A 27 year old professional soccer player presents with deep left calf pain. The pain developed during training season, which consisted of 4 weeks of training for 2-4 hours per day. The pain increased gradually and is worse with weight bearing. The player has now had to stop training.
On examination, focal tenderness and swelling on proximal tibia. Discrete bone tenderness on palpation. Normal patellar reflexes. Normal power of lower extremities. Positive hop test.
Figure 1: 4 weeks post injury Anterior view of legs
NB edema and swelling in left leg
Figure 2,3,4,5: Initial Xrays at 1 month post injury (AP, Lateral and close-ups)
Figure 2 – AP Xray
On closer look at proximal tibia corresponding with patient’s tenderness is a faint radiolucent line medially
Figure 3 – Lateral Xray of Tibia, fibula
Figure 4 – Close up of Lateral Xray of tibia, fibula
NB – callus formation posterior tibia along with radiolucent line horizontally traversing the tibia
Figure 5 – Close up AP Tibia/fibula
NB radiolucent line traverses the proximal tibia from medial to lateral
Figure 6: AP view of patient legs (3 months post injury)
Swelling can be observed isolated to the left proximal tibia.
Figure 7: AP view on plain film of left tibia and fibula (3 months post injury)
Proximal tibia shows bony calls formation, indicating stress fracture healing.
Figure 8 – Lateral tibia/fibula (3 months post injury)
Proximal tibia shows bony callus formation indicative of stress fracture healing.
A stress fracture occurs when the bone breaks after being subject to multiple tensile or compressive forces, none of which are large enough to break the bone individually. Also, the patient does not have any underlying disease that causes bone fragility.
Diagnosis of tibial stress fracture requires a combination of history, physical exam and imaging. Pain often evolves gradually over several weeks and often presents as focal pain. Pain often occurs after an increase in volume or intensity of exercise with minimal recovery time. On examination, focal pain during weight-bearing activity, pain over area of the fracture on palpation, and localized swelling. Special tests include the hop test and the tuning fork test, although there is limited supporting evidence for their use.
Plain radiography should be first considered due to its availability and low cost. Within the first 2-3 weeks, many pathological findings, such as fracture line, periosteal thickening, or endosteal thickening and sclerosis, may not be visible on plain radiography. Therefore, it is recommended to repeat plain radiographs after 2-3 weeks if urgent diagnosis is not needed. Currently, MRI is the most sensitive and specific diagnostic imaging tool, despite limitations in access and cost. It is recommended that MRI be considered next when plain radiography is negative, an urgent diagnosis is required, and clinical suspicion of stress fracture persists.
Referral to orthopedist should be considered when stress fractures that demonstrate slower healing or do not respond to conservative management. For example, tibial stress fracture involving the anterior cortex, demonstrating the “dreaded black line” on plain radiograph, that take more than 9 months to heal are often treated surgically. Also, if imaging reveals severe fractures that are considered “high risk” (risk of complete fracture, risk for nonunion or delayed union, requiring assisted/nonweight-bearing, or occurring in a high risk area) typically require surgical repair. However, most tibial stress fractures can be treated by primary care physicians.
Risk factor modification may be important to long term treatment and prevention. Risk factors that should be considered in the treatment and prevention of stress fractures are: excessive alcohol consumption, excessive physical activity with limited rest periods, female athletic triad, female sex, low levels of vitamin D, smoking, sudden increases in physical activity, and running more than 25 miles per week.
Possible differential diagnoses of pain associated with the tibia and fibula are: medial tibial stress syndrome, muscle strain, posterior tibialis tendinopathy, periostitis, acute compartment syndrome.
Diagnosis: Tibial shaft stress fracture
Conservative management for 8-12 weeks: stress reliving measures (crutches), maintenance of aerobic fitness through low-impact activity (swimming, cycling), physical therapy, and oral analgesics other than NSAIDS. Vitamin D supplementation – 1000 to 2000 international units daily. The patient can return to full impact activities 2-4 weeks after they are pain free with weight-bearing. If the pain returns, another 4 weeks is recommended before return to impact.
Follow-up at 6 months: X-rays show healing and Doppler US normal
Lucas Nguyen (Aug 16, 2018- PR ND)
1) Patel DS, Roth M, Kapil N. (2011). Stress Fractures: Diagnosis, Treatment, and Prevention. American Family Physician, 83, 39-46.
2) Kahanov, L., Eberman, L. E., Games, K. E., & Wasik, M. (2015). Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access Journal of Sports Medicine, 6, 87–95. http://doi.org/10.2147/OAJSM.S39512
3) Fields KB. (Last updated: Jan. 11, 2018). Stress Fractures of the tibia and fibula. Retrieved from https://www-uptodate-com.