Tibial Stress Fracture

By admin Last updated Nov 15, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Andrew Gregory

Basics

Stress fracture of the tibia refers to a fatigue 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 usually heals 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 (1)
Predominantly younger athletes (<20 yrs old)
Predominantly female athletes
No difference in race

Incidence

Incidence of tibial stress fractures is not known and varies greatly among sports and studies (1).

Prevalence

Prevalence of tibial stress fractures is not known and varies between sports and studies (1).

Risk Factors

Previous history of stress fractures
Track and field athletes
Female gender
Younger age
Change in training volume or intensity (1)
Multisport athletes
Osteopenia
Disordered eating
Amenorrhea
Chronic steroid use

Genetics

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

General Prevention

Most stress fractures can be prevented by:

Gradual increases in activity (The 10% Rule: No more than a 10% increase in 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)

Etiology

Insoles may reduce femoral and tibial stress fractures (2)[B].

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
Imaging studies 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, as the prognosis is much worse.

History

Pain in the shin area:
- Severe enough to limit activity
- Worse with activity and better with rest
- Worsens over time if the activity is continued
- Often associated with an increase in training duration or intensity
- Often 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, stepoff, or crepitus.
Hop test: Pain at the site with hopping on one leg
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 another bony prominence of the same bone
Examine foot function for biomechanical factors that predispose to stress fracture (heavy heel strike).

Diagnostic Tests & Interpretation

Imaging can be helpful in diagnosing stress fractures, but is often negative initially.
History and clinical examination is often all that is necessary.
MRI is the gold standard for diagnosis.

Imaging

Initial approach:

X-rays:
- May be negative for 2–3 wks; shows crack or fracture callus
- For anterior cortical fractures, shows the “dreaded black line”
Bone scan:
- Good sensitivity (74%), especially early (3)
- Good specificity (100%)
- Poor accuracy (52%)
- Helpful in multiple areas of concern, such as bilateral tibial stress fracture
MRI:
- Gold standard; sensitivity is better than bone scan (88%) (3)
- Best at demonstrating the exact location and extent of injury; specificity (100%), accuracy (90%) (3)[B]
- Shows fracture line on T1 and edema on T2
CT scan:
- Not useful in the acute setting; poor sensitivity (42%) (3)
- Useful in assessing healing of high-risk stress fractures
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 for follow-up, only for diagnosis
- 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/Surgery

Occasionally, stress fractures can be confused with tumor on imaging and a biopsy may be obtained.

Differential Diagnosis

Medial tibial stress syndrome (shin splints)
Chronic exertional compartment syndrome
Pes anserine bursitis
Osgood-Schlatter disease
Posterior tibialis tendonitis
Superficial nerve entrapment
Other bony processes: Bone cysts, osteoid osteoma, tumor, infection

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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 training).
However, the treatment of anterior tibial and posterior medial 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 progression and/or nonunion. Often requires surgery for internal fixation and bone grafting to heal.

Pre-Hospital

RICE:
- Rest
- Ice
- Compression
- Elevation
Acetaminophen
Walking boot or long Aircast, crutches if necessary based on the amount of pain with weight-bearing

ED Treatment

Continued RICE
Acetaminophen
Avoidance of NSAIDs
Walking boot
Crutches as needed
Consider surgery for anterior tibial stress fractures or nonunion of other 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, as they may delay the healing of fractures.

Additional Treatment

Measures to alleviate the pain associated with stress fractures include ice, Tylenol, a Cam Walker boot, and crutches.
Some evidence that use of a pneumatic or stirrup brace may shorten the time to return to activity [B]

Referral

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

Additional Therapies

Physical therapists can check and possibly correct poor biomechanics.

Complementary and 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 (5)[A].

Surgery/Other Procedures

Surgical treatment of anterior tibial stress fractures consists of intermedullary nailing, with or without bone graft (4).

In-Patient 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 nonweight-bearing and casting for 8–12 wks, after which intermedullary nailing and grafting still may be necessary.

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 400–800 IU of vitamin D daily for adults under age 50.

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 or delayed or partial union is high, requiring surgery

References

1. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25:37–52, viii.

2. Snyder RA, Deangelis JP, Koester MC, et al. Does shoe insole modification prevent stress fractures? A systematic review. HSS J. 2009.

3. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235:553–561.

4. Kaeding CC, Yu JR, Wright R, et al. Management and return to play of stress fractures. Clin J Sport Med. 2005;15:442–447.

5. 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;90:2322–2330.

Additional Reading

Aoki Y, Yasuda K, Tohyama H, et al. Magnetic resonance imaging in stress fractures and shin splints. Clin Orthop Relat Res. 2004;(421):260–267.

Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ. 2009;338:b351.

Spits DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am. 2002;40:313–331.

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.