Working Diagnosis:
Bilateral Anterior Tibial Stress Fractures with Prolonged Healing

Treatment:
At diagnosis: Patient was placed in CAM walker boot on left leg for 4 weeks with full non weight bearing status.
At 4 weeks: Both legs were pain free to ambulation and palpation. CAM walker boot was discontinued. Patient began exercise on bike and elliptical as long as he remained pain free. A bone stimulator was started and continued for 8 weeks along with 50,000 U vitamin D and a daily multivitamin. Continued calcium intake of 3-4 glasses of milk per day.
At 8 weeks: Patient started pool workouts and home program with resistance band. Continued to avoid pounding and full weights/conditioning.

Outcome:
At 12 weeks: Repeat CT scans indicated healing. Patient returned to weights as tolerated. Repetitions at 50% with drills/running/jumping only on turf/grass for 2 weeks. Patient was advised to stop activity if any pain occurs. If patient remained pain free at 14 weeks, we will plan to progress to repetitions at 75% with anticipated full return to football for summer practice. Will continue to monitor pain carefully, as athlete remains high risk for recurrent stress fracture in these areas, as well as traumatic fracture.

Repeat CT Left Leg: Non-acute stress/insufficiency fracture involving the anterolateral cortex 15cm superior from the tibiotalar articulation. Evidence of healing with bony bridging along the fracture site, involving at least 1cm superior to the inferior extent. Negative for periosteal bone formation, significant periosteal edema, or bony displacement. Case Photo #5

Repeat CT Right Leg: Non-acute stress/insufficiency fracture involving the anterolateral cortex 17cm superior from the tibiotalar articulation. There is evidence of healing with bony bridging along the fracture site, involving at least 1cm superior to the inferior extent. Negative for periosteal bone formation, significant periosteal edema, or bony displacement. Case Photo #6

Author's Comments:
Standard of care in athletes with anterior tibial stress fractures is 3-6 months of conservative management involving rest, avoidance of heavy tibial loading, and slow progression with rehabilitation. Due to bilateral high risk stress fractures in this athlete, tibial intramedullary nailing was considered with evidence of higher return rates and lower return times to sport. However, due to open growth plates, risks of surgery outweighed benefits and aggressive conservative treatment was chosen. An important learning point in this case study is to order an X-ray for persistent shin pain, instead of assuming that it is shin splints. Though medial tibial stress syndrome is common, thorough evaluation is important.

Editor's Comments:
Stress reactions and stress fractures are common injuries in athletes. Stress injuries found to have high amount of load bearing and a poor natural healing history are considered high risk injuries. The tibial stress fractures are among the most common stress injuries in the body and can be divided into the two low risk stress fractures, the posteromedial (compression) side stress fracture and longitudinal stress fracture, as well as the high risk anterior tibial stress fracture. As seen in this case the anterior tibial stress fracture (dreaded black line) is considered high risk as the fracture is along the tension side of the tibia predisposing the fracture to delayed or nonunion. High risk stress fractures should be made non-weight bearing or even placed in a cast to allow bony healing to exceed the rate of continued damage at the fracture site. Return to play may dictate early surgical consideration for high risk fractures but optimization of bone health must be considered if delayed healing is noted.

References:
Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017;8(3):242-255. Published 2017 Mar 18. doi:10.5312/wjo.v8.i3.242.
Franklyn M, Oakes B. Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. World J Orthop. 2015;6(8):577-589. Published 2015 Sep 18. doi:10.5312/wjo.v6.i8.577.

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