Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Anterior Tibia Stress Fracture

SYMPTOMS

There is a gradual onset of localised exercise-induced pain at the anterior edge of the tibia, often affecting ballet dancers and athletes in jumping or running sports with high-impact forces or when plyometric training is involved (e.g. basketball, high jump or long jump). Initially, the symptoms may be vague but gradually they become
so severe that they prevent jumping or running.
AETIOLOGY

This is a tension-side stress fracture that does not heal bone to bone, since fibrosis grows into the fracture site, causing non-union that gets worse over time. When the anterior cortical bone becomes thicker the fibrosis growth in the fracture line makes bone-to-bone healing impossible.


CLINICAL FINDINGS

There is tenderness on palpation and localised swelling over the fracture site.


INVESTIGATIONS

X-ray is negative until several weeks after onset of symptoms due to the lack of callus formation. CT scans or MRI may disclose the diagnosis earlier. In later stages, an X-ray will show a ‘shark bite appearance’ of the anterior cortex in
lateral view.


TREATMENT

This stress fracture may initially respond to conservative treatment including modification of training and avoiding jumping and running for three months. Unfortunately the diagnosis is often delayed and the condition turns
chronic. Surgery may be necessary to stimulate bone healing but this injury halts many athletes. Surgery is followed by a long period of partial immobilisation and rehabilitation before resuming sport.
REFERRALS

Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of six to twelve months’ return programme.
EXERCISE PRESCRIPTION

Cycling and swimming and any other low-impact activities are good alternatives to keep up general fitness.
EVALUATION OF TREATMENT OUTCOMES
Monitor clinical symptoms and signs. Note X-ray can show the typical appearance in non-symptomatic athletes. Often the athlete changes stance or jumping technique, altering the site of stress and causing a new fracture at another site.
DIFFERENTIAL DIAGNOSES

Shin splints (pain more diffuse; MRI can indicate); Chronic anterior compartment syndrome (pain in the muscle bulk);
Posterior tibia stress fracture (location of symptoms medial posterior edge; X-ray and MRI differentiate); Tumour (X-ray differentiates).


PROGNOSIS

Fair-Poor; this injury halts the careers of many top athletes.

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