Anterior Tibia Stress Fracture

Fig. 66 This X-ray shows 11 anterior stress fractures in an athlete who tried to avoid pain by changing his jump-off technique

SYMPTOMS There is a gradual onset of localised exercise-induced pain at the anterior edge of the tibia, often affecting ballet dancers and athletes in jumping or running sports with high-impact forces or when plyometric training is involved (e.g. basketball, high jump or long jump). Initially, the symptoms may be vague but gradually they become so severe that they prevent jumping or running.

AETIOLOGY This is a tension-side stress fracture that does not heal bone to bone, since fibrosis grows into the fracture site, causing non-union that gets worse over time. When the anterior cortical bone becomes thicker the fibrosis growth in the fracture line makes bone-to-bone healing impossible. CLINICAL FINDINGS There is tenderness on palpation and localised swelling over the fracture site.

INVESTIGATIONS X-ray is negative until several weeks after onset of symptoms due to the lack of callus formation. CT scans or MRI may disclose the diagnosis earlier. In later stages, an X-ray will show a 'shark bite appearance' of the anterior cortex in lateral view.

TREATMENT This stress fracture may initially respond to conservative treatment including modification of training and avoiding jumping and running for three months. Unfortunately the diagnosis is often delayed and the condition turns chronic. Surgery may be necessary to stimulate bone healing but this injury halts many athletes. Surgery is followed by a long period of partial immobilisation and rehabilitation before resuming sport.

REFERRALS Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of six to twelve months' return programme.

EXERCISE PRESCRIPTION Cycling and swimming and any other low-impact activities are good alternatives to keep up general fitness. EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Note X-ray can show the typical appearance in non-symptomatic athletes. Often the athlete changes stance or jumping technique, altering the site of stress and causing a new fracture at another site. DIFFERENTIAL DIAGNOSES Shin splints (pain more diffuse; MRI can indicate); Chronic anterior compartment syndrome (pain in the muscle bulk); Posterior tibia stress fracture (location of symptoms medial posterior edge; X-ray and MRI differentiate); Tumour (X-ray differentiates). PROGNOSIS Fair-Poor; this injury halts the careers of many top athletes.

Fig. 67 Let kids play! Apophysitis calcaneii can be similar to Osgood-Schlatter's disease and causes discomfort over a period of time for the young athlete
Fig. 68 As soon as the apophysis closes, the problem is solved and the pain is gone

SYMPTOMS There is gradual onset of diffuse exercise-induced heel pain or ache around the insertion of the Achilles tendon, most commonly in very young growing athletes of six to twelve years old. AETIOLOGY This is a growth-related condition around the vertically positioned apophysis on the calcaneus, where the Achilles tendon inserts. It often affects active children but can cause pain in non-active children as well. It is induced by a local growth spurt in this area but symptoms are made worse by jumping and running. It is often bilateral, sometimes with a time delay between left and right. CLINICAL FINDINGS There is tenderness on palpation over the posterior calcaneus and Achilles tendon insertion. Occasionally there are inflammatory signs with redness and increased temperature. Compare to the other side. INVESTIGATIONS X-ray is often normal but can sometimes show a fragmented apophysis and should be compared with the other foot. MRI will show bone oedema but is usually not required for the diagnosis. TREATMENT This often long-duration ailment responds to conservative treatment including modification of training, gentle heel lifts and natural healing by closing of the apophysis. REFERRALS Refer to physiotherapist for advice of alternative training regime for an early return to sport.

EXERCISE PRESCRIPTION Cycling and swimming and most low-impact activities are good alternatives to keep up general fitness. This is an injury where you can play sports with minor pain in most cases. It is important to inform parents carefully about this condition and not discourage them from letting their child play sports. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Bone tumour (X-ray differentiates); Osteomyelitis (signs of infection such as increased temperature and increased CRP/ESR).

PROGNOSIS Excellent.

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