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Basics ⬇

Author: Andrew J.M.Gregory, MD, FAAP, FACSM

Stress fracture of the tibia refers to an overuse injury of the bone as a result of repetitive loading that overwhelms its capacity to heal and must be differentiated from medial tibial stress syndrome, which is not a stress fracture. In general, stress fractures of the tibia can be classified into low-risk or high-risk stress fractures. The more common low-risk stress fracture of the tibia occurs on the posterior medial aspect of the bone (compression side) and heals well if treated appropriately. The less common high-risk stress fracture of the tibia occurs on the anterior aspect of the bone (tension side) and often does not heal well even when treated appropriately.

Epidemiology

  • Incidence unknown, but fairly common
  • Prevalence unknown, but fairly common
  • 19–64% of all stress fractures
  • Predominantly younger athletes (<20 yr old)
  • Predominantly female athletes
  • No difference in race

Incidence

Incidence of tibial stress fractures is not known and varies greatly among sports and studies.

Prevalence

Prevalence of tibial stress fractures is not known and varies between sports and studies.

Etiology and Pathophysiology

Insoles may reduce femoral and tibial stress fractures (1)[B].

Genetics

Little is known about the genetic predisposition for stress fracture other than osteopenia.

Risk-Factors

  • Previous history of stress fractures
  • Track and field athletes
  • Female gender
  • Younger age
  • Increase in training volume or intensity
  • Multisport athletes
  • Osteopenia/osteoporosis
  • Disordered eating
  • Oligomenorrhea/amenorrhea
  • Chronic steroid use

General Prevention

Most stress fractures can be prevented by:

  • Gradual increases in activity (the 10% rule: no more than a 10% increase in load—intensity, duration, or frequency per week).
  • Appropriate footwear (properly fitted running shoes, orthotics if indicated).
  • Appropriate nutrition (matching energy intake with expenditure; nutrition consult may be appropriate).

Commonly Associated Conditions

Female athlete triad or any of the signs:

  • Osteopenia/osteoporosis: chronic steroid use
  • Amenorrhea/oligomenorrhea: either primary or secondary
  • Energy imbalance: disordered eating, excess exercise

Diagnosis ⬆ ⬇

  • Primarily based on history and physical examination and a high index of suspicion based on risk factors
  • X-rays can be helpful if positive but are often unremarkable.
  • Hallmark is point tenderness on physical examination.
  • It is important to distinguish anterior stress fractures (the dreaded black line) from posteromedial ones because the prognosis is much worse.

History

  • Pain in the shin area:
    • Severe enough to limit activity
    • Worse with activity and better with rest
    • Night pain
    • Worsens over time if the activity is continued
    • Often associated with an increase in training duration, frequency, or intensity
    • Usually no associated injury
  • Assess for risk factors:
    • Training history should include days per week, hours per day and intensity, and footwear (how often changed and what type).
    • Dietary history (calories, foods avoided, and vitamin D and calcium intake; weight changes)
    • Menstrual history (frequency, birth control pills, prior to birth control)
    • Family or personal history of stress fractures or osteoporosis/osteopenia
    • Medications known to decrease bone density (contraceptives, glucocorticoids, antiseizure medications)
    • Supplements (sex hormones or precursors, vitamin D, calcium)

Physical Exam

  • Focal tenderness to palpation on examination is the primary method for diagnosis of a stress fracture.
  • Palpate for fracture callus, step-off, or crepitus.
  • Hop test: pain at the site with hopping on one leg→ be cautious with this because high index of suspicion can worsen fracture.
  • Fulcrum test: pain at the site with bending the long bone over a fulcrum (table edge or examiner’s leg)
  • Tuning fork test: pain at the site when applying the tuning fork to a bony prominence of the same bone not the site of injury
  • Examine foot type and function for biomechanical factors that predispose to stress fracture (pes planus, pes cavus, heavy heel strike).
  • X-rays can be helpful in diagnosing stress fractures but is often negative initially.
  • History and clinical examination are often all that is necessary.
  • Magnetic resonance imaging (MRI) is the gold standard for diagnosis.
  • Bone scan or computed tomography (CT) scan can be useful adjuncts.

Differential Diagnosis

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

Initial approach:

ALERT
  • X-rays:
    • May be negative through course; often negative for 3+ wk; shows a lucency or fracture callus
    • For anterior cortical fractures, shows the “dreaded black line”
    • Sensitivity ranged from 12% (0–29%) to 56% (39–72%) (2).
    • Specificity ranged from 88% (55–100%) to 96% (87–100%) (2).
  • Bone scan:
    • Sensitivity ranged from 50% (23–77%) to 97% (90–100%) (2).
    • Specificity ranged from 33% (12–53%) to 98% (93–100%) (2).
    • Poor accuracy (52%)
    • Helpful in multiple areas of concern, such as bilateral tibia or if MRI is not possible
  • MRI:
    • Gold standard (2)[B]
    • Sensitivity ranged from 68% (45–90%) to 99% (95–100%) (2).
    • Specificity from 4% (0–11%) to 97% (88–100%) (2)
    • Best at demonstrating the exact location and extent of injury; accuracy (90%) (3)[B]
    • Shows fracture line on T1 and edema on T2
  • CT scan:
    • Not useful in the acute setting
    • Sensitivity ranged from 32% (8–57%) to 38% (16–59%) (2).
    • Specificity from 88% (55–100%) to 98% (91–100%) (2)
    • Useful in assessing healing of fractures
  • Musculoskeletal ultrasound (MSK US):
    • Sensitivity ranged from 43% (26–61%) to 99% (95–100%) (2).
    • Specificity ranged from 13% (0–45%) to 79% (61–96%) (2).
  • Follow-up and special considerations:
    • X-rays will show the fracture healing in most cases; look for callus formation.
    • Bone scan can remain positive for over a year; therefore, not useful to determine healing
    • MRI may continue to show edema after the fracture is asymptomatic.
    • CT is useful for assessing fracture healing for fractures that are difficult to see on plain film.

Diagnostic Procedures/Other

Occasionally, stress fractures can be confused with tumor on imaging. A biopsy of the anterior tibia should be avoided if possible because it may increase the risk of nonunion.

Treatment ⬆ ⬇

  • Treatment of most stress fractures of the tibia is the same as other stress fractures, which is to remove the offending activity (usually impact activity).
  • However, the treatment of anterior tibial stress fractures is quite different:
    • Posterior medial tibial stress fractures can be allowed to continue to participate in limited activity as pain allows. Decrease practice to allow more participation in games.
    • Anterior tibial stress fractures (the dreaded black line) should not continue to participate because of the risk of fracture completion and/or nonunion; requires prolonged non–weight-bearing or often surgery for internal fixation and/or bone grafting to heal
  • Prehospital:
    • PRICE:
      • Protection: bracing
      • Rest
      • Ice
      • Compression
      • Elevation
    • Acetaminophen
    • Walking boot or long Aircast, crutches if necessary based on the amount of pain with weight-bearing
  • Emergency department (ED) treatment:
    • Continued PRICE
    • Acetaminophen
    • Avoidance of scheduled nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Walking boot
    • Crutches as needed
    • Consider non–weight-bearing or surgery for anterior tibial stress fractures or nonunion of tibial stress fractures.
    • Addressing other risk factors: nutritional, menstrual, osteopenia

Medication

  • No medications currently available to help stress fracture healing but can treat with pain medications.
  • Pain medications with anti-inflammatory drugs may be contraindicated because they may delay the healing of fractures.

Issues for Referral

  • Most athletes with anterior tibial stress fractures should be referred for surgical treatment (4).
  • Conservative treatment with casting and strict non–weight-bearing for 2 to 3 mo can be considered but still may result in nonunion.

Additional Therapies

  • Measures to alleviate the pain associated with stress fractures include ice, acetaminophen, a controlled ankle movement (CAM) walker boot, and crutches.
  • Some evidence that use of a pneumatic or stirrup brace may shorten the time to return to activity (5)[B].
  • Physical therapists can check and possibly correct poor biomechanics. Foot orthoses were not found to be effective for prevention of tibial stress fractures (6).

Surgery/Other Procedures

Surgical treatment of anterior tibial stress fractures consists of intermedullary nailing, with or without bone graft (3).

COMPLEMENTARY & ALTERNATIVE MEDICINE

Bone stimulators: Current evidence is insufficient to conclude a benefit in improving the rate of union in patients with a fresh fracture, osteotomy, delayed union, or nonunion or on time to healing in tibial stress fractures or a reduction in pain (1)[A].

Admission, Inpatient, and Nursing Considerations

Not applicable in most cases

Ongoing Care ⬆ ⬇

  • Low-risk stress fractures of the tibia: Ongoing activity modification and pain management is usually sufficient.
  • High-risk stress fractures of the tibia require intermedullary nailing and grafting or non–weight-bearing and casting for 8 to 12 wk, after which intermedullary nailing and grafting still may be necessary (approximately 70% require surgery) (4).

Diet

  • Nutritional evaluation is important, not only for healing of the current fracture but also for prevention of recurrence.
  • Current recommendations from the National Osteoporosis Foundation are 1,000 mg of calcium and 400 to 800 IU of vitamin D daily for adults age <50 yr.

Patient Education

  • Athletes should understand that training, nutrition, biomechanical, and footwear errors must be remedied.
  • Athletes with a prior stress fracture are at increased risk for a future stress fracture.

Prognosis

  • Good for low-risk stress fractures of the tibia
  • Poor for high-risk stress fractures of the tibia

Complications

  • Posteromedial stress fractures of the tibia: potential for slower healing if continued participation is allowed
  • Anterior stress fractures of the tibia: Risk of nonunion and delayed or partial union is high, requiring surgery (3).

Additional Reading ⬆ ⬇

  • Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ. 2009;338:b351.
  • Kaeding CC, Yu JR, Wright R, et al. Management and return to play of stress fractures. Clin J Sport Med. 2005;15(6):442–447.
  • Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37–52.

See-Also

Other stress fracture chapters

References ⬆ ⬇

  1. Mollon B, da Silva V, Busse JW, et al. Electrical stimulation for long-bone fracture-healing: a meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2008;90(11):2322–2330.
  2. Wright AA, Hegedus EJ, Lenchik L, et al. Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures: a systematic review with evidence-based recommendations for clinical practice. Am J Sports Med. 2016;44(1):255–263.
  3. Mallee WH, Weel H, van Dijk CN, et al. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med. 2015;49(6):370–376.
  4. Robertson GA, Wood AM. Return to sports after stress fractures of the tibial diaphysis: a systematic review. Br Med Bull. 2015;114(1):95–111.
  5. Whitelaw GP, Wetzler MJ, Levy AS, et al. A pneumatic leg brace for the treatment of tibial stress fractures. Clin Orthop Relat Res. 1991;(270):301–305.
  6. Bonanno DR, Landorf KB, Munteanu SE, et al. Effectiveness of foot orthoses and shock-absorbing insoles for the prevention of injury: a systematic review and meta-analysis. Br J Sports Med. 2017;51(2):86–96.

Clinical Pearls ⬆

  • Distinguish low-risk from high-risk stress fracture based on imaging and exam.
  • Tenderness to palpation is the main physical examination finding.
  • MRI is the imaging study of choice.
  • Evaluate for training errors.
  • Evaluate for additional risk factors.