Stress fracture of the tibia in athletes: diagnosis and natural course

Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review

Purpose

To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures.

Methods

A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score.

Results

Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment.

Conclusions

Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment.

Level of Evidence

Level IV; Systematic Review of level I-IV studies.

The prevalence and effect of the sites of pain in female soccer players with medial shin pain

BACKGROUND

Female soccer players are often diagnosed with medial shin pain, which includes tibial stress fracture, medial tibial stress syndrome, and chronic exertional compartment syndrome. As the possibility of varied sites of pain affecting sports activities has not been fully researched, an urgent discussion and evidence is required. This study investigates the prevalence and effect of sites of pain on the sports activities of female soccer players with medial shin pain.

METHODS

A questionnaire survey was conducted for 196 female soccer players with medial shin pain to assess symptom duration, the effect of practice and performance, and sites of pain. The players were classified into three conditions (tibial stress fracture, medial tibial stress syndrome, or medial shin pain with neurological symptoms) and compared based on sites of pain.

RESULTS

We observed that medial tibial stress syndrome had a lower impact on performance compared to that of tibial stress fracture and medial shin pain with neurological symptoms. While participants with tibial stress fracture had to suspend practice sessions more frequently, the difference in symptom duration between the classified groups was not statistically significant. The effect of sites of pain on sports activities was not significantly different in participants with medial tibial stress syndrome.

CONCLUSIONS

Medial shin pain should be evaluated carefully to differentiate between medial tibial stress syndrome and medial shin pain with neurological symptoms. Restriction of sports activities may help improve the patient's condition early, regardless of the presentation.

Ground reaction force metrics are not strongly correlated with tibial bone load when running across speeds and slopes: Implications for science, sport and wearable tech

INTRODUCTION

Tibial stress fractures are a common overuse injury resulting from the accumulation of bone microdamage due to repeated loading. Researchers and wearable device developers have sought to understand or predict stress fracture risks, and other injury risks, by monitoring the ground reaction force (GRF, the force between the foot and ground), or GRF correlates (e.g., tibial shock) captured via wearable sensors. Increases in GRF metrics are typically assumed to reflect increases in loading on internal biological structures (e.g., bones). The purpose of this study was to evaluate this assumption for running by testing if increases in GRF metrics were strongly correlated with increases in tibial compression force over a range of speeds and slopes.

METHODS

Ten healthy individuals performed running trials while we collected GRFs and kinematics. We assessed if commonly-used vertical GRF metrics (impact peak, loading rate, active peak, impulse) were strongly correlated with tibial load metrics (peak force, impulse).

RESULTS

On average, increases in GRF metrics were not strongly correlated with increases in tibial load metrics. For instance, correlating GRF impact peak and loading rate with peak tibial load resulted in r = -0.29±0.37 and r = -0.20±0.35 (inter-subject mean and standard deviation), respectively. We observed high inter-subject variability in correlations, though most coefficients were negligible, weak or moderate. Seventy-six of the 80 subject-specific correlation coefficients computed indicated that higher GRF metrics were not strongly correlated with higher tibial forces.

CONCLUSIONS

These results demonstrate that commonly-used GRF metrics can mislead our understanding of loading on internal structures, such as the tibia. Increases in GRF metrics should not be assumed to be an indicator of increases in tibial bone load or overuse injury risk during running. This has important implications for sports, wearable devices, and research on running-related injuries, affecting >50 scientific publications per year from 2015-2017.

Return to sports after stress fractures of the tibial diaphysis: a systematic review

INTRODUCTION

This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs).

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport.

AREAS OF CONTROVERSY

The best time to return to sport and the optimal management modalities for TDSFs remain undefined.

GROWING POINTS

Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TDSFs.

Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review

AIM

To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal.

METHODS

Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate.

RESULTS

18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low.

CONCLUSIONS

Strong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research.

STUDY REGISTRATION NUMBER

PROSPERO database of systematic reviews: CRD42013004201.

Anterior tibial stress fractures treated with anterior tension band plating in high-performance athletes

PURPOSE

The non-surgical treatment of anterior tibial cortex stress fractures requires long periods of abstention from sports activities and often results in non-union. Many different surgical techniques have already been previously described to treat these fractures, but there is no consensus on the best treatment. We describe the outcome of treatment using anterior tibial tension band plating in three high-performance athletes (4 legs) with anterior tibial cortex stress fractures.

METHODS

Tibial osteosynthesis with a 3.5-mm locking compression plate in the anterolateral aspect of the tibia was performed in all patients diagnosed with anterior tibial stress fracture after September 2010 at Santa Casa Hospital.

RESULTS

All of the fractures were consolidated within a period of 3 months after surgery, allowing for an early return to pre-injury levels of competitive sports activity. There were no infection, non-union, malunion or anterior knee pain complications.

CONCLUSIONS

Anterior tibial tension band plating leads to prompt fracture consolidation and is a good alternative for the treatment of anterior tibial cortex stress fractures. Bone grafts were shown to be unnecessary.

Anterior Mid-Tibial Stress Fractures. Results of Surgical Treatment

Background and Aims:

An anterior mid-tibial stress fracture is an uncommon, but possibly career threatening condition for an athlete. We wanted to evaluate the results of the surgical treatment of this notorious stress fracture and compare two different surgical methods.

Material and Methods:

Forty-nine anterior mid-tibial stress fractures were treated surgically in 45 patients during the years 1985–2005. All the patients were athletes, mainly runners. The mean age of the patients was 26 years. Thirty-four of the fractures occurred in men and 15 in women. The first method of treatment (anteromedial and lateral drilling) was used in 20 operations and the second method (laminofixation) in 29 operations.

Results:

Good results were achieved with drilling in only 50% of the operations, where as with laminofixation good results were achieved in 93% of operations. This difference was statistically significant (p = .002). Healing of the stress fracture after laminofixation occurred in less than 6 months. The length of the plate used in the laminofixation had no effect on the end result.

Conclusions:

An anterior mid-tibial stress fracture may often lead to delayed union or non-union in vigorously training athletes. Surgical treatment with laminofixation proved to be superior to tibial fracture site drilling.

Local bone deformation at two predominant sites for stress fractures of the tibia: an in vivo study

Local bone deformation was registered at two predominant injury sites for tibial stress fractures in a healthy female volunteer. Two instrumented strain gauge staples were inserted under local anesthesia to the anterior middiaphysis (AM) and to the posteromedial part of the distal tibia (PD). Calibration and reliability of the instrumented staple system have previously been demonstrated in vitro. Concomitant ground reaction forces were registered with a Kistler force plate. Studying peak values, it was shown that during a voluntary 30-cm forward jump, PD deformation was greater during forefoot landing (2700-4200 microstrain) than during a heel strike landing (1200-1900 microstrain) and also compared with the concomitant AM deformation under both above testing conditions (1300-1900 microstrain). The stance phase during walking resulted in PD deformation of 950 microstrain, whereas the concomitant AM deformation was 334 microstrain. The greatest AM deformation (mean, 2128 microstrain) was registered during ground contact after a voluntary vertical drop from a height of 45 cm, concomitant with a PD deformation of 436 microstrain. These data are the first to show different local deformations at various sites of the tibia in vivo. The PD deformation was larger than previously noted from other parts of the tibia, whereas the middiaphysis data are consistent with other reports. The results may support the clinical assumption of different etiologies for stress fractures at these predominant sites.

The reliability and validity of an instrumented staple system for in vivo measurement of local bone deformation. An in vitro study

We recently presented a pilot study using an instrumented staple system for measuring in vivo local deformation on tibia. Methodological development has now proceeded in vitro. Consecutively, we performed 1. a sheep bone micrometer study, 2. a sheep bone four-point bending test and 3. a pig bone four-point and three-point bending test. This was done in order to secure a standardized application of the staple, to analyze the interaction of the bone and the staple and to secure calibration and the reliability of the system to be used in vivo. With reference to the above studies: 1. There was a linear relationship (r = 0.998) between the applied deformation of the bone and the measured deformation of the staple. ICC values ranged from 0.866 to 0.997. 2. An excellent intra-test reliability as well as linearity between staple measures and surface strain on the bone was observed (r = 0.998). 3. The slope of regression lines (k) was min 7.2 and max 9.4. The results from this test are used for calibration of the instrumented staple. Great variations were found between tension and compression measurements. However, within each test the SD was negligible. We suggest that the instrumented staple system may be calibrated in vitro and validly used for in vivo measurement of local bone deformation.

Bone scintigraphy in sports medicine: a review

Bone scintigraphy is of growing interest to the sports physicians in the evaluation of benign disorders of the musculoskeletal system. It is atraumatic and easily applied, and being very sensitive a normal scintigram excludes pathophysiological conditions or mechanical disorders of the bones and joints. The indication is mainly suspicion of stress fractures, where a graduation is possible allowing prognostic interpretation. The finding of stress fractures in female athletes with long-lasting amenorrhea may warrant further interest in the bone mineral content of the skeleton. In the diagnostic evaluation of particularly longer-lasting joint-related pain in younger subjects without obvious degenerative disease, bone scintigraphy is very sensitive to exclude joint affection, but not very specific to reveal an exact diagnosis. In athletes with back pain and radiographically demonstrated spondylolysis, tomography of bone scintigrams (SPECT) may discern between an actively healing process, probably eliciting the pain, and an inactive, healed process not responsible for the back pain. Bone tumors always show increased uptake in bone scintigraphy, but the method does not allow a reliable differentiation between benign and malign etiology.

The anterior stress fracture of the tibia: an atrophic pseudoarthosis?

Histopathological examination of biopsies from the fracture site in two cases of anterior stress fractures of the tibia demonstrated no bone remodelling activity, absence of inflammatory cells, extensive fibrotic infiltration and local avascular bone necrosis. The biopsies were taken peroperatively from two elite soccer players who earlier had to stop training due to severe exertional pain. When non-operative treatment failed to heal the fractures within 1 year and 6 months, respectively, surgery was performed in order to stabilize the fractures. Both subjects were relieved from exertional pain within 6 months of surgery. Consecutive radiographs showed the pattern of direct healing and 8 months postoperatively confirmed complete healing without callus formation. Both elite soccer players returned to pre-injury activity level. We suggest that the excessive fibrotic tissue ingrowth and hypovascularity under repetitive stress causes the delayed healing and histopathological signs similar to an atrophic pseudoarthosis. Treatment should consequently consider the pseudoarthrotic character of the anterior stress fracture of the tibia.

An experimental in vivo method for analysis of local deformation on tibia, with simultaneous measures of ground reaction forces, lower extremity muscle activity and joint motion

This paper presents the pilot procedures of a new in vivo experimental method for measures of local bone deformation on tibia. The tibia transducer consists of a strain gauge mounted on a surgical staple, and was designed to measure local bone deformation. Pilot measurements were undertaken during two standardized conditions of forefoot and heel landing in seven healthy volunteers. Implantation of two tibia force transducers on tibia were performed under local anaesthesia. The local peak tibia deformation occurred at 20-42 ms (median) after ground contact, and was up to eight times higher during stance phase loading compared with standing still on one leg. Ground reaction forces, muscle activation patterns and kinematics were registered simultaneously, and were used to validate that the observed local deformation on tibia occurred under controlled and clinically relevant conditions. The new method may be used for investigating local deformation within various bone structures of the lower extremity. There are further methodological issues to address before major clinical interpretations may be concluded. In order to verify that the strain gauge transducer system was valid, a controlled displacement of the staple shanks was performed with a micrometer, and showed a linear relationship between applied deformation and strain gauge response (r = 0.97-0.99). In addition, a linear relationship was found between externally applied static forces and strain gauge response in a four-point bending cadaver system (r = 0.96-0.98).

A study of intrinsic factors in patients with stress fractures of the tibia

We aimed to study intrinsic factors in 29 consecutive patients with well-documented unilateral stress fractures of the tibia. Anthropometry, range of motion, isokinetic plantar flexor muscle performance, and gait pattern were analyzed. The uninjured leg served as the control. A reference group of 30 uninjured subjects was compared regarding gait pattern. Anterior stress fractures of the tibia (N = 10) were localized in the push-off/ landing leg in 9/10 athletes, but were similarly distributed between legs in posteromedial injuries (N = 19). Ten (30%) of the stress fracture subjects had bilateral high foot arches, similar to those found in the reference group. There were no other systematic differences in anthropometry, range of motion, gait pattern, or isokinetic plantar flexor muscle peak torque and endurance between injured and uninjured legs. No other differences were found between anterior and posteromedial stress fractures. We conclude that anterior stress fractures of the tibia occur mainly in the push-off/landing leg in athletes. Within the limitations of our protocol, no registered intrinsic factor was found to be directly associated with the occurrence of a stress fracture of the tibia.

Overuse injuries of the lower extremity in runners

The purpose of this article is to review the literature on overuse injuries of the lower extremity in runners and to discuss briefly today's knowledge concerning etiology, diagnosis and treatment. Running is a natural entity in many sports and a majority of runners will sustain one or more overuse injuries throughout the career, in most cases affecting the lower extremity. A runner may be regarded as an athlete who regularly runs as the predominant physical activity. From that point, we should subdivide the definition "runner" considering the character of different sports or recreational activities performed. Overuse injuries are often described merely from symptoms, including several different etiological and pathoanatomic correlates covering a variety of ailments. The clinical approach should be focused on a thorough history and physical examination. Analysis of possible injury mechanisms, correction of associated extrinsic and intrinsic factors and advice on alternative training should be given. A knowledge of specific demands from the type of running performed is necessary to evaluate the symptoms presented. Overuse etiology has to be considered multifactorial with a yet unsolved exact pathophysiology needing further research. The definition of a "runner", of "running" and of "overuse injury" should be established and agreed upon. This review attempts to draw attention to the huge multidisciplinary work that has to be done to better understand the mechanisms causing an overuse injury in a runner and to define diagnoses on a scientific base, whether or not excentric or intrinsic factors predispose or trigger.

The plantar flexor muscle attachments on the tibia. A cadaver study

Thirty-six tibiae from 11 female and 7 male cadavers were dissected. Anatomical and histological examinations of the plantar flexor muscle origins at the posteromedial border of the tibia were performed. Many individual variations in the type and size of muscle origin were observed. Muscle fibers and/or connective tissue in different proportions attached the muscle to the periosteum or directly to the cortical bone. The length of the attachments varied greatly and there was a considerable overlap of the muscles in some individuals. The attachments of the flexor digitorum longus overlapped the tibialis posterior and the flexor digitorum longus muscle was overlapped by the soleus muscle. In two cases the soleus muscle did not attach to the tibia at all. Our findings may shed some light on the question as to why some athletes sustain posteromedial tibial stress fractures and others develop shin splits or other posteromedial injuries from similar precipitating activity.