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Tibial Stress Fracture

Tibial Stress Fracture is an overuse injury that subjects the bone to repetitive stress, resulting in microfractures. It’s commonly seen in runners and military recruits.

Recognition of anterior tibial stress fractures is important because these fractures are prone to nonunion and avascular necrosis. They are also at greater risk of becoming displaced than are posterior tibial stress fractures.

In military recruits, these injuries most commonly occur at the metaphyseal– diaphyseal junction, with sclerosis being most marked at the posteromedial cortex. While in ballet dancers, these fractures most commonly occur in the middle third of the tibia.

See Also: Femoral Stress Fracture

The most common risk factors for tibial for stress fractures include:

  1. A narrow tibial shaft,
  2. High degree of hip external rotation,
  3. Osteopenia, osteoporosis,
  4. Pes cavus.
Tibial Stress Fracture - posterior cortex
Tibial Stress Fracture at posterior cortex
Tibial Stress Fracture - anterior cortex
Tibial Stress Fracture at anterior cortex

Tibial Stress Fracture Classification

Stress fractures may be classified as complete versus incomplete or acute versus chronic or recurrent. They rarely are displaced or angulated.


Patients typically presents with an antalgic gait that is relieved by rest. The pain is usually described as insidious in onset, worse with activity, and improved at night. During activity, patients may report decreased muscular strength and cramping.

Palpation may reveal crepitus in well-developed stress fractures and point tenderness isolated to a single spot along the shaft of the bone.

Swelling is generally not present, although the patient may complain of a vague ache over the site of fracture with tenderness to palpation.

Knee and ankle range of motion are usually full and painless.

Occasionally, the patient’s symptoms and signs may be bilateral.

Muscle sprains, infection, and osteosarcoma must be excluded. Exercise-induced compartment syndrome overlying the tibia may have a similar clinical presentation.

The Heel Thump test has also been recommended to assess the possible presence of tibial stress fractures

Tuning forks test have been advocated as an inexpensive alternative to identifying the presence of stress fractures. A vibrating tuning fork is placed on the shaft of the suspected bone. In the presence of a stress fracture, the vibration would cause pain. This test’s low positive likelihood ratio and high negative likelihood ratio mean that its findings add little to the diagnostic decision making.

See Also: Heel Thump Test


AP and lateral views of the leg should be obtained to rule out acute fracture or other injuries, although stress fractures are typically not evident on standard radiographs for 10 to 14 days after initial onset of symptoms. Radiographic evidence of fracture repair may be visualized as periosteal new bone formation, endosteal radiodensity, or the presence of “eggshell” callus at the site of fracture.

The dreaded black line is seen on lateral x-ray anteriorly, indicating tension fracture from posterior muscle force.

Technetium bone scan reveals a localized area of increased tracer uptake at the site of fracture and may be performed within 1 to 2 days of injury.

Computed tomography rarely demonstrates the fracture line, although it may delineate increased marrow density and endosteal/periosteal new bone formation and soft tissue edema.

MRI may demonstrate a localized band of very low signal intensity continuous with the cortex.

dreaded black line
Dreaded black line
Tibial Stress Fracture - bone scan
Bone scan
Tibial Stress Fracture MRI

Differential Diagnosis

Potential Causes of Anteromedial Lower-Leg Pain include:

  1. Stress fracture of tibia ,
  2. Medial tibial stress syndrome ,
  3. Saphenous neuritis ,
  4. Osteomyelitis of tibia ,
  5. Soleus syndrome ,
  6. Shin splints,
  7. Greater saphenous vein thrombosis.

Tibial stress fractures are a common cause of shin soreness and a very common cause of exertional leg pain. Simple muscle strains are probably the most common cause of acute exercise induced leg pain, whereas more subacute or chronic pain may be caused by stress fracture shins or chronic (exertional) compartment syndrome.

Tibial Stress Fracture Treatment

Tibial Stress Fracture Treatment include rest with activity restriction with protected weightbearing or casting and anti-inflammatory medication.

Surgical treatment for tibial stress fracture is indicated in case of non-union or avascular necrosis that are mostly seen in anterior tibial stress fractures. It’s mainly treated with intramedullary tibial nailing.

Bone grafting, electrical stimulation, and internal localization are sometimes needed.

This increased susceptibility to complication has been attributed to a predominance of tensile forces along the anterior diaphysis rather than compressive forces along the posterior diaphysis.


  1. Lesho EP. Can tuning forks replace bone scans for identification of tibial stress fractures? Mil Med. 1997 Dec;162(12):802-3. PMID: 9433085.
  2. Giladi, M, et al: Stress fractures: identifiable risk factors. Am J Sports Med, 19:647, 1991.
  3. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
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