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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



  • 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]


  • See: Stress Fractures (Main)
  • 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

Associated Conditions

Anatomy of the Tibia

  • Major weight bearing bone of the lower leg

Risk Factors

Differential Diagnosis

Differential Diagnosis Leg Pain

Clinical Features


  • History is insidious with a slow onset of leg pain over weeks-months
  • 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
  • Can progress to pain at rest or with walking
  • Rarely, a full cortical break can occur

Physical Exam: Physical Exam Leg

  • Point tenderness over the area of induration
  • Swelling on inspection

Special Tests


Shin Pain Scoring System (SPSS)

  • General
    • Designed as a clinical scoring tool to help identify stress injuries early[4]
    • 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%


  • 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


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


  • Role in stress fractures is not well defined


  • 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



  • 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[6]


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

Rehab and Return to Play


  • Basic Rehabilitation Program
    • Useful for low risk stress fractures
    • Proposed by Dr Fields[7]
  • 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)

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[8]
  • 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


  • 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[9]
    • Batt et al was able return 4 athletes to play at a mean of 12 months using bracing, modified rest[10]
    • Rettig et al returned 8 basketball players to sport at a mean of 12.5 months[11]
  • Anterior cortex operative management
    • Borens had 4 athletes treated with surgery return to play an average of 10 weeks[12]


  • Delayed Union
    • Represents about 5% of tibial stress fractures[13]
  • Delayed return to sport
  • Physical deconditioning

See Also


  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. Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports Med. 1998 Oct;26(4):265-79.
  3. 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.
  4. 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.
  5. 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:
  6. 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.
  7. https://www.uptodate.com/contents/image?imageKey=SM%2F101610&topicKey=SM%2F218&source=see_link
  8. 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.
  9. Beals RK, Cook RD: Stress fractures of the anterior tibial diaphysis. Orthopedics 1991;14(8):869-875.
  10. 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.
  11. 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.
  12. 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.
  13. Orava S, Hulkko A. Stress fracture of the mid-tibial shaft. Acta Orthop Scand1984;55:35–7
Created by:
John Kiel on 7 July 2019 07:18:17
Last edited:
15 May 2023 06:11:27