Working Diagnosis:
Stress fracture of the posteromedial tibia.
Stress fracture of the medial femoral condyle.

Treatment:
Initial treatment at urgent care facility was strict non-weight bearing for least 3 weeks. She was advised to take naproxen for breakthrough pain. She was also given a hinged knee brace, locked at 30 degrees flexion to assist in stability and serve as a reminder for non-weight bearing status.

Outcome:
She was seen for follow up weekly after initial evaluation at urgent care. Serial radiographs and MRI of the left knee consistent with stress reaction of the medial femoral condyle and posteromedial tibia. She has completed 3 weeks of non-weight bearing with hinged knee brace for stability. She has experienced gradually decreasing levels of pain. She only uses naproxen for breakthrough pain. She was allowed to partially weight bear ensuring continuous symptomatic improvement. Hard knee brace was unrestricted. Recommendation given regarding rehabilitation exercises including toe touch, gradually increasing weight-bearing. She will also be referred to formal physical therapy. Patient does have a swimming pool at home and will assist in home exercises. She will continue to follow up periodically.

Author's Comments:
Tibial stress fractures are relatively common overuse injuries. These are usually seen after acute changes in training routine. Typical mechanism involves linear microfractures in the trabecular bone from repetitive loading. Onset of symptoms is usually insidious. Plain radiographs are usually normal early on but with time may show periosteal reaction, new bone formation, or even a distinct fracture line. The typical posteromedial stress fracture is considered lower risk. In contrast, the anterior or "dreaded black line" stress fractures are considered high risk.

Editor's Comments:
Stress fractures are common injuries in adolescent athletes. Lower extremity stress fractures are more common than upper extremity and are often seen in athletes that participate in activities that involve repeated running or jumping. They can also occur when an athlete increases the volume or frequency of their training without taking adequate rest. Initially pain is present during or after high impact activities like running or jumping. Later on, athletes will develop pain with low impact activities and then even at rest. For tibial stress fractures, pain may initially be diffuse but will become more localized as the athlete continues to participate in physical activity.

One of the most important determinations when diagnosing a stress fracture is whether the fracture is considered low risk or high risk. Low risk stress fractures generally occur on the compression side of a bone. Treatment involves activity modification and modified weight bearing with crutches or a walking boot if the athlete is having pain ambulating. Examples of low risk stress fractures include second and third metatarsal shafts, posteromedial tibial shaft, fibula, proximal humerus or humeral shaft, ribs, sacrum, and pubic rami. High risk stress fractures generally occur on the tension side of a bone. They have higher rates of nonunion or mal-unionn eventually necessitating surgery to achieve healing.

When a female athlete presents with a stress fracture, it is important to assess for other contributing factors, such as low energy availability sometimes associated with irregular or absent menstrual cycles. Athletes who are underfueling have an increased risk of developing a stress fracture due to poor bone health. If an athlete is underfueling, whether deliberately or not, they should be referred to a sports dietitian for further evaluation. If there is concern for disordered eating or an eating disorder, athletes should also be referred to a mental health provider and medical provider experienced in treating eating disorders.

References:
Musculoskeletal Imaging: The Requisites
Fracture Management for Primary Care.
1. Logan, Kelsey,M.D., F.A.A.P. (2007). Stress fractures in the adolescent athlete. Pediatric Annals, 36(11), 738-9, 742, 744-5.
2. Beck, B.; Drysdale, L. Risk Factors, Diagnosis and Management of Bone Stress Injuries in Adolescent Athletes: A Narrative Review. Sports 2021, 9, 52.

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