there are many

predispositions to MTSS. Such susceptibilities include: gender, number of years as an

athlete, history of the injury, and foot structure which will be discussed later. Lastly,

there are several treatments which have been used to treat the pain caused by MTSS.

The most common treatments are ice massage and manual massage. Other treatments

include cold whirl pool (CWP), ultrasound, low level laser therapy (LLLT), electrical

stimulation, tape, and decreased activity/rest.

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Problem Statement

Both athletes and athletic trainers find it difficult to treat MTSS as there is no one

specific protocol to eliminate the pain caused by MTSS. Many of the treatments listed

above partially assist with the alleviation of pain, but no one modality has been shown to

fully reconcile the injury. The current time for return to play for athletes with MTSS

ranges from four weeks to 10 months, resulting in too much time away from activity

(Moen et al, 2012). Therefore, it is essential to establish a protocol to decrease athletes’

time spent away from participation due to pain from MTSS. The goal of this series of

case studies is to determine which treatment will decrease the pain, allowing the fastest to

return to activity for athletes.

Hypotheses

This research conducted case studies on six MSUB athletes who were diagnosed

with MTSS. Once diagnosed, each athlete was randomly assigned to one of three

treatments: LLLT, MCT (a low level form of electrical stimulation), and the traditional

treatment of a combination of ice massage and manual massage.

It was hypothesized the athletes who received LLLT would show the most

improvement during their treatment sessions. The null hypothesis was there would be no

difference between the three groups.

Operational Definitions

Medial Tibial Stress Syndrome (MTSS) - persistent pain in low to mid shaft of the

posteromedial of the tibia.

Acute MTSS- sudden onset of pain in low to mid shaft of posteromedial tibia

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Chronic MTSS- pain lasting longer than 6 months in low to mid shaft of posteriormedal

tibia

Micro current (MCT) - This study used the following parameters wit pulse frequency- 75

Hz, pulse duration- 0.5msec, intensity- 50μA, treatment time- 25 minutes daily (Starkey,

2004)

Low Level Laser Therapy (LLLT) - this study used the following parameters (based on

Achilles tendonapathy)

2-3 points per treatment, 9 diode cluster (5-850nm, 200mW Laser; 4-670nm,

10mW LEDS), 7J/cm2 per point, treatment time approximately 3 minutes

Intensity of this treatment was altered during the study to 3.5J/cm2 per point with

the duration changing to 34 seconds per site (World Association for Laser

Therapy (Walt), n.d.).

Traditional treatment- treatment consisted of five minutes of manual massage prior to

practice and seven minutes of ice cup massage after practice daily.

Limitations

There were several limitations to this study. First was the limited number of

participants available for the research and second was the amount of attrition throughout

the study. Originally there were seven participants, but only four completed the full four

weeks of required treatment. Even if the seven participants who signed the informed

consent would have completed the treatment, it still would not have been enough for

reliable and valid statistical data. Lastly, there was limitation associated with the Vectra

Genisys’s™ pre-programming for the LLLT. The pre-programming of the machine

prevented changing the duration of the treatment from the intensity setting. Delimitations

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The literature review for this paper only included studies and meta-analyses

written in the English language. Exclusion criteria for participants in this study were

those who were not MSUB athletes (i.e. staff, recreational athletes, general student

population, etc.). During the third week of treatment for the LLLT group, intensity of

treatment was altered. Due to further research in the laser treatment and increased pain

from each participant, the decision was made to decrease the intensity of the laser

treatment by half.

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Chapter 2

Review of Literature

Athletes no longer have to solely rely on the conservative treatment of anti-

inflammatory medications, ice and rest to treat their pain. In the past, many athletes

have relied on conservative treatment to treat pain caused by Medial Tibial Stress

Syndrome (MTSS). Today there are many alternative therapies to assist with the coping

of pain levels, including but not limited to laser, electrical stimulation, acupuncture,

cupping, ultrasound, prolotherapy injections, and massage. Now that there are more

treatment modalities available, it can be challenging for a clinician to determine the

correct treatment for a given injury. The following is a review of literature for MTSS as

well as modalities used in the treatment of pain, specifically MTSS.

Medial Tibial Stress Syndrome

MTSS is one of the most common injuries in not only athletes, but military

personnel as well. Studies of MTSS in the military show that MTSS incidences vary

anywhere from 4% to 35% of the injuries reported (Moen, Tol, Weir, Steunebrink, &

DeWinter, 2009).

Many consider MTSS is an overload or overuse injury. Some believe MTSS is

the result of perostitis (inflammation of the periosteum), while others believe that bony

resorption is the culprit of this commonly malady. Typically, patients suffering from

MTSS have characterized the pain in the posteriomedial tibial border during exercise,

pain upon palpation in lengths of 5cm or more (Moen et al, 2009). In the late 19802’s a

study discovered patients with MTSS had a lower regional tibial bone density than those

of healthy athletes (Chisin, Milgrom, Giladi, Stein, Marqulies, & Kashtan, 1987) further

supporting the idea MTSS is not an inflammatory condition, but rather a bony injury.

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Furthermore in a study by Moen et al., (2009) the researchers used magnetic resonance

imaging (MRI) to investigate the cause of MTSS and the resultant pain. Their study

revealed bony resorption was one of the main culprit to the pain. Conversely, Garth &

Miller (1989) performed a case-control study on 17 athletes, finding decreased range of

motion in the second metatarsophalangeal joint and weakness of the toe flexors, thus

concluded permanent increased activity from the flexor digitorum longus muscle was the

cause of persistent shin pain.

Etiology of MTSS

Several risk factors for MTSS have been identified throughout the years. An

intrinsic risk factor that was identified in multiple studies has been over pronation of the

foot (Gehlsen & Seger, 1980; Viitasaalo & Kvist, 1983; Yates & White, 2004). This

excessive pronation can be identified using the navicular drop test.

Additionally, an Australian military study conducted by Burne, Khan, Boudville,

Mallet, Newman, Steinman, & Thorton, E., (2004) found greater hip internal and external

rotation contributed to the risk of occurrence with MTSS. They discovered the

additional hip range of motion among patients tested was 8-12 degrees. The researchers

also found leaner calf muscles may be biomechanically associated with MTSS due to

reduced shock absorbency. Increased body mass index (BMI) and gender have also

been found to be intrinsic risk factors for MTSS. Researchers have found MTSS occurs

more commonly in women than in men (Bennett, Reinking, Pluemer, Pentel, Seaton, &

Killian, 2001; Yates & White, 2004; Burne et al, 2004).

Another risk factor to developing MTSS is the number of years a person has run.

Authors of a retrospective Canadian study found a correlation between number of years

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running and MTSS. Taunton, Ryan, & Clement (2002) concluded adult athletes, who

had been running for less than eight years were more likely to experience shin splints

than those who were more practiced. These results were later confirmed by Hubbard,

Carpenter, & Cordova in 2009. Hubbard et al., (2009) also concluded a person has an

increased likelihood of suffering from MTSS if he/she has a history of the condition.

Other risk factors which have been researched include: change of footwear, worn-

out footwear, change in activity, and change in running surface (Kortebein, Kaufman,

Basford, & Stuart, (2000). However, none of these aforementioned risk factors have

scientific evidence for support.

Current Treatment

In 1974, a study by Andrish, Bergfeld, & Walheim compared different therapies

for the treatment of MTSS. The subjects were drawn from Marines who reported having

pain, anywhere from one to 14 days, in the lower leg. Nearly 100 soldiers were divided

into five different treatment groups. The first group applied ice to the painful area three

times per day and did not return to running until pain free. Group two was administered

650mg of aspirin (acetylsalicylic acid) four times daily for one week in addition to icing

three times per day. Group three also applied ice three times per day with the addition of

100mg of phenylbutazone (an NSAID no longer legal in the United States) four times

daily for one week. The fourth group was instructed to perform gastrocnemius and

soleus strengthening exercises, three minutes, three times a day and applied ice to the

area of pain, three times daily. The fifth and final group had a plaster walking cast

applied for one week. The study revealed time to recovery for each group resulted as

follows: group one) - 6.4 days, group two) - 9.4 days, group three)-7.5 days, group four) -

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8.8 days, and group five) - 10.8 days. These results indicated those individuals who

utilized conservative treatment of ice and limited activity recovered the quickest.

Johnston, Flynn, Bean, Breton, Scherer, Dreitzler, & Thomas (2006) also utilized

soldiers as the test subjects. This rehabilitation program consisted of reduced activity

and ice massage over the pain site. After seven days of treatment, a gradual walk to run

program was introduced. Once the soldiers could complete 800m of running pain free,

they were cleared to return to duty. Days to completion of the running program was

13.4 ±4.5.

Low Level Laser Therapy

In 1968, the Food and Drug Association (FDA) approved LLLT for safe and

effective treatment of pain in 2002. This approval was based on 40 years of research and

over 1200 studies that indicated LLLT creates beneficial changes and promotes healing in

the tissue at a cellular level (Seymore & Cappelletti, 2014). The first to research LLLT

was Dr. Endre Mester where he demonstrate the healing qualities of low power laser

therapy. His series of studies from 1968 to 1973 revealed the therapeutic power of light

therapy for tissue repair and pain reduction (Mester, Lundany, & Sellyei, 1968; Mester,

Spiry, Szende, & Tota, 1971; Mester & Jaszsagi-Nagi, 1973). In a double-blind,

randomized study, Moholkar, Zukowski, Turbill, (2001) assessed 64 patients who

suffered from a variety of 72 different injuries and concluded that LLLT is a safe and

effective form of treatment for some soft-tissue injuries and the most effective reduction

of pain resulted after 4-6 treatments.

Other studies have also investigated LLLT for wound healing, reduction of

inflammation at pain site, decreased pain, and increased range of motion in associated

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joints and soft tissue (Fulop, Dhimmer, Deluca, Johanson, Lenz, et al, 2009; Chow,

Johnson, Lopes-Martins, & Bjordal, 2009; Carrasco, Guerisoli, Guerisoli, & Mazzetto

2009; Kostantinovic, Cutovic, Milovanovic, Jovic, Dragin, Letic, Miler 2010). One

interesting study found the use of LLLT after inguinal herniation surgery to be effective

in preventing keloid formation. These researchers also demonstrated laser treatment

reduced scar appearance at the surgical site (Carvalho, Alcantara, Kamamoto, Cressoni,

& Cassaroto, 2010). An important note here is that application outcomes are based on

the parameters of the laser treatment, therefore, the most important parameter which

should be maintained is the dose or energy density (J/cm2) (Hawkins & Abrahamse,

2007).

A recent study found LLLT decreased patients’ rating of pain and improved balance, with

an average gain of 50% on the Barthel scale (activities of daily living index). Here

Chang, Ku, Hsu, Hu, Shyu, & Chang (2014) evaluated 54 patients with periostitis in the

lower leg. Patients were divided into two groups: placebo and LLLT. The LLLT group

contained 29 patients, while the placebo group held 25 patients. Participants receiving

LLLT had treatment three times per day for five days with a dosage of 1.4J/cm2.

Results showed a decrease in pain over the course of the five day treatment and an

increase in balance scores.

One of the first meta-analysis which investigated LLLT was performed by

Enswemeka, Parker, Dowdy, Harkness, Sanford, & Woodruff, (2004). Here the authors

reviewed the literature and found 34 studies which met the inclusion criteria for tissue

repair. Additionally, nine studies were examined for the effect size. Their analysis

revealed laser therapy positively influences tissue repair in all three stages: 1)

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inflammation, 2) cell proliferation, and 3) tissue maturation. This also found laser

treatment was effective for wound closure. The conclusion of this meta-analysis was

that LLLT is a highly effective treatment for tissue repair and pain control, however they

did note wavelength may play a role in the outcome of the therapy (Enswemeka et al,

2004).

Another meta-analysis performed by Woodruff, Bounkeo, Brannon, Dawes,

Barhman, Waddell, & Enwemeka, (2004) included 24 studies in its statistical data. The

authors found the overall mean effect of laser therapy to be highly significant (d = +2.22).

The sub-analysis also revealed a significant effect size for wound healing (d = +0.54).

Overall, the meta-analysis demonstrated laser promotes accelerated healing of recalcitrant

and non-healing wounds and ulcers. However, the outcome of treatment varies with

treatment parameters (i.e. power, intensity, wavelength, duration of treatment, number

and frequency of treatment, etc.) (Woodruff et al, 2004).

In a third meta-analysis on LLLT and pain management, the authors examined 22

articles that met inclusion criteria and results were consistent with that found in the meta-

analysis performed by Enswemeka et al, (2004). Fullop et al (2010) also concluded laser

therapy was an effective treatment for tissue repair and pain management. They

determined the effectiveness of laser therapy was due to increases in local and systemic

microcirculation, thereby, reducing pain and swelling in the damaged tissue. Fullop et al

(2010) also found evidence to support the theory that laser therapy promotes release of

endorphins- the body’s natural pain reliever as previously revealed by Basford, 1986 and

Gibson & Kernohant, 1993. The meta-analyses conducted by Enswemeka et al, 2004;

Woodruff et al, 2004 & Fullop et al, 2010 all concluded previous research which

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suggested that LLLT was not effective, was based off of poor research designs and lack

of proper documentation throughout studies.

Lastly in a meta-analysis performed by Bjordal, Johnson, Iversen, Aimbire, &

Lopes-Martins (2006) they reviewed possible mechanisms of action and clinical effects

for LLLT. The researchers discovered nine of the 22 studies they examined

demonstrated LLLT modulated inflammatory pain by reducing the levels of specific

biomechanical markers in a dose dependent manner. They also concluded LLLT can

reduce pain and inflammation in acute, soft-tissue injuries for a short-term effect,

however further research needs to be conducted on the long-term effects. Lastly, the

authors found negative outcomes resulted from researchers who used less than 5J per

day and positive outcomes were the result of using daily doses of above 5J (Bjordal et al,

2006).

Micro current therapy

Electro-medicine has been used for over 150 years for the treatment of non-union

fractures (Mercola & Kirsch, 1995). In addition to the treatment of fractures, MCT has

been shown to be effective in a number of ways including: pain reduction, reduction of

inflammation, reduction of edema and swelling, increases range of motion, strength, and

muscular relaxation, and accelerates wound healing (Reich & Tarjan, 1990; Vodovnik &

Karba, 1992).

Typically, MCT uses currents in the micro ampere range, 1000 times less than

that of other electrical stimulation and below the sensation threshold. A typical MCT

pulse is approximately 2500 times longer than other electrical stimulation at about 0.5

seconds (Mercola & Kirsch, 1995). MCT works because of its ability to stimulate

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cellular physiology and growth. The electrical current must be set at a specific range to

allow maximum benefits, where an increase in the current can actually decrease effects of

the treatment. Cheng, Van Hoff, Bockx E, Hoogmarten, M.J., Mulier, J.C., DeDiicker,

F.J., Sansen, W.M., & DeLoecker, W. (1982), found that MCT can increase ATP

production and enhance amino acid transport and protein synthesis.

The intensity of MCT can be explained by Arndt’s Law where weak stimuli

excite physiological activity, moderate stimuli favor it, and strong stimuli inhibit it.

Research has shown MCT applied at 500 mA increases ATP by 500%, but drops below

baseline at 5mA an at 100-500 mA, amino acid transport rises 30% to 40% above

controls (Kirsch, 2002). MCT has been shown to be effective in a number of ways

including: pain reduction, reduction of inflammation, reduction of edema and swelling,

increases range of motion, strength, and muscular relaxation, and accelerates wound

healing (Reich & Tarjan, 1990; Vodovnik & Karba, 1992).

Poltawski, Johnson, & Watson (2012) conducted a 15 week study with

assessments performed at baseline, 3, 6, and 15 weeks to determine the necessary

intensity for pain reduction. Results from their study indicated 93% of participants

receiving 50 mA intensity, felt “much better” or were fully recovered at 15 weeks,

compared to only 47% in the 500 mA group. Therefore they concluded that a

monophasic MCT treatment at a peak intensity of 50 mA may reduce symptoms and

normalize the tendon in chronic tennis elbow.

Another researcher found significant pain reduction in chronic myofascial trigger

points in the neck as a result of MCT treatment. In her study, McMakin (1998) studied

50 patients in a private chiropractic clinic and found 49 of the 50 patients treated with

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MCT had reduced myofascial pain following an average of 11.2 treatments. Side effects

such as slight to moderate nausea, flu-like body aches, and sometimes a slight increase in

pain were noted in some of the patients, beginning approximately 90 minutes after

treatment. These side effects lasted anywhere from 6-24 hours and Dr. McMakin (1998)

discussed these side effects could generally be avoided with proper patient hydration.

A second study performed by McMakin (2004) recorded 90% of the 22 patients

receiving MCT felt more myofascial pain reduction with chronic low back pain than with

alternative treatments including: spinal manipulation, acupuncture, physical therapy,

naturopathic treatment, and pharmaceutical drug therapy. She concluded MCT was the

single factor contributing to the pain reduction of patients who had suffered low back

pain for sometimes more than five years.

There have been mixed results on benefits of MCT over the last several decades.

One of those results is discussed by Ho, Kwong, & Cheing’s (2007) study on

epicondylitis. This pilot study consisted of ten treatments over a three week time span.

Sixteen subjects were randomly assigned to two groups in a single-blind study where one

group received exercises for lateral epicondylitis, while the other group received MCT

and exercises. Results showed improvements in both groups with no significant

difference between the group receiving MCT and those who did not. The authors

concluded more tests with larger sample sizes would need to be completed in the future

to determine the effects of MCT (Ho et al, 2007). Driban (2004) found similar results

when he investigated uses of MCT. He stated that further research must be done to

support validity of the use of MCT. He also stated this modality shows promise for the

future of treatment on a variety of injuries.

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Additionally a four week study by Park, Son, Kim K., Kim S., & Oh (2011)

revealed MCT was an effective treatment for the prevention of foot ulcers in the diabetic

patients. Here MCT was combined with regular walking for exercise and it was found

electrical stimulation increased the blood flow to the foot, thereby, preventing pain and

ulcers in that area. Furthermore Poltawski & Watson (2009) reviewed and discussed the

convincing evidence of MCT for MCT’s use in bone remodeling. Here several studies

dating back to the early 1970’s indicated MCT can be used for enhancement of bone

healing in non-union fractures.

After more than 150 years of research, MCT has shown to have a positive effect

on healing many types of tissue within the body. Most clinicians researching this

modality believe more studies need to be conducted in a controlled and reliable

environment. As of now, electrotherapy appears to be a great substitution for

pharmaceutical injections and other medications as the direct current of the stimulation

promotes healing in tissue and assists in the anti-inflammatory process in a safer

approach than NSAIDs and other drugs (Odell & Sorgnard, 2008).

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Chapter 3

Methodology

Participants and sampling

After departmental approval of the proposed study, an application to the MSUB

Institutional Review Board was submitted and approved (Appendix A). Athletes who

complained of medial shin pain were recruited to participate in this study. After

recruitment, an informed consent (Appendix B) was obtained during the initial

evaluation.

Equipment

All equipment was supplied by the MSUB Athletic Training Department, with

permission granted by the Head Athletic Trainer. No corporate sponsorship was

provided for this study nor did the research have an affiliation with the equipment

companies.

Both the LLLT and the MCT were part of the Vectra Genisys® unit and

manufactured by Chattanooga Company. The Vectra Genisys® provides multiple forms

of electrical stimulation, ultrasound, LLLT, and electrotherapy/ultrasound combination.

The traditional treatment group required massage lotion for manual massage prior to

practice. As the medium of choice, Biotone® is a hypoallergenic massage cream

frequently used in athletic training facilities. Ice cups for massage were paper

Powerade® cups, purchased by the Athletic Training Department.

All participants were asked to utilize the Mosby Pain Rating Scale© (Appendix

C) during their initial evaluation and each consecutive week. The Mosby© scale is a

Likert scale that consists of numerical values from zero to 10. The numbers on the scale

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correlate with images of a face which depicts the amount of pain the numerical value

represents. This combination of numbers and facial expression assist in the accuracy of

pain measurement.

Procedures

Once the participants signed informed consent forms, participants were educated

on the treatment that they would be receiving. They were asked to not stray from their

particular treatment by icing or participating in any other typical activities to reduce pain.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) were permitted as needed for pain

reduction, but not beyond the recommended dosage of medication. This was asked in

order to control for outside treatments that may have interfered with the efficacy of the

study.

The participants were randomly placed into three separate groups. The first group

was the control group, whose treatments consisted of five minutes of manual massage

preceding practice and seven minutes of ice cup massage (self-administered) proceeding

practice. The second group received LLLT targeting soft tissue healing. Parameters for

LLLT were used as recommended by the manufacturer. The third group received MCT

aimed to reduce healing time for bony injuries. Each group received treatment for four

weeks and within that time frame, the researcher wrote weekly progress notes regarding

pain levels and ability to perform in their respective sports.

In addition to obtaining consent during the initial evaluation, other information

(sport, gender, previous history of this injury, self-reported body weight and stature)

which has been shown to increase the risk for MTTSS was also collected. Along with

the initial data collected, a self-reported pain assessment was established using the Pain

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Assessment Scale© Mosby.

During the initial evaluation, the navicular drop test was also performed. The

navicular drop test is performed using an index card. Here the evaluator palpates the

navicular bone located on the medial aspect of the foot and then marks the center of the

bone with a pen. While the patient places his/her foot on the floor in a non-weight

bearing position, the index card is held on the ground perpendicular with the navicular

and a mark on the card is placed where the navicular bone lines up with the index card in

the non-weight bearing position. Then patient is then asked to stand. With the index

card held in the same place, a mark is placed on the card noting where the navicular bone

is located in the weight bearing position. The first and second marks on the index card

are then measured. If the drop of the navicular from non-weight bearing to weight

bearing is >10mm, it is indicative of pes planus (flat feet) or excessive pronation. Moen

et al., (2012) discussed, “one of the most consistent risk factors for MTSS is an increased

pronation of the foot” (37). The authors continued to define a positive navicular drop test

at >0.5cm.

Nielsen, Rathleff, Simonsen, & Langberg H (2009) conducted a study on the

navicular drop test and compared it to increased foot length. They found that per 10mm

increase in foot length, the navicular drop increased by 0.40mm for men and 0.31mm for

women. The researchers concluded the lack of adjustment for length of foot is the cause

for the discrepancy of the test. The Navicular Drop test is important for MTSS

evaluation due to the fact that many studies have found a correlation between pes planus

and MTSS.

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Research Design and Data Analysis

The design of research was determined by the researcher, in consideration for and

based on the specific number of available participants. Due to the small sample size, it

was decided a series of case studies was the most appropriate research design. Six

athletes agreed to participate in this study of MTSS. Data was collected from the six

participants throughout the four week intervention period and was analyzed on a case by

case basis. Each case study has been evaluated individually based on his and her reports

of pain throughout the treatment sessions.

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Chapter 4

Results

Participants

All participants in these case studies were college aged MSUB athletes. Each

individual was asked to participate in the MTSS study based on his or her report on pain

and evaluation findings. All participants were provided an opportunity to ask questions

about the study prior to signing an informed consent. All of the participants were under

no obligation to participate in the study and were free to discontinue treatment at any

point in their therapy.

Athlete 1

The first participant was a male, track and field athlete, who had a history of

previous injuries. This athlete was five feet eleven inches and weighed 155 pounds.

Athlete one had been out of participation for approximately one month due to another

injury and within three days of returning to activity he started having pain in his lower leg

due to repetitive stress after not being active for about a month because of a different

injury. The pain was present for approximately three days prior to his report of the

injury to athletic training staff.

Upon examination, palpable pain was located along the distal 1/3 of the medial

tibia. His navicular drop was measured at 10mm on both the right and the left foot,

which indicated a positive finding. The athlete’s initial measurement on the Mosby©

pain scale was 6/10. He reported he had a history of compartment syndrome in the

affected leg approximately four years prior. After determining that his pain was caused

by MTSS and not any deferential diagnosis such as compartment syndrome or stress

20

fractures, he was asked to participate in the MTSS study. All requirements and

expectations were explained to him and he agreed to participate. Upon signing the

informed consent, he was placed in the LLLT group.

After the first few treatments, the athlete reported that his pain was decreasing.

On the sixth day after initial treatment he noted his pain decreased. Unfortunately, his

practice warm up drastically changed and he was asked to jog around campus with the

team. Up to that point he had not run any long distance in approximately three months.

He stated that the pain increased so much during the run that it made him sick to his

stomach. When asked to rate the pain on the Mosby© scale, he rated it a 9/10,

commenting that he would prefer to “amputate” his lower leg at that time. At this time

in the study, he had only received four LLLT treatments and spent a total of 20 minutes

in the ice bath prior to his drastic increase in pain. He was advised to take 600mg of

ibuprofen and sat in the cold whirlpool (CWP) up to his knees for 10 minutes. Before

going home for the day, he reported the pain had decreased although he was not asked to

give a rating.

Over the next two days, he was unable to practice due to pain. Three days after

his drastic increase in pain, he reported having a pain rating back to 6/10 on the Mosby©

scale. He was incredibly point tender along the mid shaft of medial tibia and he chose to

CWP for eight minutes that day. During his second week evaluation, he reported his pain

had slowly decreased. His pain rating was 5/10 on the Mosby© scale and he did not

need to CWP that week. He had demonstrated positive signs for improvement and the

athlete was able to return to full practice without the pain increasing.

During the athlete’s third week of treatment, his pain returned to the original level

21

as he rated the pain at 6/10, even though he stated that the two days prior to the

evaluation he was feeling much better. He did not receive treatment during one of these

days because he forgot to come in to the Athletic Training Room. Additionally due to

more research on LLLT his therapy was cut in half day and for the remaining week of his

treatment. He began receiving 3.5J/cm2 for 26 seconds per site. This switch came as

the result of further research on laser therapy and the belief that the treatment settings at

present, were creating too much heat in the injured tissue.

On his final day of treatment, the athlete reported his pain was only 4/10 and it

was the best his lower leg had felt in over a month. Overall, he dropped from a pain

rating of 6/10 to 4/10 during the four week treatment and he only missed two days of

therapy. This may not be a drastic decrease, however, it was a two point decrease on the

Mosby© scale from week three to week four. The athlete discontinued treatment for

pain after he completed his four week session. Additionally, he did not report to the

Athletic Training Room for over one month for any sort of pain management therapy.

Approximately five weeks after his LLLT was completed, he returned to the Athletic

Training Room with an increased pain in his lower leg however he did not want to

continue with the LLLT. He instead used a combination of cryotherapy and manual

massage, similar to the treatment of those in the traditional treatment group. A couple of

weeks after traditional treatment he noted that his lower legs were only painful when he

wears his “loafers” throughout the day. If he wore regular tennis shoes, the pain was not

present.

Athlete 2

The second athlete was a female track competitor who was approximately five

22

feet and five inches and weighed roughly 135 pounds. She presented with pain in her

low, medial lower leg, stating the pain began about three days prior to her report and the

pain occurred during practice only. The athlete stated that she had a history of “shin

splints” in both of her legs, but only felt pain in the left leg at present. She also reported

she began participating in sports approximately 15 years ago. Upon evaluation, she was

found to have palpable pain along the distal 1/3 of the medial shaft of the tibia. Her

range of motion and strength were not affected by the pain during the evaluation. The

testing of her navicular drop revealed the right navicular to drop 4mm and the left 5mm,

with both measurements within normal limits for navicular drop. After the evaluation,

she was asked to participate in the MTSS treatment study. All criteria of the study was

explained to her and she agreed to participate. After signing the informed consent, she

was placed in the LLLT group. Additionally, during the initial evaluation, she was

asked to rate her current level of discomfort on the Mosby© pain scale. She rated her

pain at 6/10. After the first week of treatment, her pain stayed consistent at 6/10. She

did not receive any ice or other cold therapies during this week. The athlete did not

report taking any NSAIDs for pain relief.

On the second week, she reported her leg felt better and rated her pain at 4/10. It

is important to note here she also chose to CWP three times at eight minutes per

treatment between weeks one and two.

During the third week, she revealed a slight increase in pain and indicated she was

a 5/10 on the pain scale. Her treatment time, like the previous athlete, was cut in half

just prior to her three week evaluation. During her final week, she reported that the pain

level decreased back down to 4/10. She stated her leg that was receiving treatment was

23

feeling better, however, she reported that her opposite leg had started to become painful.

As with the first athlete, she showed a two point decrease in pain over the course of the

treatment. Major decreases came during two times: 1) when using the CWP and 2) after

the treatment intensity was cut in half.

Upon completion of her four week treatment, she discontinued all pain treatment.

She did not report to the Athletic Training Room for nearly six weeks. Her return was

coupled with increased shin pain. She decided cryotherapy was the course of treatment

she wanted pursue for pain management. She continued to report to the Athletic

Training Room one to two times per week for an eight minute session in the CWP. No

other treatment had been applied.

Athlete 3

The third athlete, a male baseball player, reported to the Athletic Training Room

after having persistent pain in his lower legs for a few days. His pain was present in

both legs while he was running and pain increased the longer he was active. The athlete

stated he had been ice massaging at home once per evening since the onset of pain. He

had a previous history of injury dating back to the previous semester, however the pain

had resolved during the break between fall and spring semesters. The athlete was six

feet and four inches tall and weighed 185 pounds.

Initial evaluation revealed palpable pain along the medial middle shaft of both

tibias. The pain did not affect range of motion or strength of the ankles or knees. The

navicular drop test found a drop of 8mm on the right foot and 5mm on the left. No

abnormal findings were present during the initial evaluation. After the initial evaluation,

the athlete was asked to participate in the MTSS study and was explained the criteria.

24

The individual agreed to sign the informed consent and he was placed in the traditional

treatment group. Upon initial evaluation, he reported his initial pain on the Mosby©

scale at 6/10.

After the first week of traditional treatment, the athlete reported his pain was only

4/10. It should be noted here the athlete missed two days of therapy during his first

week. Even with his missed treatments, he felt a two point decrease in pain since the

commencement of therapy. During the following week, he only missed one day of

treatment. He reported both legs felt better during practice and that he could run for

longer durations without the pain causing him to cease activity. He rated his pain at 3/10

on the Mosby© scale. His final evaluation revealed another decrease in pain. He stated

the pain was rarely noticeable during activity and he rated it 2/10. After his completion

of the four week traditional therapy, he did not returned to the Athletic Training Room

for pain in his lower legs. He stated that the pain was nonexistent and was able to

participate fully in practice as if the injury never occurred.

To this point in the series of case studies, the traditional treatment had been the

only therapy to show a decrease in pain after each week. Athlete 3 was the only athlete

who did not have an increase in pain at any time after the treatment sessions were

discontinued.

Athlete 4

The fourth athlete was a male track and field competitor, who was five feet and

eight inches tall and 160 pounds. The athlete presented to the Athletic Training Room

complaining of pain in both shins and stated his pain gradually progressed over two

weeks prior to his report of the injury. He reported he has been an athlete for roughly

25

eight years and he had suffered from lower leg pain during the last four track seasons.

He also reported his pain was significantly worse in his left leg than the right throughout

the last four years, however, during this examination, he stated that his right leg was more

painful than his left.

During the examination, palpable pain and crepitus were located along the medial

mid shaft of both tibias. No swelling was present in the lower legs. No decreased range

of motion or strength was present, however, pain was felt during resistive plantar flexion.

The MTSS study was described to him and he was asked to become a participant. Upon

answering all questions, he signed the informed consent form and his navicular drop

measurements were taken. The navicular drop revealed a depression of 12mm on the

left foot and 5mm on the right. The 12mm drop on the left foot could be a possible

reason for the increased pain in his left lower leg. He rated his current pain for both legs

at a 6/10 on the Mosby© scale. He was then assigned to the LLLT group.

After the first week of treatment, he stated his pain slightly diminished. He rated

his pain at a 4/10 on the pain scale and he did not use any cryotherapy during the first

week of treatment. During the second week evaluation, he reported consistent pain

levels. . Unlike the other two in the LLLT group, his pain did not increase during this

week, but it did not decrease either. He reported once again his pain was 4/10. The

third week of treatment resulted in a slight increase of pain and he rated his pain at 5/10.

Like the previous two athletes in this group, this week his therapy was cut in half. He

did not show up for his last two days of treatment, so a final pain measurement was

unable to be obtained.

This athlete did not come back in to the Athletic Training Room for over a month.

26

He stated he did not have enough pain to warrant treatment until roughly six weeks later.

Once the pain returned, he came in one to two times per week to utilize the CWP. He

also received ice bags wrapped on both shins after his competition. No further treatment

with LLLT was pursued.

Athlete 5

The fifth athlete in this series of case studies is a female, softball player with a

chronic case of MTSS. She stood five feet, six inches tall and weighed about 140

pounds. Her pain began approximately one year prior to this study during her last

softball season. The athlete stated that the pain decreased with decreased activity and

increased when she ran or when pressure was applied to the area. In her history, she

indicated she had participated in sports for more than 16 years. Additionally during her

initial evaluation she revealed she was placed in a walking boot for four weeks last

season. During this time, she wore the boot at all times except when she played softball.

She would wear the boot until she arrived at practice or a game, then she would put her

softball shoes on, play her game, and then return to the walking boot. This case is

different from the rest because when the pain increased, she developed a light colored

contusion over the affected area. Previously, the athlete had used ice after practice and

ultrasound for pain modulation neither of which had proven to be successful at pain

reduction for this athlete.

Upon physical examination she had palpable pain along the distal mid shaft of the

medial tibia. A small amount of ecchymosis (discoloration) was present over that same

area of palpable pain. Her navicular drop revealed her left navicular to drop 9mm and

her right to drop 6mm. After answering all questions, she decided to participate in the

27

MTSS study and signed the informed consent. She was shown the Mosby© pain scale,

and she rated her pain level at 6/10. The athlete was then placed in the traditional

treatment group.

After the first week of treatment, the athlete reported that the pain had significantly

decreased. She rated the pain at 2/10 on the Mosby© scale. She reported that the pain

had not bothered her nearly as much this week as it had the weeks preceding the

treatment.

The following week, the athlete reported that her lower leg still felt “pretty good.”

However, she continued to rate the pain at a consistent 2/10 during activity. She stated

that she no longer was feeling the pain after activity, but noticed it was still present

during her runs.

The following week, the athlete traveled out of state for a softball tournament.

She traveled with softball for about two weeks and did not continue her treatment while

on the road. The athlete decided to discontinue her treatment upon her return. She

stated the pain dissolved during her time away. She did not return to the Athletic

Training Room for treatment on her shin for roughly four weeks. After four weeks she

stated the pain had returned. She stated that she could not handle the pain of manual

massage over the area every day therefore her treatment was discussed and it was agreed

the manual massage would be cut back to twice a week as long as she agreed to ice cup

massage every day. This newly agreed upon treatment lasted for approximately two

weeks before her travel schedule removed her from the Athletic Training Room once

again. She continued to report to the Athletic Training Room for treatment once a week

for general pain management.

28

Athlete 6

The sixth and final athlete in this series was a female softball player. This athlete

stood five feet seven inches tall and weighed around 170 pounds. This athlete attempted

to push through the pain for two weeks prior to reporting to the Athletic Training Room

for bilateral lower leg pain. During these initial two weeks, the athlete reported icing her

lower legs each day after practice. She has been an athlete for seventeen years and she

reported a history of “shin splints” the last few years.

Her clinical evaluation discovered palpable pain along the majority of both medial

tibias. Range of motion and strength in the ankle were unaffected by the pain in her

lower legs. She reported increased pain during resistive plantar flexion. The athlete

agreed to participate in the MTSS study and signed her informed consent form. She was

then assigned to receive micro current for the next four weeks. According to the

Mosby© pain scale she indicated her initial discomfort was 6/10. Her navicular drop

was measured at a 6mm drop on the left and 5mm drop on the right.

The first week of treatment went better than anticipated. She rated her pain as

2/10 on the pain scale. She indicated that she felt almost no pain during practice. The

following week resulted in another 2/10 pain rating. The athlete stated that the pain was

a consistent dull ache. This athlete was the only subject who completed two full weeks

of MCT. After the second week, she traveled out of state for a softball tournament.

Upon returning, she reported having next to no pain in either shin during activity. She

decided to discontinue treatment. She has not returned to the Athletic Training Room

with any pain in her lower legs.

29

Statistical Analysis

Due to the low amount of participants in this study, a statistical analysis was

unable to be performed. This research project has since been turned in to a series of case

studies, to explain each individual case and the progression that they made during each

treatment type. Analysis of each participant’s case will be discussed in the results and

discussion section.

30

Chapter 5

Discussion

After evaluating each participant, it was interesting to see that all participants

indicated that they were experiencing the same level of pain (6/10) prior to beginning

their individual treatments. Moreover, each participant reported decreased pain from the

initial treatment to the final session. Some athletes’ reported a more significant decline

than others. Most participants reported being an athlete for over ten years. One

reported participating in sports for 17 years. In the following discussion, athletes are

grouped according to treatment and related to previous research.

Laser Participants (n=3)

Participant 1 showed a decrease of two points on the pain scale from beginning to

end. His pain level declined almost immediately after the change in therapy, but that

may not be due to the alteration as this athlete also continued to use the CWP on a regular

basis during his four weeks of treatment. His circumstance was much different from the

other LLLT participants, due to his previous history of stress fractures. Also, the fact

that he had just recovered from another injury which had kept him out of participation

during practice, makes his situation unique. Once he pinpointed the connection to his

footwear and his pain, he was able to make the necessary adjustments. He did not report

back to the Athletic Training Room since his footwear modification. Kortebein et al,

(2000) noted change of shoes has been discussed as a possible risk factor for MTSS.

These researchers stated that this is a common factor reported, but no scientific evidence

has supported this claim.

Athlete 1’s predisposition to this particular injury will most likely result in

31

continuation of pain throughout his athletic career. It may be beneficial for this athlete

to seek the use of orthotics to correct his excessive pronation of the foot. Additionally, if

the proper adjustments were made to the LLLT, he may see more positive results for pain

reduction in the future.

Participant 2 also showed a two point pain reduction over the course of the four

week treatment. According to the research, this athlete is predisposed to having MTSS

because of 1) gender and 2) her previous history of MTSS. With regular cryotherapy

treatments, her pain continued and helped her continue to participate in practice daily.

Since the first report of her injury, she stated that pain had kept her from participation

only two different times.

Participant 4 showed the smallest reduction in pain for both LLLT group and all

of the participants. He had the largest navicular drop of all the participants. His left

foot showed excessive pronation with a 12mm navicular drop, whereas his right foot only

measured a 5 mm drop. This navicular drop in the left foot may explain why both lower

legs are frequently tender and could further explain why the left leg is generally more

painful. Even though he had an initial two point decrease in pain during the first week,

his pain increased by one point in the week following. The last recorded pain rating was

5/10, which is only a one point decrease over the four week time span. This athlete also

reported having the least amount of running experience of all the subjects and the

correlation between pain and running experience was discussed by Taunton et al., (2002)

where they found athletes who had been running for eight or less years were more likely

to suffer from MTSS. Additionally, his excessive pronation of the left cannot be

overlooked as a predisposing factor for this condition.

32

Recommendations for this athlete would be corrective orthotics for the left foot.

He would most likely benefit from calf strengthening exercises as noted in the literature

review. Early pain intervention will be necessary for him in the future to keep this

condition at a manageable pain level. His therapy of choice, like most athletes, appears

to be cryotherapy.

Traditional treatment (n=2)

Participant 3 was one of two participants who received traditional treatment. He

also reported the largest reduction of pain of those who completed the study. His initial

pain level was a six and it decreased to a two after four weeks of therapy. This

participant was also one of two athletes who did not to return with complaints of shin

pain once the treatment was complete. The cause for not returning may be one of two

reasons 1) he felt that his obligation to participate in the study was fulfilled and therefore

did not feel the need to return even if pain was present, or 2) the traditional therapy

resulted in an effective management of the injury, therefore, the athlete did not need to

return. Another possible cause for his rapid healing compared to the others is the

minimal amount of factors predisposing him for MTSS. Although his navicular drop on

the right foot than the left, it was not as significant as what researchers deem to be a

predisposing factor. Also, when compared to the other participants, he had the lowest

report for previous history of the injury.

Athlete 5 had the longest history of lower leg pain. Her pain was reported as

affecting her for nearly an entire year. With the traditional treatment, we were able to

attain a manageable pain level for participation and her self-reported pain decreased from

a six to a two over two and a half weeks of treatment. The pain did return after a few

33

weeks, but with some adjustments to treatment we were able to once again bring her pain

down. There are also a few characteristics that predispose athlete 5 to MTSS. The first

characteristic was she is female, the second is her history of MTSS, and the last is her

navicular drop of 9mm. The last predisposition of navicular drop is borderline of what

some researchers have deemed a characterizing factor for MTSS.This athlete would most

likely benefit from corrective foot orthotics for the left foot. The traditional treatment

appeared to be an effective therapy for this athlete as shhe has maintained a tolerable

level of pain while receiving traditional treatment.

MCT (n=1)

Participant 6 was the only one to receive MCT. She showed a drastic decrease in pain

after only two weeks of therapy. Her results are promising regarding the idea that MCT

may be one of the best treatments for MTSS. She is the only other athlete to not return

with complaints of shin pain. Keeping in mind the athlete’s pain decreased from a six to

a two in just one week, one could posit the pain may have been eliminated had the

treatment continued. If the athlete would have continued receiving MCT during her

final two weeks of the outlined time line, we may have seen the first 0/10 Mosby© pain

rating. Additionally, other factors which may have contributed to her rapid decrease in

pain could be due to her limited amount of predisposing factors. Her navicular drop was

within normal limits, she has been an athlete well beyond eight years (which has been

previously linked to MTSS) however she self-reported a two year history of MTSS and

she is female.

After reviewing all of the participants’ data, it is difficult to say if any one

modality was best for the treatment of MTSS. Once adjusted, the LLLT seemed to show

34

a decrease in pain, however, the adjusted treatment did not last long enough to show any

significant data. Additionally, all participants who received LLLT returned with lower

leg pain within one month of completion of treatment. More studies must be done with a

larger sample size and with the adjusted settings in order to draw any finite conclusions

on this treatment.

One positive aspect for LLLT for athletes is that it is fast and painless. The

treatment sessions do not last longer than three minutes. The subject may feel a slight

warming sensation, but no report of pain during the treatment has been recorded. The

negative aspect of LLLT is that it is not commonly found in an athletic training facility.

The subject who received MCT showed a significant decrease in pain with no

report of pain returning. This could be considered the treatment of choice for clinicians,

if there was a larger sample size. One case report on the significant pain reduction from

MCT after two weeks is not enough to show reliability or validity to the modality.

Additionally, the benefit of MCT is that it is painless. Unlike other forms of electrical

stimulation, one does not feel the pulses of MCT. Some subjects have reported feeling a

“tingle” but nothing that caused pain. Some individuals do not care for other forms of

electrical stimulation because of the pin pricking sensation. The downfall to MCT is that

it is a longer treatment session and this modality is not always readily available in all

athletic training facilities.

Conclusion and Future Research

Traditional treatment appears to be the therapy of choice for athletes. This may

be because it is “traditional” and “safe”. Most athletes have been taught when their

lower legs hurt to start with some form of cryotherapy in combination with massage. The

35

two athletes who received traditional treatment showed promising results as both

participants’ pain decreased throughout their treatment. One did not return with

reoccurring pain, the other, after adjustments, has maintained a manageable level of pain.

Unfortunately, the goal of the study was not to create “manageable” pain, but to

examine which modality would eliminate the pain in the shortest amount of time. The

results are inconclusive due to the lack of numbers for the research.

More research needs to be completed to find a protocol for treatment of MTSS.

All of the modalities used in this research show promise for tissue healing, however a

larger sample size is necessary to demonstrate significant findings. It is also

recommended that the decrease in intensity of the laser should be considered a permanent

fixture in future studies if using the Vectra Genisys. The adjustments made to the

traditional treatment, such as cutting the massage back to twice a week, should be

considered for pain tolerance and continued participation. The MCT settings appeared to

be the proper dosage, but more subjects were necessary to obtain conclusive results.

Gait analysis in those who have excessive compared to minimal pronation would

also be interesting to investigate. It would be beneficial to see if those with excessive

pronation change their walking or running gait pattern when compared to those who do

not have flat feet. If an altered gait is present, this could be an indicator for why MTSS is

more prevalent for individuals with excessive pronation.

36

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A

Appendix A. Montana State University Billings – Institutional Review Board approval

40

41

Appendix B. Consent Form

Effect of micro-current and low level laser therapy

On return to play for medial tibial stress syndrome in MSUB athletes

You are asked to participate in a research study on different treatments for shin splints.

The purpose of this study is to examine which of three treatments are the most beneficial

for eliminating shin pain. Identification of the most efficient treatment for shin pain will

reduce the time that it takes to return to play when pain-free. All treatments have been

shown to reduce pain of an injury.

Description of your participation in the study:

You will be randomly placed in one of three groups: traditional treatment, low

level laser therapy (LLLT), or micro-current.

The traditional treatment group will be asked to do no other treatment other than

rest, ice, and massage.

The LLLT group will come in for treatment each weekday. Treatment will last

approximately 5 minutes.

The micro-current group will come for treatment each weekday. Treatment will

last approximately 35 minutes.

All groups will be allowed to consume a recommended dose of nonsteroidal anti-

inflammatory drug (NSAID) if needed.

Each group will be expected to come in each weekday for 4 weeks to receive their

respective treatment.

Your participation is completely voluntary and have the right to choose not to participate

or withdraw from the study at any time without adverse consequences.

Confidentiality:

All information collected during the study is confidential. This information will be kept

private per terms of the Health Insurance Portability and Accountability Act of 1996

(HIPAA).

Risks and Benefits:

There are no known risks for any of these particular treatments. Potential benefits of this

study is a faster decrease in pain felt during activity.

Contact:

Please ask me any questions or share any concerns:

Elizabeth Davis

(406)589-6163

1500 University Dr. c/o Athletic Department

Billings, MT 59101

e.a.davis010@gmail.com

42

Any questions or concerns about your rights as a participant should be directed to the

MSU Billings Institutional Review Board at 406.657.2046

This project has been approved by the IRB.

I have read this consent form and have been given the opportunity to ask questions.

I freely give my consent to participate in this study.

Name (Print): ___________________________________________ Date: ____________

Name (Signed): _________________________________________ Date: __________

Witness: _______________________________________________Date: ___________

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Appendix C. Mosby Pain Rating Scale