Comparison of ESWT and Deep Tissue Massage in Individuals With Medial Tibial Stress Syndrome

"Joint mobilization exercises:~-Active ankle range of motion exercises~Ankle strengthening with resistance band (Thera-band®):~* Resisted dorsiflexion~* Resisted plantar flexion~* Resisted inversion~* Resisted eversion~* Leg muscle strengthening exercises:~* Heel raises (standing)~* Heel raises (sitting)~* Toe raises (standing)~* Toe raises (sitting)~Hip and pelvis stabilizer muscle strengthening exercises:~* Pelvic bridge~* Side leg lifts with hip and knee at 0°~* Side leg lifts with hip and knee at 90°~Stretching exercises:~* Calf stretch with towel~* Gastrocnemius stretch (standing)~* Soleus stretch (standing)~* Anterior compartment leg stretch~These exercises will be applied three times a week in 40-minute sessions, for a total of 12 sessions."

"The Extracorporeal Shock Wave Therapy (ESWT) will be administered once a week for a total of four sessions. Each session will deliver 2000 pulses at a pressure of 2.5 bar and a frequency of 8 Hz using radial shock wave technology. The total energy flux density per session is planned to be approximately 200 mJ/mm².~Patients will be positioned in a supine lying position during the treatment. A generous amount of ultrasound gel will be applied to the medial tibial border and surrounding tissues to ensure effective transmission of shock waves and patient comfort.~The application of shock waves will follow the clinical focusing principle: treatment will start from the point of greatest tenderness and maximal pain on the medial tibial border, progressing in a circular motion from medial to lateral. The treatment area will typically cover a region approximately 2-4 cm in width and 4-8 cm in length."

The deep tissue massage begins with the patient lying on their side, the affected leg on top, knee flexed at about 45 degrees, and the medial surface of the tibia facing upward. The sensitive line along the medial tibia is identified by palpation, and the area is prepared with petroleum jelly. The massage starts with 4-5 superficial strokes along the medial calf using the palm, followed by 2-3 deep strokes to assess muscle tone and patient tolerance. Moderate pressure is applied with the thumb perpendicular to the tibial line, moving slowly from just above the medial malleolus toward the medial tibial plateau. Then, the thumb shifts one finger width posteriorly and moves upward along the soleus muscle with similar pressure. These two steps are repeated 6-8 times, each lasting 10-15 seconds, with pain adjusted to 7-8 on the VAS scale. A 10-second rest is given between applications, and the massage ends with 4-5 superficial strokes.