Stress Fracture: Tibial Stress Fractures
Content
Patient Information Sheet
Tibial Stress Fractures
Tibial Stress Fractures
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: Pain and Symptoms Symptoms can include some or all of the following: • 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. 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 fracture. 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:
• 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
What Structures can be affected?
• Muscle Periosteum • Tibia
Arrow shows thickened bone indicating tibial stress fracture
• 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 the pain 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.
335 Hillsborough Rd, Warners Bay NSW 2282 T.(02) 4954 5330 | F.(02) 4954 5380 | [email protected] | W.www.advancephysio.com.au
Patient Information Sheet
Tibial Stress Fractures
• 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.
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 factors that have the potential to influence bone health and therefore stress fracture risk are glucocorticoids, growth hormone and thyroxin. Nutritional Factors Abnormal eating behaviours or poor diet can increase the risk of stress fractures and need to be addressed in management. Calcium balance can be affected by other dietary factors 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 bony overstress. 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 and may 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.
335 Hillsborough Rd, Warners Bay NSW 2282 T.(02) 4954 5330 | F.(02) 4954 5380 | [email protected] | W.www.advancephysio.com.au
Patient Information Sheet
Tibial Stress Fractures
Training type It is crucial that a detailed training history prior to the stress fracture 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 multivariable loading 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 well as other factors
335 Hillsborough Rd, Warners Bay NSW 2282 T.(02) 4954 5330 | F.(02) 4564 5380 | [email protected] | W.www.advancephysio.com.au
Tibial Stress Fractures
Tibial Stress Fractures
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: Pain and Symptoms Symptoms can include some or all of the following: • 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. 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 fracture. 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:
• 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
What Structures can be affected?
• Muscle Periosteum • Tibia
Arrow shows thickened bone indicating tibial stress fracture
• 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 the pain 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.
335 Hillsborough Rd, Warners Bay NSW 2282 T.(02) 4954 5330 | F.(02) 4954 5380 | [email protected] | W.www.advancephysio.com.au
Patient Information Sheet
Tibial Stress Fractures
• 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.
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 factors that have the potential to influence bone health and therefore stress fracture risk are glucocorticoids, growth hormone and thyroxin. Nutritional Factors Abnormal eating behaviours or poor diet can increase the risk of stress fractures and need to be addressed in management. Calcium balance can be affected by other dietary factors 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 bony overstress. 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 and may 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.
335 Hillsborough Rd, Warners Bay NSW 2282 T.(02) 4954 5330 | F.(02) 4954 5380 | [email protected] | W.www.advancephysio.com.au
Patient Information Sheet
Tibial Stress Fractures
Training type It is crucial that a detailed training history prior to the stress fracture 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 multivariable loading 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 well as other factors
335 Hillsborough Rd, Warners Bay NSW 2282 T.(02) 4954 5330 | F.(02) 4564 5380 | [email protected] | W.www.advancephysio.com.au
