Working Diagnosis:
Bilateral anterior tibial stress fractures, likely chronic.

Treatment:
Our patient underwent intramedullary nail fixation of bilateral anterior tibial stress fractures. Case Photo #5 , Case Photo #6 , Case Photo #7 , Case Photo #8 .

Outcome:
He is currently undergoing rehabilitation. He has experienced slow wound healing and is advancing to full weight-bearing. His collegiate scholarship depends on his post-operative recovery.

Author's Comments:
The tibia is a frequent site for stress fractures in active athletes. Our patient's injury was in the middle and distal third which may be common in activities requiring repetitive jumping. The "dreaded black line" seen on radiographs in the mid-anterior tibia is associated with a worse prognosis in terms of requiring a more prolonged course of conservative treatment and having a higher risk of non-union of the stress fracture, thus being more likely to require surgical treatment. Complete healing for anterior tibial fractures may take as long as 2 years. Medical history, bone density, and diet must be considered. Conservative treatment consists of rest and cessation of exacerbating activities. Surgery is considered after 6 months with no radiographic evidence of healing. Due to our patient's high activity level, an accelerated approach was advocated. Intramedullary nail fixation facilitates fracture healing and can allow unrestricted activity earlier than conservative management.

Editor's Comments:
This case is a good demonstration that not all stress fractures are equal in their morbidity and some have a higher risk of requiring surgical intervention. Anterior tibial stress fracture is a classic example. Typically, plain radiographs will not show findings of a stress fracture until the process is significantly progressed. It often requires additional imaging modalities to diagnosis stress fractures in an accurate and timely manner. Stress fractures of the anterior tibia are "tension-side" fractures meaning that surface of the tibia is under a distraction-type tension stress with normal loading of the bone. Thus, in the context of a stress fracture, normal weight-bearing activities have the propensity to put continued, detrimental stress on that portion of the bone. This accounts to a large degree for the poor prognosis associated with stress fractures of this part of the tibia in comparison to posteromedial tibial stress fractures. In contrast, stress fractures involving the posteromedial cortex are "compression-side" lesions. Without the tension-distraction forces on that aspect of the tibia it is more amenable to the balance of bone remodeling to shift toward increasing bone density, healing, with rest from the inciting activities. In patients presenting with shin pain it is especially important to distinguish the exact area of their pain. Since there can be a continuum of progression from MTSS to stress fracture, regular follow-up and monitoring of the patient's symptoms should be done to ensure that there is improvement with the treatment plan and opportunities for further intervention are available if there is any progression of symptoms. Keep in mind that the precipitating activity is only part of the milieu that can lead to stress fracture. Consideration of nutrition, biomechanical features of the athlete, and possible comorbid conditions, such as endocrine or metabolic disorders, may be important factors in the development of stress fractures and also affect their treatment.

References:
- Batt, M.E., Kemp, S., Kerslake, R. Delayed Union Stress Fractures of the Anterior Tibia: Conservative Management. Br J Sports Med. 2001; 35: 74-77.

- Burrows, H.J. Fatigue Infraction of the Middle of the Tibia in Ballet Dancers. J Bone Joint Surg Br. 1956; 38: 83-94.

- Martinez, S.F., Murphy, G.A. Tibial Stress Fracture in a Male Ballet Dancer. Am J Sports Med. 2005; 33: 124-130.

Return To The Case Studies List.