{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T13:19:58Z","timestamp":1770815998912,"version":"3.50.1"},"reference-count":46,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T00:00:00Z","timestamp":1770768000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Muscles"],"abstract":"<jats:p>Objectives: Medial tibial stress syndrome (MTSS) is a common overuse injury among athletes, yet limited evidence exists regarding muscle-specific deficits. This study aimed to (a) examine differences in gastrocnemius and soleus strength and endurance between the affected and healthy lower limb, and (b) investigate the relationships between gastrocnemius and soleus strength, endurance, and pain intensity in athletes with MTSS. Methods: Thirty athletes aged 18\u201340 years with MRI-confirmed MTSS, who had completed a standardized physiotherapy program, underwent isometric dynamometry and heel-rise endurance testing under knee-extended (gastrocnemius) and knee-flexed (soleus) conditions. Relative strength values and heel-rise repetitions were compared between limbs using paired t-tests. Correlations and regression analyses were performed between pain intensity, strength, and endurance of the affected limb using Pearson\u2019s r and simple linear regression. Results: Significant deficits were found in both muscles of the affected limb, with reduced isometric strength and fewer heel-rise repetitions (gastrocnemius heel-rise: t(29) = \u22126.47, p &lt; 0.001; gastrocnemius strength: t(29) = \u22126.27, p &lt; 0.001; soleus heel-rise: t(29) = \u22125.37, p &lt; 0.001; soleus strength: t(29) = \u22124.87, p &lt; 0.001). Strong positive correlations were observed between muscle strength and endurance, while higher pain intensity was negatively associated with gastrocnemius performance. Moreover, pain intensity significantly predicted gastrocnemius strength (F(1,28) = 5.90, p = 0.022, R2 = 0.17) and endurance (F(1,28) = 7.56, p = 0.009, R2 = 0.22), but not soleus function. Physiotherapy duration, number of physiotherapy sessions, and self-reported pain improvement were not significant predictors to either soleus or gastrocnemius endurance, only training frequency emerging as the only independent variable. Conclusions: Athletes with MTSS exhibited notable impairments in plantarflexor function. These findings underscore the importance of targeted strength and endurance interventions for both the gastrocnemius and soleus muscles to optimize recovery, enhance load tolerance, and reduce recurrence risk. Future research should include pre- and post-rehabilitation assessments, larger sample sizes, and sport-specific cohorts.<\/jats:p>","DOI":"10.3390\/muscles5010014","type":"journal-article","created":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T09:15:12Z","timestamp":1770801312000},"page":"14","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Examining Relationships and Differences Between the Gastrocnemius and Soleus of the Affected and Healthy Lower Limb of Athletes with Medial Tibial Stress Syndrome"],"prefix":"10.3390","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6744-2979","authenticated-orcid":false,"given":"Anna","family":"Christakou","sequence":"first","affiliation":[{"name":"Laboratory of Biomechanics, Department of Physiotherapy, University of Peloponnese, 23100 Sparta, Greece"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7757-5094","authenticated-orcid":false,"given":"George","family":"Plakoutsis","sequence":"additional","affiliation":[{"name":"Laboratory of Advanced Physiotherapy, Department of Physiotherapy, University of West Attica, 12243 Athens, Greece"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Athanasios","family":"Gkagkalis","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy, University of Peloponnese, 23100 Sparta, Greece"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5552-5101","authenticated-orcid":false,"given":"Eleftherios","family":"Paraskevopoulos","sequence":"additional","affiliation":[{"name":"School of Physical Education and Sports Science, National and Kapodistrian University of Athens, 17237 Dafne, Greece"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,11]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e2","DOI":"10.1136\/bjsm.2010.081570.9","article-title":"Medial tibial stress syndrome","volume":"45","author":"Batt","year":"2011","journal-title":"Br. J. Sports Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"29","DOI":"10.3810\/psm.2002.06.337","article-title":"Tibial stress injuries: Decisive diagnosis and treatment of \u2018shin splints\u2019","volume":"30","author":"Couture","year":"2002","journal-title":"Physician Sportsmed."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"229","DOI":"10.2147\/OAJSM.S39331","article-title":"Risk factors associated with medial tibial stress syndrome in runners: A systematic review and meta-analysis","volume":"4","author":"Newman","year":"2013","journal-title":"Open Access J. Sports Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"265","DOI":"10.2165\/00007256-199826040-00005","article-title":"Tibial stress injuries: An aetiological review for the purposes of guiding management","volume":"26","author":"Beck","year":"1998","journal-title":"Sports Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"577","DOI":"10.5312\/wjo.v6.i8.577","article-title":"Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments","volume":"6","author":"Franklyn","year":"2015","journal-title":"World J. Orthop."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"772","DOI":"10.1177\/0095399703258776","article-title":"The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits","volume":"32","author":"Yates","year":"2004","journal-title":"Am. J. Sports Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1136\/bjsports-2014-093462","article-title":"Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: A systematic review and meta-analysis","volume":"49","author":"Bliven","year":"2015","journal-title":"Br. J. Sports Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"523","DOI":"10.2165\/00007256-200939070-00002","article-title":"Medial tibial stress syndrome: A critical review","volume":"39","author":"Moen","year":"2009","journal-title":"Sports Med."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Raissi, G.R.D., Cherati, A.D.S., Mansoori, K.D., and Razi, M.D. (2009). The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes. BMC Sports Sci. Med. Rehabil., 1.","DOI":"10.1186\/1758-2555-1-11"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1016\/j.jsams.2006.12.115","article-title":"Endurance of the ankle joint plantar flexor muscles in athletes with medial tibial stress syndrome: A case-control study","volume":"10","author":"Madeley","year":"2007","journal-title":"J. Sci. Med. Sport"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1186\/s13047-021-00485-5","article-title":"Lower leg muscle structure and function are altered in long-distance runners with medial tibial stress syndrome: A case control study","volume":"14","author":"Mattock","year":"2021","journal-title":"J. Foot Ankle Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"789","DOI":"10.2214\/AJR.05.0303","article-title":"High-resolution CT grading of tibial stress reactions in distance runners","volume":"187","author":"Gaeta","year":"2006","journal-title":"Am. J. Roentgenol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1080\/00913847.1992.11947542","article-title":"Relieving Painful \u2018Shin Splints\u2019","volume":"20","author":"Fick","year":"1992","journal-title":"Physician Sportsmed."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1007\/s12178-009-9055-6","article-title":"Medial tibial stress syndrome: Conservative treatment options","volume":"2","author":"Galbraith","year":"2009","journal-title":"Curr. Rev. Musculoskelet. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1097\/00005768-200201000-00006","article-title":"The prevention of shin splints in sports: A systematic review of literature","volume":"34","author":"Thacker","year":"2002","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"670","DOI":"10.2519\/jospt.2007.2534","article-title":"Exercise-related leg pain in collegiate cross-country athletes: Extrinsic and intrinsic risk factors","volume":"37","author":"Reinking","year":"2007","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"438","DOI":"10.2522\/ptj.20090012","article-title":"Increasing muscle extensibility: A matter of increasing length or modifying sensation?","volume":"90","author":"Weppler","year":"2010","journal-title":"Phys. Ther."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1123\/jsr.2022-0344","article-title":"Comparing the effect of exercises with different gluteal-to-tensor fasciae latae activation index in patients with chronic low back pain","volume":"32","author":"Jahandideh","year":"2023","journal-title":"J. Sport Rehabil."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"553","DOI":"10.2519\/jospt.1993.18.4.553","article-title":"Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test","volume":"18","author":"Picciano","year":"1993","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1123\/att.13.2.34","article-title":"Medial tibial stress syndrome: Etiological theories, Part 2","volume":"13","author":"Craig","year":"2008","journal-title":"Athl. Ther. Today"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1016\/j.physio.2017.03.002","article-title":"Updated reliability and normative values for the standing heel-rise test in healthy adults","volume":"103","author":"Wessman","year":"2017","journal-title":"Physiotherapy"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"009","DOI":"10.36950\/2024.9ciss009","article-title":"Reliability of a standardized protocol of the Single Leg Heel Rise Test","volume":"9","author":"Schrefl","year":"2024","journal-title":"Curr. Issues Sport Sci. (CISS)"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2316","DOI":"10.14260\/jemds\/2020\/502","article-title":"Impact of physiotherapy rehabilitation on patients with bilateral osteoarthritis knee pain-a case report","volume":"9","author":"Bhandakkar","year":"2020","journal-title":"J. Evol. Med. Dent. Sci."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.humov.2014.04.009","article-title":"Gastrocnemius and soleus are selectively activated when adding knee extensor activity to plantar flexion","volume":"36","author":"Suzuki","year":"2014","journal-title":"Hum. Mov. Sci."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"BIO061810","DOI":"10.1242\/bio.061810","article-title":"Knee position affects medial gastrocnemius and soleus activation during dynamic plantarflexion: No evidence for an inter-muscle compensation in healthy young adults","volume":"13","author":"Csala","year":"2024","journal-title":"Biol. Open"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"132","DOI":"10.4103\/jdmimsu.jdmimsu_184_19","article-title":"Impact of fall on anterior cruciate ligament of 33-year-old male","volume":"15","author":"Bele","year":"2020","journal-title":"J. Datta Meghe Inst. Med. Sci. Univ."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1093\/milmed\/158.6.410","article-title":"A review of lower limb overuse injuries during basic military training. Part 1: Types of overuse injuries","volume":"158","author":"Ross","year":"1993","journal-title":"Mil. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/S0958-2592(98)90043-8","article-title":"Chronic shin splints: A review of the deep posterior compartment","volume":"8","author":"Finch","year":"1998","journal-title":"Foot"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"92","DOI":"10.2340\/1650197719702239298","article-title":"Perceived exertion as an indicator of somatic stress","volume":"2","author":"Borg","year":"1970","journal-title":"Scand. J. Rehabil. Med."},{"key":"ref_30","first-page":"379","article-title":"A learning protocol improves the validity of the Borg 6\u201320 RPE scale during indoor cycling","volume":"35","author":"Romero","year":"2014","journal-title":"Inter. J. Sports Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1111\/j.1365-2702.2005.01121.x","article-title":"Pain: A review of three commonly used pain rating scales","volume":"14","author":"Williamson","year":"2005","journal-title":"J. Clin. Nurs."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1446","DOI":"10.1113\/EP091687","article-title":"Exercise-induced pain within endurance exercise settings: Definitions, measurement, mechanisms and potential interventions","volume":"109","author":"Smith","year":"2024","journal-title":"Exp. Physiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1037\/0033-2909.112.1.155","article-title":"A power primer","volume":"112","author":"Cohen","year":"1992","journal-title":"Psychol. Bull."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1779","DOI":"10.1016\/j.ultrasmedbio.2016.03.010","article-title":"Shear modulus of the lower leg muscles in patients with medial tibial stress syndrome","volume":"42","author":"Akiyama","year":"2016","journal-title":"Ultrasound Med. Biol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1080\/02640410400022029","article-title":"Effects of viscoelastic properties of tendon structures on stretch\u2013shortening cycle exercise in vivo","volume":"23","author":"Kubo","year":"2005","journal-title":"J. Sports Sci."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"2350","DOI":"10.1080\/02640414.2020.1785186","article-title":"Is high soleus muscle activity during the stance phase of the running cycle a potential risk factor for the development of medial tibial stress syndrome? A prospective study","volume":"38","author":"Naderi","year":"2020","journal-title":"J. Sports Sci."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"3413","DOI":"10.1096\/fj.201500100R","article-title":"Mitochondrial adaptations to high-volume exercise training are rapidly reversed after a reduction in training volume in human skeletal muscle","volume":"30","author":"Granata","year":"2016","journal-title":"FASEB J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1447","DOI":"10.1152\/physrev.00031.2010","article-title":"Fiber types in mammalian skeletal muscles","volume":"91","author":"Schiaffino","year":"2011","journal-title":"Physiol. Rev."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1063","DOI":"10.2165\/00007256-200131150-00003","article-title":"Long-Term Metabolic and Skeletal Muscle Adaptations to Short-Sprint Training","volume":"31","author":"Ross","year":"2001","journal-title":"Sports Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1113\/jphysiol.2007.139477","article-title":"Muscle fatigue: What, why and how it influences muscle function","volume":"586","author":"Enoka","year":"2008","journal-title":"J. Physiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1111\/j.1440-1681.1997.tb01229.x","article-title":"Influence of muscle blood flow on fatigue during intermittent human hand-grip exercise and recovery","volume":"24","author":"Pitcher","year":"1997","journal-title":"Clin. Exp. Pharmacol. Physiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/j.semarthrit.2009.10.001","article-title":"Quadriceps arthrogenic muscle inhibition: Neural mechanisms and treatment perspectives","volume":"40","author":"Rice","year":"2010","journal-title":"Semin. Arthritis Rheum."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/0022-510X(73)90023-3","article-title":"Data on the distribution of fibre types in thirty-six human muscles: An autopsy study","volume":"18","author":"Johnson","year":"1973","journal-title":"J. Neurol. Sci."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"576725","DOI":"10.3389\/fphys.2020.576725","article-title":"Strength-Endurance: Interaction Between Force-Velocity Condition and Power Output","volume":"11","author":"Peyrot","year":"2020","journal-title":"Front. Physiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1","DOI":"10.17338\/trainology.2.1_1","article-title":"Isometric force production symmetry and jumping performance in collegiate athletes","volume":"24","author":"Bailey","year":"2013","journal-title":"J. Trainol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1016\/j.arthro.2023.04.020","article-title":"Psychological readiness to return to sport: Fear of reinjury is the leading reason for failure to return to competitive sport and is modifiable","volume":"39","author":"Sheean","year":"2023","journal-title":"Arthroscopy"}],"container-title":["Muscles"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2813-0413\/5\/1\/14\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T10:19:26Z","timestamp":1770805166000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2813-0413\/5\/1\/14"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,11]]},"references-count":46,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["muscles5010014"],"URL":"https:\/\/doi.org\/10.3390\/muscles5010014","relation":{},"ISSN":["2813-0413"],"issn-type":[{"value":"2813-0413","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,11]]}}}