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Sports Injury Prevention & Rehabilitation

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Tibial Stress Fracture

(Also known as Stress Fracture of the Tibia, Medial Tibial Stress Fracture)
What is a tibial stress fracture?
A tibial stress fracture is a condition characterized by an incomplete crack in the lower leg bone / shin bone (tibia).
During weight-bearing activity (such as running), compressive forces are placed through the tibia. In addition, several muscles attach to the tibia, so that when they contract, a pulling force is exerted on the bone. When these forces are excessive, or too repetitive, and beyond what the bone can withstand, bony damage can gradually occur. This initially results in a bony stress reaction, however, with continued damage may progress to a tibial stress fracture.

Causes of a tibial stress fracture
A stress fracture of the tibia is an overuse injury that typically develops gradually over time due to excessive weight bearing activity such as running, sprinting or jumping. It often occurs following a recent increase in activity or change in training conditions.

Signs and symptoms of a tibial stress fracture
Patients with this condition typically experience a gradual onset of localized pain at the inner aspect of the shin bone. The pain is often sharp or acute in nature and typically increases with impact activity and decreases with rest. Occasionally pain may be felt with rest or even at night. In severe cases, walking may be enough to aggravate symptoms. Patients with this condition typically experience tenderness on firmly touching the inner aspect of the shin bone. Occasionally, a tibial stress fracture may present as calf pain rather than shin pain.

Diagnosis of a tibial stress fracture
A thorough subjective and objective examination from a physician may be sufficient to diagnose a tibial stress fracture. Further investigations such as an X-ray, bone scan and CT scan are usually required to confirm diagnosis and determine the severity of injury.

Treatment for a tibial stress fracture
Treatment for a stress fracture of the tibia typically involves an initial period of rest. This may involve a period of non-weight bearing on crutches to protect the fracture and allow healing to occur. This may be for a period of approximately 2 - 6 weeks depending on the severity of the stress fracture. Following this, a gradual increase in weight bearing activity and exercise can usually occur as tolerated, provided symptoms do not increase. This should take place over a period of weeks to months with direction from the treating physician and will vary depending on the severity of the injury.
Patients should also perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. Alternative exercises placing minimal weight bearing forces through the affected bone should be performed to maintain fitness such as swimming, cycling and water running. The treating physical therapist can advise which exercises are most appropriate for the patient and when they should be commenced.
A review with a podiatrist may be required for the prescription of orthotics and footwear advice, particularly in those patients whose foot posture and lower limb biomechanics have contributed to the development of the condition.

Contributing factors to the development of a tibial stress fracture
There are several factors that may contribute to the development of this condition. These need to be assessed and corrected with direction from a physical therapist. Some of these factors include:
  • inappropriate or excessive training (particularly on hard or uneven surfaces)
  • poor foot posture (particularly excessive high arches or flat feet)
  • poor biomechanics
  • muscle weakness
  • muscle fatigue
  • inadequate flexibility (particularly of the calf muscles)
  • ankle joint stiffness
  • inappropriate footwear
  • inadequate diet
  • leg length discrepancies
  • being overweight
  • menstrual disturbances

Physical therapy for a tibial stress fracture
Physical therapy treatment for patients with this condition is vital in to hasten healing, ensure an optimal outcome and prevent injury recurrence. Treatment may comprise:
  • soft tissue massage (particularly to the calf muscles)
  • joint mobilization (particularly to the ankle)
  • electrotherapy (e.g. ultrasound)
  • dry needling
  • the use of crutches
  • the use of an appropriate brace
  • activity modification advice
  • arch support taping
  • biomechanical correction
  • exercises to improve strength, balance and flexibility
  • education
  • a gradual return to activity plan
  • correct footwear advice

Other intervention for a tibial stress fracture
Despite appropriate management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating physical therapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, bone scan, CT scan or MRI, extended periods of non-weight bearing or immobilization, review with a podiatrist for orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.