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Tibial Stress Fracture

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Other Names

  • Tibial Shaft Stress Fracture
  • Stress Fracture of the Tibia
  • Dreaded Black Line Fracture
  • Anterior tibial stress fracture
  • Posteromedial tibial stress fracture
  • Tibial Stress Injury
  • Tibial Stress Reaction
  • Shin Stress Fracture
  • Stress Fracture of the Tibia
  • Medial Tibial Stress Injury

Background

History

  • Needs to be updated

Epidemiology

  • Most frequent stress fracture in athletes, military trainees (need citation)
  • Among a case series of 320 stress fractures in athletes, 49% were in the tibia[1]

Introduction

Lateral radiograph of anterior mid-tibia stress fracture (A). High magnification photograph clearly shows site of typical stress fracture with V-or wedge-shaped defect in the cortex of the anterior midtibia (bone umbauzone) (B, arrowhead).[2]

General

  • Tibial stress fractures are overuse injuries resulting from repetitive submaximal loading which overwhlems the bones reparative capacity[3]
  • They are particularly common in runners, jumpnig sports and military recruits
  • Diagnosis is made with clinical suspicion and XR or MRI if needed
  • Management is conservative unless there are anterior tibial cortical stress fractures which are considered high risk
  • See: Stress Fractures (Main)

Pathoanatomy

  • Location by age
    • Adolescents: proximal 1/3 is most common
    • Runners: junction of middle and distal 1/3
  • Posteromedial
    • Occurs on compression side of tibia
    • Good prognosis with non-operative management
  • Anterolateral
    • Occurs on the tension side of the tibia, associated with higher risk of nonunion
    • Anterior black lines or dreaded black line increase risk of poor healing
    • High propensity to propagate to full cortical break

Pathophysiology

  • General
    • Develops when repetitive submaximal loading creates an imbalance between bone resorption and formation
    • Leading to microdamage accumulation and eventual cortical failure
  • Histopathology[4]
    • Repetitive overloading increases osteoclastic activity that exceeds the rate of osteoblastic new bone formation
    • Resulting in bone weakening and microtrabecular disruption (stress injury) that may progress to a cortical break
    • Unsuccessful adaptation of bone to changes in its mechanical environment caused by repetitive loading.

Associated Conditions

Anatomy of the Tibia

  • Major weight bearing bone of the lower leg

Risk Factors

Sports

  • Sports that involve running and jumping
    • Track and field
    • Basketball
    • Volleyball

Activity related

  • Excessive training
  • Poor footwear
  • Unfavorable surfaces, irregular or hard terrain

Biomechanical

Metabolic

Differential Diagnosis

Differential Diagnosis Leg Pain

Clinical Features

Focal tenderness to palpation, sometimes called the Shin Palpation Test<[7]
Demonstration of the tibial fulcrum test using the hand to produce the force. The arrow depicts the direction of force application on an individual with pain over the medial tibia (star).[7]

History

  • History is insidious with a slow onset of leg pain over weeks-months[8]
    • Absence of trauma is a key part of history
  • Patients may have previously had MTSS which has progressed
  • Point tenderness along the tibia at the area of pain
  • Pain initially with sport and training activity only
    • Initially, pain improves with rest
    • Can progress to pain at rest or with walking
  • Rarely, a full cortical break can occur

Physical Exam: Physical Exam Leg

  • Swelling on inspection
    • Less commonly, redness
  • Localized point tenderness over the area of induration[9]
    • This is the most consistent finding
    • Distinguished from MTSS, which presents with diffuse, non focal tenderness
    • Occasional periosteal thickening

Special Tests

Evaluation

Medial tibial stress syndrome evaluated as Grade 4b in the Fredericson classification. a The lateral view of the lower leg X-ray demonstrated cortical thickening and fracture line of the tibial diaphysis (arrow). b MRI showed abnormal signal intensity in the tibial cortex and bone marrow oedema on STIR (arrow)[10]
Injury radiographs. (A) Anteroposterior and (B) lateral radiographs of the right tibia show a clearly transverse lucency (arrow), the ‘‘dreaded black line’’ in the midtibial diaphysis, as well as a thickened anterior cortex and narrowed medullary canal. (C) Anteroposterior and (D) lateral radiographs of the left tibia show an oblique midtibial shaft fracture through stress fracture nonunion.[11]
Lateral radiograph shows a stress fracture with stress reaction of the anterior tibial cortex (blue arrow)[12]

Shin Pain Scoring System (SPSS)

  • General
    • Designed as a clinical scoring tool to help identify stress injuries early[13]
    • Scored from 1-29 to predict likelihood of tibial stress fracture
  • Questions about history (8 points)
    • Is this the first time you are participating in the sporting activity?
    • Do you participate in more than one sport?
    • Have you ever broken a bone?
    • Do you suffer frequent athletic injuries or illnesses?
    • Are you lactose intolerant?
    • Do you have irregular menses?
    • Have you ever been diagnosed with a stress fracture?
  • Clinical Exam (21 points)
    • Palpation to identify the location of bony tenderness
    • Two-finger tap test
    • Vibration sensitivity using a 128-Hz tuning fork
    • Fulcrum test for tibia
    • Active ankle range of motion during a weight bearing lunge
    • Single-leg hop test
  • Diagnostic Yield (when compared to MRI)
    • Sensitivity: 96%
    • Specificity: 26%
    • PPD: 76%
    • NPD: 71%

Radiographs

  • Standard Radiographs Tibia Fibula
    • Initial imaging modality of choice
  • Early Findings
    • Lag behind clinical exam for weeks
    • May demonstrate subtle radiolucency, poor definition of the cortex
  • Late findings
    • Thickening and sclerosis of the endosteum
    • Periosteal new bone formation
  • Dreaded Black Line
    • Thickened anterior cortex
    • Radiolucent line (or lines) in the anterior midshaft of the tibia

MRI

  • Gold standard for stress fractures of the tibia
  • Benefits
    • More sensitivity than XR
    • Helps to differentiate stress fracture from shin splints

Ultrasound

  • Role in stress fractures is not well defined

Classification

  • Posteromedial
    • Occurs on compression side of tibia
    • Good prognosis with non-operative management
  • Anterolateral
    • Occurs on the tension side of the tibia, associated with higher risk of nonunion
    • Anterior black lines or dreaded black line increase risk of poor healing
    • High propensity to propagate to full cortical break
    • Often treated surgically

Management

Tall Walking Boot

Stirrup Air Cast

Nonoperative

  • Activity modification
    • Initially, athlete must discontinue all sporting activity
  • Non weight bearing with Crutches
    • Strongly consider with athletes who have pain while walking
    • When pain with ambulation resolves, can ween off crutches
  • Immobilization
  • Supplements
  • Pulsed Ultrasound
    • RCT of navy recruits showed no benefit compared to placebo[15]

Operative

  • Indications
    • Failure of conservative measures
    • Non-union
    • Anterior tibial cortex/ dreaded black line
  • Technique
    • Intramedullary Nail

Rehab and Return to Play

Rehabilitation

  • Basic Rehabilitation Program
    • Useful for low risk stress fractures
    • Proposed by Dr Fields[16]
  • Phase 1: Cross training (typical duration 2 weeks)
    • Wear Long Air Splint continuously while standing, during cross training, not needed for sleep
    • Ice Therapy to fracture site 2-3 times daily 20 minutes; may repeat if swelling increases and after training sessions
    • Supplements: Calcium (1500 mg), Vitamin D 800 IU throughout rehabilitation
    • 45 minutes stationary cycle daily
    • Heel raises, toe raises, and squats with weight every other day
      • 25 to 30 percent of body weight is used for three sets of 15 repetitions for each exercise
    • Advance to Phase 2 when patient can jog 50 steps with no pain in a long air splint
  • Phase 2: Initiation of weight bearing exercise (typical duration 2 weeks)
    • Perform all weight bearing activity in long air splint
    • Every other day, run 400 m/walk 400 m for eight laps (lap = 400 m) on a soft track; perform three sessions
    • Next, run 500 m/walk 300 m for eight laps; perform three sessions, one session every other day
      • Continue progression, performing three sessions at each level, as follows: run 600 m/walk 200 m; run 700 m/walk 100 m; total of eight laps for each session, one session every other day
    • 45 minutes stationary cycle on alternate (non-running) days
    • Perform weight exercises as described in Phase 1 on non-running days
    • Advance to Phase 3 when patient can complete 8 laps of 700M run/100 M walk without limp or pain
  • Phase 3: Initiation of protected training (typical duration 2 weeks)
    • Perform all weight bearing activity in long air splint
    • 45 minutes stationary cycle on alternate days
    • Run 2 miles (3.2 km) every other day for three sessions
    • Run 2.5 miles (4 km) every other day for four sessions
    • Continue strength exercises as described in Phase 1 on non-running days
    • Advance to Phase 4 if running for Phase 3 is completed without limp or pain; fracture site is non-tender; and, patient is able to hop 10 times and to jog without limp with air splint off
  • Phase 4: Weaning from long air splint (typical duration 2-3 weeks)
    • Begin running 2.5 miles (4 km) every other day
    • Run without splint on first day and with splint on second day; thereafter, alternate splint use every other day
    • Continue strength exercises as described in Phase 1
    • Advance to Phase 5 when pain free on all run days without splint
  • Phase 5: Progressive training (typical duration 4 weeks)
    • Increase run duration by five minutes after two workouts at each level; no air splint
    • Five runs per week during weeks 9 and 10
    • Six runs per week during weeks 11 and 12
    • When tolerating 40 continuous minutes of running without significant pain, resume normal training
  • Protocol guidelines
    • If patient has problems at any stage of rehabilitation, move back one level for an additional week and then try to advance
    • Continue all training for the first 12 weeks on a soft, level surface, the softer the better
    • Evaluate patient in the office every two weeks for evidence of healing and signs of injury until they reach phase 5
    • Apply ice after every activity (per phase 1)

Rehab Program PDFs

Return to Play/Work

  • General
    • The athlete should move through a structured rehabilitation program
    • Goal: progressive exercise allowing for bone healing while maintaining some degree of fitness
    • Most athletes will be able to return to normal level of training around 12 weeks[17]
  • Return to work
    • Patients with low demand jobs can return fairly quickly in immobilization if they can spend more time in a seated position

Prognosis and Complications

Prognosis

  • General
    • Can result in non-union even after 4-6 months of conservative treatment
    • Can persist for over 1 year
  • Anterior cortex non-operative management
    • Do not do well with non-operative management
    • In one study, 5/8 non-op patient went on to develop a full cortical break[18]
    • Batt et al was able return 4 athletes to play at a mean of 12 months using bracing, modified rest[19]
    • Rettig et al returned 8 basketball players to sport at a mean of 12.5 months[20]
  • Anterior cortex operative management
    • Borens had 4 athletes treated with surgery return to play an average of 10 weeks[21]

Complications

See Also

References

  1. ↑ Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987 Jan-Feb;15(1):46-58.
  2. ↑ Uchiyama, Yoshiyasu, et al. "Effect of low-intensity pulsed ultrasound treatment for delayed and non-union stress fractures of the anterior mid-tibia in five athletes." Tokai J Exp Clin Med 32.4 (2007): 121-5.
  3. ↑ Hoenig, Tim, et al. "Bone stress injuries." Nature Reviews Disease Primers 8.1 (2022): 26.
  4. ↑ Morrison, William B., et al. "ACR Appropriateness Criteria® Stress (Fatigue-Insufficiency) Fracture Including Sacrum Excluding Other Vertebrae: 2024 Update." Journal of the American College of Radiology 21.11 (2024): S490-S503.
  5. ↑ Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports Med. 1998 Oct;26(4):265-79.
  6. ↑ Friberg O. Leg length asymmetry in stress fractures. A clinical and radiological study. J Sports Med Phys Fitness. 1982 Dec;22(4):485-8. PMID: 7169791.
  7. ↑ 7.0 7.1 >Rosenthal, Michael D., Mitchell J. Rauh, and James E. Cowan. "Prospective Assessment of Clinical Tests Used to Evaluate Tibial Stress Fracture." Orthopaedic Journal of Sports Medicine 10.9 (2022): 23259671221122356.
  8. ↑ Brukner, Peter, and Kim Bennell. "Stress fractures in female athletes: diagnosis, management and rehabilitation." Sports Medicine 24.6 (1997): 419-429.
  9. ↑ Sterling, James C., et al. "Stress fractures in the athlete: diagnosis and management." Sports Medicine 14.5 (1992): 336-346.
  10. ↑ Adachi, Takuya, et al. "Imaging-detected bone stress injuries at the Tokyo 2020 summer Olympics: epidemiology, injury onset, and competition withdrawal rate." BMC Musculoskeletal Disorders 23.1 (2022): 763.
  11. ↑ Hattori, Hiroyuki, and Toshiyuki Ito. "Recurrent fracture after anterior tension band plating with bilateral tibial stress fracture in a basketball player: a case report." Orthopaedic journal of sports medicine 3.10 (2015): 2325967115610069.
  12. ↑ DeFroda, Steven F., et al. "Bone stress injuries in the military: diagnosis, management, and prevention." Am J Orthop 46.4 (2017): 176-83.
  13. ↑ Nussbaum ED, Gatt CJ Jr, Epstein R, Bechler JR, Swan KG, Tyler D, Bjornaraa J. Validation of the Shin Pain Scoring System: A Novel Approach for Determining Tibial Bone Stress Injuries. Orthop J Sports Med. 2019 Oct 30;7(10):2325967119877803.
  14. ↑ Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005 Apr 18;2005(2):CD000450. doi:
  15. ↑ Rue JP, Armstrong DW 3rd, Frassica FJ, Deafenbaugh M, Wilckens JH. The effect of pulsed ultrasound in the treatment of tibial stress fractures. Orthopedics. 2004 Nov;27(11):1192-5. PMID: 15566133.
  16. ↑ https://www.uptodate.com/contents/image?imageKey=SM%2F101610&topicKey=SM%2F218&source=see_link
  17. ↑ Miller TL, Jamieson M, Everson S, Siegel C. Expected Time to Return to Athletic Participation After Stress Fracture in Division I Collegiate Athletes. Sports Health. 2018 Jul-Aug;10(4):340-344. doi: 10.1177/1941738117747868. Epub 2017 Dec 14.
  18. ↑ Beals RK, Cook RD: Stress fractures of the anterior tibial diaphysis. Orthopedics 1991;14(8):869-875.
  19. ↑ Batt ME, Kemp S, Kerslake R: Delayed union stress fractures of the anterior tibia: Conservative management. Br J Sports Med 2001;35(1):74-77.
  20. ↑ Rettig AC, Shelbourne KD, McCarroll JR, Bisesi M, Watts J: The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia. Am J Sports Med 1988;16(3): 250-255.
  21. ↑ Borens O, Sen MK, Huang RC, et al: Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: A report of 4 cases. J Orthop Trauma 2006;20(6): 425-430.
  22. ↑ Orava S, Hulkko A. Stress fracture of the mid-tibial shaft. Acta Orthop Scand1984;55:35–7
  23. ↑ Boden, Barry P., and Daryl C. Osbahr. "High-risk stress fractures: evaluation and treatment." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 8.6 (2000): 344-353.
Created by:
John Kiel on 7 July 2019 07:18:17
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12 December 2025 01:53:41
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