A stress fracture occurs when a bone breaks after being subjected to repetitive stresses, none of which would be large enough individually to cause the bone to fail. During running, compressive forces are placed through the tibia by several muscles which exert forces on the bone when they contract. When these forces are excessive or too repetitive in nature for the tibia to withstand, bone damage occurs. This initially results in a stress reaction; however, with continued damage this may progress to a tibial stress fracture. In particular, tibial stress fractures are the most common stress fractures in athletes and are the most common among runners where the incidence may be as high as 15%.

Causes of tibial stress fractures

A stress fracture of the tibia is an overuse injury that typically develops gradually over time due to excessive running or mismanaged training. Stress fractures can result secondary to increasing your intensity or volume of training prior to establishing adequate lower extremity and core strength. Stress fractures may also be the simple result of overtraining, a sudden change in running surfaces, or improper footwear. An athlete can have an increased risk of a stress reaction or fracture if their bone density is decreased. Biomechanical causes of tibial stress fractures include ankle joint stiffness, gastroc/soleus (calf) complex tightness, leg length discrepancies, and poor foot alignment. Additionally, improper nutrition or menstrual disturbances can be underlying causes of stress fractures. Finally, a history of stress fractures is also a strong predictor of future stress fractures, according to several prospective studies. The relative risk is over six-fold in distance runners with a history of at least one stress fracture. Among track athletes, 60% of those who sustained a stress fracture had a history of stress fracture, and the one year recurrence rate in these runners was 12.6%.

Signs, symptoms and potential treatment of tibial stress fractures

Patients with this condition typically experience a gradual onset of localized pain at the inner aspect of their tibia. This pain is often times referred to as ‘crescendo pain’ because it tends to ramp up gradually during the act of running, beginning as an annoying irritation and progressively becoming sharp and severe in nature. The pain tends to dissipate with rest or inactivity. In severe cases, walking may be enough to aggravate symptoms and the pain may be present at night. Patients with a tibial stress fracture also typically experience tenderness at the inner aspect of their tibia.

When experiencing any of these symptoms it is best to have a physician evaluate you as soon as possible to avoid any further damage to the tibia. Often times this is misdiagnosed as shin splints secondary to the type and location of the pain. Following a physician visit and depending on the severity of the injury, many individuals may be placed on a modified activity or training schedule, informed to use crutches for an extended period or time, or just rest for up to 6 weeks. After this period of rest and healing, if it is appropriate, many individuals may enroll in physical therapy where a complete biomechanical evaluation will be addressed. Treatment may consist of lower extremity strengthening, core strengthening, lower extremity flexibility, soft tissue massage, orthotic fitting, video gait analysis, training modifications or even Alter-G Anti-Gravity Treadmill training.

If you or someone you know is experiencing these problems please contact a physician for an evaluation.

The author of this article is Kyle Leonard, PT, MSPT, CSCS, the Facility Manager at the Niles/Northwest Chicago AthletiCo.