A tibial stress fracture is a hairline fracture of the tibia bone in the lower leg caused by overuse or repetitive stress. Symptoms are very similar to ‘shin splints’ with gradual onset pain on the inside of the shin. Here we explain the symptoms, causes, and treatment for a stress fracture of the tibia.
Symptoms of a tibial stress fracture are very similar to shin splints (medial tibial stress syndrome) and include:
- Pain on the inside of the shin, usually on the lower third.
- Symptoms often occur after running long distances.
- When pressing in over the area your leg will feel tender and sore.
- You may even have swelling over the site of the fracture.
- If you have a stress fracture you may also feel a particularly tender spot at the exact point of the stress fracture.
It can be difficult to distinguish a tibial stress fracture from a case of shin splints. This is because a stress fracture will not show up on an X-ray until it has begun to heal. It is the new cells along the line of the fracture which will become visible.
- If you suspect a stress fracture of the tibia then a period of at least 4 weeks rest is required before a second X-ray is taken.
- Often new bone growth can be seen where it has begun to heal.
What is a tibia stress fracture?
The lower leg consists of two bones, called the tibia and fibula. The tibia is the larger, thicker of the two and its role is load-bearing. The fibula is the smaller, thinner bone and its purpose is mainly as an area for muscles to attach. Either of these bones can develop stress fractures.
The most common site, however, is two to three inches above the bony bit on the inside of the ankle (called medial malleolus) on the tibia bone.
Long bones such as the tibia have an outer sheath surrounding the hard compact bone called the periosteum with the inner core containing bone marrow. The bone is overloaded through continuous muscle contractions and stress forces of impact when running.
In particular, when fatigued, the distribution of the forces in the bone is altered because your muscles are unable to absorb some of the load. Therefore, there is more load on the bone. Lots of small impacts on the bone even though they may be very small, a cumulative effect can build up.
What causes a tibia stress fracture?
The obvious cause of a tibial stress fracture is overuse, however, there are a number of factors which can increase the chances of sustaining a tibial stress fracture.
Training – a sudden change in a running surface, for example, going from grass training to lots of track or road running can increase the chances of a stress fracture.
Foot biomechanics – such as overpronation or oversupination can increase the stress on the tibia bone. If your foot overpronates and rolls in, flattening the arch of the foot, this has the effect of rotating the shin bone inwards. As a result, additional torsion or twisting stresses are placed on the bone.
Tibial stress fracture treatment
What can the athlete do?
- If a stress fracture is suspected then a sustained period of rest is needed to allow the injury to begin to heal. Rest for around eight weeks, avoiding weight-bearing exercise especially running.
- Substitute swimming or cycling if it can be done pain-free or use the opportunity to work on upper body strength in the gym, or technical aspects of your sport if possible. Running in water with a buoyancy aid or belt is also an excellent substitute for running on the road.
- A simple shin taping technique can help reduce the strain on the shin. It works by supporting the muscles of the lower leg, pulling them towards the bone and helping to reduce rotation of the tibia. But do not use the tape to resume running if you have a suspected tibial stress fracture.
- Exercises to maintain strength and flexibility in the lower leg such as light calf raises as long as they are not painful and wobble balance board training can be done.
- It is especially important to stretch and strengthen the muscles at the back of the lower leg when returning to weight-bearing exercise. After a period of rest, they may be tight and in poor condition. This increases the likelihood of sustaining further shin pain from medial tibial stress syndrome (shin splints).
Training methods should be analyzed to try and identify if or how this has contributed to your injury. Does footwear need to be changed? Running shoes should have a life of about 500 miles after which they should be changed.
What can a sports injury specialist or doctor do?
- A doctor will x-ray the leg and advise on when it is safe to resume training. Initially, the stress fracture will not show up on an x-ray, however, some signs may be seen after 2 or 3 weeks so it is important to follow up with another x-ray after a period of rest.
- Gait analysis can identify any biomechanical problems of the foot which may have increased the chances of injury. Orthotic inserts worn in the shoes can correct foot problems such as overpronation.
- Sports massage for the calf muscles at the back of the lower leg can relax them, releasing any muscle spasm, tight knots, lumps or bumps in the muscle, making them more efficient at absorbing running forces when normal training resumes.
References & further reading
- Popp KL, Hughes JM, Smock AJ et al. Bone geometry, strength, and muscle size in runners with a history of stress fracture. Med Sci Sports Exerc 2009;41(12):2145–50.
- Fields KB, Sykes JC, Walker KM et al. Prevention of running injuries. Curr Sports Med Rep 2010;9(3):176–82.