Tibial Stress Fracture

A tibial stress fracture is another source of leg pain in the athlete. Stress fractures in general may be defined as subclinical microfractures that progress to become symptomatic and may even result in a displaced fracture when improperly treated. In the tibia, they are relatively common, representing approxi mately 17% of all stress fractures, and they are the most common stress fracture in the athlete.33 Typically, they occur posteriorly in the proximal or distal third of runners and tend to heal with rest.34 However, they may also occur in other sports and, more significantly, may occur at the anterior mid-diaphysis where healing is less predictable.35

Most patients present with a characteristic history. The leg pain is of insidious onset, associated with repetitive activities, and relieved by rest. Running and jumping sports are most often affected, including track, basketball, volleyball, dance, and football. While the cause is not completely clear, there is an obvious association with overuse. Thus, the athlete may describe an increase in training frequency or intensity, a change of shoes or practice surface, or another variation that could lead to excess biomechanical stresses. At the time of presentation, most often the pain has been present for weeks to months and sometimes even years. The pain may initially occur only after strenuous exercise, later becoming present even with simple walking. It may fluctuate with athletic seasons or gradually worsen with time until the athlete can no longer participate in sports. The examiner should obtain a history regarding amenorrhea in the female, thyroid disease, nutritional deficits, or other factors that may influence bone health.

On physical examination, there is typically point tenderness only at the fracture, with relatively normal surrounding soft tissues. In contrast, shin splints are tender over a larger extent of the medial tibia. Symptoms of paresthesias, weakness, or motion restriction are generally absent. Some authors describe the use of tuning forks or distant bony percussion as pain reproductive methods.

Imaging studies include radiography, bone scan, computed tomography, and MRI. Radiographs are generally normal for the first few weeks and may take months to show typical abnormalities, which include periosteal reaction, cortical lucency, sclerosis, or even a distinct fracture line. The anterior tibial stress fracture is recognized by its characteristic "dreaded black line": on a lateral radiograph, this is a thickened area of anterior cortex in the middle third of the tibia with a distinct radiolucent line extending anterior to posterior (Fig. 64-5). While both bone scan and MRI are more sensitive than radiography, a bone scan is thought to be the more sensitive of the two, especially early in the disease course. In fact, it can continue to be positive long after clinical symptoms have resolved and should therefore not be used to monitor healing. The advantages of MRI include its noninvasive nature, ability to visualize soft-tissue pathology, and higher specificity.

Treatment of tibial stress fractures depends on location. As stated previously, they most commonly occur on the compres-sive side of the bone (posterior), typically posteromedially, at the proximal and distal thirds of the bone. Treatment with non-steroidal anti-inflammatory drugs, ice, physiotherapy, and activity modification generally reduces symptoms within 1 month and allows full sports participation by 3 months. Activity modification includes complete rest until pain free, cross-training, or restriction from running and jumping. Use of a long pneumatic splint has been reported to allow continued sports participation and symptom resolution within a month.36

Treatment of anterior tibial stress fractures is far more controversial. While most authors continue to recommend a trial of conservative treatment, it is well established that, without surgery, the healing rate of these fractures is significantly lower. In addition, the risk of progression to complete fracture is a real, albeit undefined, risk. A review of the literature revealed 15

Tibial Dreaded Black Line
Figure 64-5 Anterior tibial stress fracture, the "dreaded black line."

documented stress fractures progressing to complete fracture.37 Both physician and athlete alike should be aware of this possibility and its consequences should the athlete be allowed to continue play prior to documented healing. This same review noted that of 73 attempts at conservative treatment, only 20 (27%) went on to radiographic healing. Surgical treatment has varied widely, including nonunion excision and bone grafting, intramedullary nailing, and plating. Of 57 surgical interventions reported in the literature, 32 (56%) had documented healing within 6 months. Many athletes were able to return to play prior to radiographically proven healing. In general, for patients with a radiographically apparent stress fracture of the anterolateral tibia, early surgery is commonly now employed. The most common surgical treatments are reamed intramedullary nailing and compression plating.

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