![]() In the majority of cases, tenderness and pain will be felt to the posteromedial border of the tibia. Pain can be elicited with the use of a tuning fork – creating unpleasant vibrations localising to the site of bone stress. With established lower limb stress fractures, pain may be present with activities of daily living, and may wake patients at night from aching.Įxamination will usually elicit an area of specific localised tenderness at the site of tibial or fibular stress facture, as opposed to typically a more diffuse area of posteromedial tenderness seen with MTSS / periostitis. As the injury moves through the spectrum of severity (provided there is not adequate rest for bone healing), pain onset will typically be earlier in activity, may be more severe, and may persist for longer after activity ceases. Early on with bone stress, pain may commence towards the end of or after activity. Whilst in most cases of MTSS (at least in its earlier stages), subjects can ‘warm into’ activity and then report pain upon cooling down again, those with stress fractures typically report pain that worsens with activity and eases with rest. The distinction between medial tibial stress syndrome ( click here) and tibial stress fractures is often blurred and difficult to distinguish between clinically and many believe the former to be an early phase within what is a continuum that culminates in stress fractures and overt cortical breach. In the adult population, most fractures are typically situated posteromedially, in the mid to lower thirds of the tibia, where compressive forces are caused by posterior muscle contraction with running.(2) There are other stress fracture variants of the tibia (some being much higher risk fractures – see below) and the fibula also can be affected – typically again in the mid to lower third.Įxertional calf pain – injury progression In 16% of cases, tibial stress fractures are bilateral. Stress fractures in general account for up to 20% of attendances to Sports Medicine clinics and of these, tibial stress fractures make up half of cases, in particular in those athletes participating in high impact and intensity running based activity. In runners, and all sports involving a large amount of running or jumping, stress fractures of the lower leg are commonplace. In the lower leg, this later group of insufficiency fractures can often be seen in the upper third of the tibia and is likely contributed to by coronal plane angular deformities (valgus / varus) in the older population due to arthritic change in the knee joint. Another group of patients (typically older patients, moreso females, or patients with chronic medical conditions) can suffer from insufficiency fractures, whereby an acceptable amount of load can result in fractures to those with abnormal, osteoporotic bone. ![]() Stress fractures are often also referred to as fatigue fractures, coming about from excessive loading of bones with normal mineralisation (bone density). To learn more about stress fractures in general, click here As mentioned in earlier articles, there may often be a degree of overlap between these three entities (and a fourth less common condition being popliteal artery entrapment syndrome – PAES), rendering diagnostic challenges at times for treating practitioners. One other subset of exertional lower leg pain however is that of bone stress. ![]() Tuning fork broken bone series#Previous blogs in this lower leg series have discussed exertional lower leg pain with inflammatory features (medial tibial stress syndrome (MTSS) / “shin splints”) and those with features of crescendo pain with definitive improvement upon cessation of activity (chronic exertional compartment syndrome). Stuart Down (Sport & Exercise Medicine Physician). ![]()
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