Working Diagnosis:
Based on the imaging findings the patient was diagnosed with bilateral medial tibial bone stress injuries.

Treatment:
The patient was advised to abstain from play, avoid exacerbating exercises, and cross train as tolerated. He was given a bone stimulator to use daily on his lower extremities to expedite healing. Additionally, he was fitted for orthotics for better arch support and distribution of stress on the lower extremities.

Outcome:
After the initial diagnosis, the patient reduced his activity level and used the bone stimulator regularly. He was gradually able to return to his usual activity level and worked alongside his private trainer to build his stamina again. He was able to return to full game play and have a significant impact for his team throughout a winning season.

Author's Comments:
Bone stress injuries are common overuse injuries in high level athletes and military recruits. Increased activity intensity or duration causes repetitive microtrauma that overwhelms the rate of osseous remodeling. Bilateral symmetric, synchronous stress fractures are rare, and when siblings endure similar cases we must consider an underlying predisposition. Loss of function mutations in the P2X7 gene receptor have been found to increase risk of stress fractures and can lead to accelerated bone loss. While training environment and lifestyle have a dominant role in stress fractures, when recurring within a family we must be mindful of potential hereditary susceptibilities.

Editor's Comments:
Bone stress injuries (BSIs) occur most commonly in the lower extremity (80-90% of BSIs). It is important to recognize that radiographs are often unremarkable in the first two weeks of symptoms (sensitivity as low as 10%) with increased likelihood of findings (30-70% sensitivity) 2 to 8 weeks after symptom onset. BSIs are seen more commonly in females. BSI etiology is multifactorial and can be influenced by nutrition, biomechanics, and training patterns. Anatomical risk factors should also be considered; the pronated foot in this case, for example, may predispose to development of tibial BSI.

References:
1. Kaur M, Garg NK. Symmetrical Synchronous Stress Fractures of Bilateral Tibial Medial Condyles. JCR. 2019; 9:139-141.
2. Waterman B et al. Epidemiology of Lower Extremity Stress Fractures in the United States Military. Military Medicine. 2016;181(10):1308-1313
3. Varley I et al. Functional polymorphisms in the P2X7 receptor gene are associated with stress fracture injury. Purinergic Signalling. 2016;12:103-113.
4. Sharma J, Heagerty R. Stress Fracture: A Review of the Pathophysiology, Epidemiology and Management Options. J of Fract Sprains. 2017; 1(1):10006
5. Fredericson M, Jennings F, Beaulieu C, and Matheson G. Stress Fractures in Athletes. Top Magn Reson Imaging. 2006;17(5):309-325.

Return To The Case Studies List.