stress fracture: tibial stress fractures

7/30/2019 Stress Fracture: Tibial Stress Fractures

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What is this?

This is an injury to the tibia (shin bone). The

condition usually develops over a period of

time resulting in a progressive overload to the

muscle and bone..

Causes

There are a few factors that are thought to

contribute to the development of stress

fractures and these include:

What Structures can be affected?

Pain and Symptoms

Symptoms can include some or all of the

following:

Diagnosis

The diagnosis is usually made from the history

and from clinical testing. Further investigations

such as x-ray, MRI and ultrasound can be

undertaken to confirm the diagnosis and to

assess other structures. Bone scan or an MRI will

be the most sensitive form of imaging to assess

for a stress frac ture.

Treatment

One of the main focuses of treatment involves

trying to correct the predisposing factors that

contributed to the stress fracture.

Conservative management would usually

involve the following:

Tb al Stress Fracture

Patient Information Sheet

Tbal Stress Fracture

335 Hillsborough Rd, Warners Bay NSW 2282

Pain will usually be aggravated by exercise

and slowly settle with rest.

Localised tender area over the tibia at the

site of the lesion.

Can sometimes develop significant night

pain.

Rest A period of rest from aggravating

activities is important to allow the area to

settle. This may even involve a period of

non-weight bearing on crutches until thepain settles

Bracing In severe cases the use of a splint

can be helpful in controlling the symptoms

and allowing the stress fracture to settle.

Address Biomechanics If there is poor foot

biomechanics i.e. over pronating feet then

orthotics may be indicated to help unload

the area both in the short term and long

term.

High levels of running especially on hard

surfaces.

Sudden change in training volumes

Poor foot and ankle biomechanics

Lower limb weakness

High impact sports

Poor bone density

Dietary

Hormonal

Muscle Periosteum

Tibia

(02) 4954 5330 | F.(02) 4954 5380 | [email protected] | W.www.advancephysio.co m.au

Arrow showsthickened boneindicating tibial

stress fracture


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Rehabilitation and Prevention will address the

following:

Rest from aggravating activities Stress fractures

generally follow a predictable course and will

recover clinically within several weeks of rest

and activity modification.

Hormonal Overtraining or low body weight has

the potential to cause lowering of oestrogen

and subsequently lower bone density,

accelerated bone remodelling or a negative

calcium balance. Other endocrine fac tors that

have the potential to influence bone health

and therefore stress fracture risk are

glucocorticoids, growth hormone and thyroxin.

Nutritional FactorsAbnormal eating behaviours

or poor diet can increase the risk of stress

fractures and need to be addressed inmanagement. Calcium balance can be

affec ted by other dietary fac tors such as a high

intake of salt, phosphorus, fibre, protein,

caffeine and alcohol. The evidence is

uncertain as to whether dietary

supplementation with calcium or inadequate

calcium in the diet is a factor in stress fractures

but it is clear that restrictive or abnormal eating

behaviours are a risk.

Gait mechanics / foot mechanics.

Over-pronation or under-pronation have

potential to cause respectively greater muscle

activity/fatigue or less ability to absorb shock.

Either of these can predispose to stress

fractures. Interventions such as orthotics (for the

over-pronator), foot-ware changes, stretches

and perhaps subtalar and midtarsal

mobilisations and stretches (for the

under-pronator) can be undertaken during the

rest phase. Shock absorbing insoles including

an orthotic can be used for the under-pronator.

Other factors that could adversely affect stress

through the foot are poor flexibility through the

calf, and weakness of any of the muscles of the

lower limb and core which may lead to

suboptimal shock attenuation or adverse

alterations to running mechanics. Leg length

differences may also contribute to bonyoverstress. Poor running technique also needs

to be addressed.

Footware. Footware must be appropriate to

the foot type ie over-pronators require a shoe

that reduces pronation and under-pronators

require a more shock absorbing shoe. The shoes

should have appropriate midsole construction,

heel height, shock absorption and torsional

flexibility. Many race shoes are ultra-light and

sacrifice optimal biomechanics for weight andmay not be appropriate for large volume

training. Shoe age (in time but more importantly

in distance) should not be too old.

Running surface Harder running surfaces are

likely to be a risk factor and should be

minimised early in the return to sport. The overall

volume of road running should be monitored

and modified if necessary.

Cross Training Impact sparing exercise can

be used to help maintain fitness levels and to

make sure that it is an easier transition when

returning to your normal activities e.g.

exercise bike and swimming.

High Level Sport Specific Training If required

a sport specific training program will be

developed to help with your return to

sporting activities.


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Training type It is crucial that a detailed training

history prior to the stress frac ture is established

paying particular attention to any significant

changes in training volume or intensity, or

changes to rest periods which may have

occurred prior to the stress fracture occurring.

Any changes to the training environment eg

surface, number of hills should also be

examined as possible causes. If the athlete

does not keep a detailed log book of their

training they should be encouraged to do so in

the future.

Muscle strengthening and endurance of the

whole kinetic chain must be addressed and

much of this can be done during the recovery

period. Muscles exert a protective effect on

bone and muscle fatigue has been associated

with increased bone fatigue.

Return to training This should be gradual to

enable the bone to adapt to the increased

load. The return to training can be determined

on the basis of clinical examination and the

athlete should be able to demonstrate no

discomfort on repetitive impact loading eg

jumping. Cyclic training rather than progressive

training may be preferable to enable both

bone and soft tissue to recover from progressive

loading. Multi-directional and multivariableloading is probably beneficial as it will distribute

the forces variably through bone and may lead

to healthier bone as well as reduce focal stress.

Recovery Time

With a thorough rehabilitation plan this

conditon will usually settle over a 8 -12 week

period, however this can vary according to the

exact site of the injury, the age and health of

the patient and the extent of the injury as wellas other factors


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stress fracture: tibial stress fractures

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