How you get relief from Stress Fracture of the Tibia?
Stress fractures are more commonly a cause of shin pain in athletes in impact, running and jumping sports. Overall limb and foot alignment as well as limb length discrepancy may also play a role. The incidence of stress fractures is increased by playing on more rigid, unforgiving surfaces.
Approximately 90% of tibial stress fractures will affect the postero-medial aspect of the tibia, with the middle third and junction between the middle and distal thirds being most common. Proximal metaphyseal stress fractures may be related to more time loss from sports as they do not respond as well to functional bracing, which allows earlier return to play.
Stress fractures on the anterior edge of the tibia, the tension side of the bone, are more resistant to treatment and have a propensity to develop a non-union when compared to the risk of posteromedial stress fractures. A simple memory tool for the problematic anterior tibial stress fracture is anterior is awful.
A classic case presentation for a routine postero-medial stress fracture is as follows:
- Gradual onset of leg pain aggravated by exercise.
- Pain may occur with walking, at rest or even at night.
- Examination-localized tenderness over the tibia.
- Biomechanical examination may show a rigid, cavus foot incapable of absorbing load, an excessively pronating foot causing excessive muscle fatigue or a leg length discrepancy.
- Tenderness to palpation along the medial border with obvious tenderness. A stress fracture of the posterior cortex produces symptoms of calf pain.
- Bone scan and MRI appearances of a stress fracture of the tibia. MRI scan is of particular value as the extent of edema and cortical involvement has been directly correlated with the expected return to sport.
- A CT scan may also demonstrate a stress fracture.
Prior to initiating treatment or during the treatment plan, it is important to identify which factors precipitated the stress fracture. The most common cause is an acute change in training habits, such as a significant increase in distance over a short period of time, beginning double practice days after lying off training for a season, or a change to a more rigid playing surface. Shoe wear, biomechanics and repetitive impact sports such as running and gymnastics have also been implicated. The athletes coach can play a key role in modifying training patterns to reduce the risk of these injuries. In women, reduced bone density due to hypoestrogenemia secondary to athletic amenorrhea (the female athlete triad) may be a contributing factor. All female athletes with a first-time stress fracture should be screened for the female athlete triad.
The classic treatment plan is as follows:
- Initial period of rest (sometimes requiring a period of non-weight-bearing on crutches for pain relief) until the pain settles.
- The use of a pneumatic brace has been described. Studies have shown a markedly reduced return to activity time with such use compared with average times in two of three studies and compared with a traditional treatment group in the third. In this latter study the brace group returned to full, unrestricted activity in an average of 21 days compared with 77 days in the traditional group. The brace should extend to the knee as the mid-leg version may actually increase the stresses across a mid shaft stress fracture. Once a stress fracture is clinically healed the athlete is advised to use the brace during practise and competition. Clinical healing implies minimal to no palpable pain at the fracture site and minimal to no pain with activities in the brace. Using this plan, there have been no reported cases of progression to complete catastrophic fracture of the tibia.
- If pain persists, continue to rest from sporting activity until the bony tenderness disappears (four to eight weeks).
- Once the patient is pain-free when walking and has no bony tenderness, gradually progress the quality and quantity of the exercise over following month. The athlete should be asked to continue to use a pneumatic brace to complete the current season until an appropriate period (four to eight weeks) of rest can occur.
- Cross training with low impact exercises, including swimming, cycling and deep water running, maintains conditioning and reduces risk of recurrence.
- Pain associated with soft tissue thickening distal to the fracture site can be treated by soft tissue techniques.
- General principles of return to activity following overuse injury should be followed.