[Medial tibial pain in runners]

Pain at the site of the tibial insertion of the flexor digitorum longus and the soleus near the middle third of the medial border of the tibia may be encountered in young athletes, who have usually started to run in late adolescence. Heel valgus, abnormal mid-foot pronation and excessive tibial torsion may be seen in association. The symptoms are brought on after excessive training. Radiographs may show cortical thickening at the site of the pain, and a bone scan may demonstrate a mild increase in the uptake of the isotope at this site. The pain appears to be related to a strain of the attachment of the flexor digitorum longus and the aponeurotic insertion of the soleus into the tibia. The pressure in the deep posterior compartment of the tibia is normal. Histological examination of specimens from the flexor digitorum longus may demonstrate ischaemic changes in the muscle. Treatment is based on an understanding of the biomechanics of the foot in running, modification of training methods and the use of suitable orthotics. If these measures fail, partial division of the aponeurotic attachment of soleus and freeing of the insertion of the flexor digitorum longus is usually successful.