Stress fractures of the tibia and fibula
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health Sciences University
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Associate Professor of Pediatrics
- Harvard Medical School
Stress fractures of the tibia and fibula occur in many athletes, especially runners, and also in nonathletes who suddenly increase their activity level or have an underlying illness predisposing them to stress fractures. Many factors appear to contribute to the development of these fractures including changes in athletic training, specific anatomic traits, decreased bone density, and disease states .
This topic review will discuss stress fractures of the tibia and fibula in adults. An overview of stress fractures and discussions of other specific fractures are found separately. (See "Overview of stress fractures" and "Stress fractures of the metatarsal shaft".)
The tibia is the major weight-bearing bone of the lower leg (picture 1 and picture 2). The proximal tibial plateau forms the lower surface of the knee joint (figure 1 and picture 3). The tibial shaft bridges the distance to the distal tibia, which contributes the superior articular surface of the ankle joint at the tibiotalar articulation as well as the medial malleolus. Another key bony landmark is the tibial tuberosity, which sits several centimeters below the joint line and serves as the attachment site for the patellar tendon. Although the tibial shaft is the most common site for stress fractures, they may also occur at the tibial plateau and the medial malleolus .
A strong fibrous structure, the interosseous membrane or ligament (figure 2), connects the tibia and fibula along the length of the two bones. Proximally, this structure, reinforced by strong anterior and posterior ligaments, forms a synovial joint, the proximal tibiofibular articulation (picture 4). Distally the interosseous membrane and three ligaments, the anterior, posterior, and transverse tibiofibular ligaments (figure 3 and figure 4), stabilize the superior ankle joint. Another fibrous structure, the crural fascia, surrounds the bones and muscles of the lower leg. Thus, although it bears far less weight than the tibia, the fibula is closely bound to the tibia by membranous and ligamentous attachments and is therefore susceptible to strain from some of the same deforming forces that cause tibial stress fractures .
Fascial extensions and the interosseous membrane separate the muscles, nerves, and vessels of the lower leg into four distinct compartments (figure 5). Three of these, the anterior, posterior, and deep posterior compartments, all border the tibia and can be compromised by tibial injury. The lateral compartment borders the fibula.
- Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports Med 1998; 26:265.
- Niva MH, Kiuru MJ, Haataja R, Pihlajamäki HK. Bone stress injuries causing exercise-induced knee pain. Am J Sports Med 2006; 34:78.
- Wheeless CR III. Blood supply to the tibia. Wheeless' Textbook of Orthopaedics. Duke Orthopaedics. http://www.wheelessonline.com/ortho/blood_supply_to_the_tibia (Accessed on May 26, 2015).
- Bahney CS, Hu DP, Miclau T 3rd, Marcucio RS. The multifaceted role of the vasculature in endochondral fracture repair. Front Endocrinol (Lausanne) 2015; 6:4.
- Lundon, K, Melcher, L, Bray, K. Stress fractures in ballet: a twenty-five year review. J Dance Med Sci 1999; 3:101.
- Hulkko, A, Alen, M, Orava, S. Stress fractures of the lower leg. Scand J Sports Sci 1987; 9:1.
- Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes. A study of 320 cases. Am J Sports Med 1987; 15:46.
- DiFiori JP. Stress fracture of the proximal fibula in a young soccer player: a case report and a review of the literature. Med Sci Sports Exerc 1999; 31:925.
- Shindle MK, Endo Y, Warren RF, et al. Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg 2012; 20:167.
- Bennell KL, Brukner PD. Epidemiology and site specificity of stress fractures. Clin Sports Med 1997; 16:179.
- Friberg O. Leg length asymmetry in stress fractures. A clinical and radiological study. J Sports Med Phys Fitness 1982; 22:485.
- Sullivan D, Warren RF, Pavlov H, Kelman G. Stress fractures in 51 runners. Clin Orthop Relat Res 1984; :188.
- Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001; 29:100.
- Yagi S, Muneta T, Sekiya I. Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. Knee Surg Sports Traumatol Arthrosc 2013; 21:556.
- Pamukoff DN, Blackburn JT. Comparison of plantar flexor musculotendinous stiffness, geometry, and architecture in male runners with and without a history of tibial stress fracture. J Appl Biomech 2015; 31:41.
- Crossley K, Bennell KL, Wrigley T, Oakes BW. Ground reaction forces, bone characteristics, and tibial stress fracture in male runners. Med Sci Sports Exerc 1999; 31:1088.
- Davey T, Lanham-New SA, Shaw AM, et al. Fundamental differences in axial and appendicular bone density in stress fractured and uninjured Royal Marine recruits--a matched case-control study. Bone 2015; 73:120.
- Fatima ST, Jeilani A, Abbasi NZ, et al. Validation of tuning fork test in stress fractures and its comparison with radionuclide bone scan. J Ayub Med Coll Abbottabad 2012; 24:180.
- Schneiders AG, Sullivan SJ, Hendrick PA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. J Orthop Sports Phys Ther 2012; 42:760.
- O'Connor FG, Wilder R, Nirschl R. Textbook of Running Injuries, McGraw Hill, New York 2001.
- Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005; 235:553.
- Waterbrook AL, Adhikari S, Stolz U, Adrion C. The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED. Am J Emerg Med 2013; 31:1352.
- Joshi N, Lira A, Mehta N, et al. Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review. Acad Emerg Med 2013; 20:1.
- Beck BR, Bergman AG, Miner M, et al. Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT Severity grades to clinical severity and time to healing. Radiology 2012; 263:811.
- Clare, DJ. Stress fractures of the ankle in the athlete. Oper Tech Sports Med 2001; 9:32.
- Robertson GA, Wood AM. Return to sports after stress fractures of the tibial diaphysis: a systematic review. Br Med Bull 2015; 114:95.
- Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev 2005; :CD000450.
- Dickson TB Jr, Kichline PD. Functional management of stress fractures in female athletes using a pneumatic leg brace. Am J Sports Med 1987; 15:86.
- Hong SH, Chu IT. Stress fracture of the proximal fibula in military recruits. Clin Orthop Surg 2009; 1:161.
- Coady CM, Micheli LJ. Stress fractures in the pediatric athlete. Clin Sports Med 1997; 16:225.
- Walker RN, Green NE, Spindler KP. Stress fractures in skeletally immature patients. J Pediatr Orthop 1996; 16:578.
- de la Cuadra P, Albiñana J. Pediatric stress fractures. Int Orthop 2000; 24:47.
- Yngve DA. Stress fractures in the pediatric athlete. In: The Pediatric Athlete, Sullivan JA, Grana WA. (Eds), American Academy of Orthopedic Surgery, Park Ridge 1988.
- CLINICAL ANATOMY
- EPIDEMIOLOGY, RISK FACTORS, AND MECHANISM OF INJURY
- CLINICAL PRESENTATION AND EXAMINATION
- DIAGNOSTIC IMAGING
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
- INITIAL TREATMENT
- FOLLOW-UP CARE
- Tibial stress fractures
- Fibular stress fractures
- Risk factor identification
- RETURN TO WORK AND SPORTS
- PEDIATRIC CONSIDERATIONS
- SUMMARY AND RECOMMENDATIONS