Tibia Stress Fracture


Tibia Stress Fracture, Tibial Stress Fracture, Dreaded Black Line

  • Epidemiology
  1. Most common Stress Fracture
    1. Accounts for >50% of Stress Fractures
  2. Common overuse injury in runners and jumpers
  3. Mid-tibial shaft Stress Fractures
    1. Occur in dancers
    2. Occur in jumping athletes
  • Risk Factors
  • Symptoms and signs suggestive of Tibial Stress Fracture
  1. Nocturnal pain
  2. Extremely painful focal area of tibia
  3. Provocative maneuvers
    1. Pain on application of vibrating tuning fork
    2. Pain elicited on heel thump or "Hop Test"
    3. Pain with local Ultrasound at 2.5 to 3 W/cm2
      1. Not recommended currently for initial diagnosis
      2. Boam (1996) J Am Board Fam Pract 9:414-7 [PubMed]
  4. Common locations of Stress Fracture
    1. Children: Anterior proximal one third of tibia
    2. Adults: Junction of middle and distal third of tibia
  • Diagnostics
  1. XRay with cone down view
    1. Horizontal lucency (Dreaded Black Line)
      1. Transverse Fracture through entire anterior shaft
      2. Seen more often in jumping sports
      3. Higher likelihood of nonunion
  2. Triple phase bone scan
    1. Focal hot spot at point of maximal tenderness
  3. Magnetic Resonance Imaging (MRI) Tibia
  • Management
  1. See Stress Fracture
  2. Activity
    1. Avoid Running for 6-8 weeks
    2. May weight bear unless painful
    3. Slow, graded return to activity
    4. Return to sport may be as long as 3-10 months
      1. Robertson (2015) Br Med Bull 114(1):95-111 [PubMed]
  3. Other measures
    1. Consider Aircast Splinting
    2. Cast mid-shaft Fractures until pain-free
    3. Surgical repair indicated for delayed healing >6 months
  • Prognosis
  1. Anterior Fracture with more non-union than anteromedial