Tibial Stress Fracture
Summary
A tibial stress fracture is a localized fracture of the lower leg bone (tibia) at the microscopic level – it often cannot be seen on plain x-rays. It is caused by increased repetitive loading through the tibia – commonly in runners as a result of overtraining. Tibial stress fractures are distinguished from shin splints as the pain is more localized and more intense. Individuals with lower bone density (ex. osteoporosis) are at higher risk of developing a tibial stress fracture. Most tibial stress fractures respond well to rest and a complete return to full activity is generally expected.
Clinical Presentation
Initially symptoms commonly resemble shin splints (medial tibial stress syndrome). However, a tibial stress fracture can often be distinguished by more localized pain and a longer course of onset. The pain will gradually increase over the course of weeks and can reach the point that pain is felt at rest. In athletes, an increase in training intensity or volume precedes the onset of pain.
The most common site of tibial stress fracture is the shaft of the bone, though they may also occur on the inside bony prominence of the ankle (medial malleolus) or the upper portion of the tibia that involves the knee joint (tibial plateau).
Patient with lower bone density (osteoporosis) due to aging, vitamin D deficiency, or low body weight are at higher risk for developing a tibial stress fracture.
Physical Exam
Physical exam will show pain that is specific to one area of the lower leg (tibia). Some swelling and localized tenderness of the bone will often be present. Sensitivity to vibration and the inability to hop on the affected leg without pain are also suggestive of a tibial stress fracture.
Imaging Studies
Symptoms such as pain and discomfort precede signs of a fracture on x-ray. Confirmation of a tibial stress fracture on initial x-rays occurs in less than half of the cases. In most cases a positive x-ray is not necessary to begin treatment. Three to four weeks after the diagnosis, an x-ray will typically show findings of a healing fracture.
When confirmatory imaging is required, such as an athlete who will be performing vigorous rehabilitation, magnetic resonance imaging (MRI), or a bone scan can show the presence of the stress fracture at an earlier stage.
Treatment
Initial treatment includes rest and stabilization. In some cases, a short period of non-weight-bearing may be necessary with the affected leg being splinted. The patient may resume weight-bearing on the injured leg once they are able to walk without pain. Intermittent use of crutches may help with the transition.
Recovery
Complete recovery of uncomplicated stress fractures is typically around 12 weeks. During the recovery period the patient can take increased calcium and vitamin D through diet or supplements. Isolated tibial stress fractures usually heal very well and have little impact on the ability to return to full activity.
Edited June 6th, 2020