How to Prevent Tibia Stress Fractures

Call us at 281-633-8600.  If you’re a basketball player or a runner or you’re involved in an activity that places repeated stress on your lower legs, you may be heading for a stress fracture.  In this video, Dr. J. Michael Bennett describes the anatomy of the leg, and he talks about how repetitive stresses on the leg can cause periostitis and shin splints or tibia stress fractures.  He also talks about the need to treat periostitis and stress fractures early on and to determine the causes of the stresses being placed on the lower leg.

Dr. J. Michael Bennett is a Board Certified Orthopedic Surgeon and a Fellowship-Trained Sports Medicine Physician with a Certificate of Added Qualification (CAQ) in Sports Medicine.  He serves patients from Richmond, Katy, Sugar Land and Metro Houston from offices in Sugar Land and Houston.

The topic of tibia stress fractures is timely because of the recent serious injury of University of Louisville basketball player, Kevin Ware.  Press reports indicate that Kevin Ware’s compound fracture of the tibia or shinbone may have been caused by an undetected stress fracture.

Here’s Dr. J. Michael Bennett:

This is a transcript of the Tibia Stress Fracture video:

Hello, my name is J. Michael Bennett. I’m a Board Certified Orthopedic Surgeon who specializes in sports medicine, primarily arthroscopic and minimally invasive surgery of the shoulder, elbow and knee.

Today were going to talk a little bit about stress fractures. There is been a lot of buzz going around about the most famous stress fracture which occurred approximately one week ago with Kevin Ware of the Louisville Cardinals. He sustained what we call an open fracture of the tibia, also known as a compound fracture. There are a number of ways you can have a fracture of the tibia, but when it breaks the skin it’s considered a compound fracture which is a very serious injury.

There are ways to minimize or prevent these types of injuries from happening. The key with these types of injuries is to identify it early and to make sure that you see your orthopedic surgeon and you come up with a plan to prevent abnormal stresses across the tibia, particularly when you’re doing a repetitive, active sport like running or basketball, or where you have a repetitive activity performed over and over and over again. What happens is that you have these loading stresses across the tibia that’s overloading the bone’s ability to basically heal itself. These repetitive stresses are building, building, and building up, and the bone is trying to heal quickly enough, but sometimes it overloads that ability to heal and then you get what’s called a stress fracture.

So this is basically a very crude drawing of the tibia and fibula bone. The tibia is right here and this is also known as the shinbone. And then the fibula is over here and this is the outside bone that help support the tibia in the lower leg. This is the front view and then this is the side view. These are usually the two views that we will get on x-ray when we’re evaluating a patient for tibial stress syndrome or also known as shin splints, or if were concerned about a stress fracture.

Typically the area that were concerned about is this distal one third of the tibia and what typically happens in a patient with stress issues across the tibia is that you’ll get an inflammation of the lining of the bone and the bone has this lining called periosteum. That lining of the bone can become easily inflamed by these repetitive stresses. You’re not going to see anything on an x-ray. This is going to be something that you’ll feel and describe to your doctor. A lot of times you’ll see a little bit of swelling in this area and have some point tenderness in this area on your physical exam.

So the key is to make sure that you treat it appropriately to prevent it from getting worse. If this periostitis does not go away or does not get better, you definitely want to see a doctor to get an x-ray. What we look for on an x-ray is, when you have a repetitive stress, that has not been treated or diagnosed or has not been allowed to heal, you can get evidence of a stress fracture.

Now sometimes on an x-ray will see a little bit of abnormality across the bone like a little bump like that across the bone, where the bone is trying to heal and trying to build up and heal across those stresses. Occasionally on the x-ray, we’ll see a little black line there. We call that the dreaded black line. We get an x-ray of that and we see this area, this is an indication you have a stress fracture.

On both views you’ll typically have this abnormality so you’ll see a lump here with that little black line across that area. So what happens if you do not treat this appropriately early on, that little black line can propagate and eventually it can split across and go all the way across the tibia. And what will happen if you go out and play and don’t treat this accordingly, is a that you’ll develop a fracture at the distal third of the tibia, and you’ll have a broken bone.

So it is key that you do need to be evaluated by an orthopedic surgeon to make sure that number one, you get the correct diagnosis and you get treated early, and number two, you have a physician repetitively following you to make sure this heals completely before you’re allowed to return to full sports and activities.

Now what causes this problem? This is a very common problem in regards to the periostitis, but it’s less common to see the stress fractures. However we are still seeing this in a certain demographic of patients, and it seems to be a little bit younger than they used to be. And it may have to do with the increased year-long sports and activities, and also the fact that these just aren’t being diagnosed early enough.

Now what causes it? There’s a couple of things. Number one, it could be a structural issue meaning that those stresses across the tibia are occurring because there’s an abnormal amount of stress occurring in that distal third due to an abnormal stress pattern across the tibia because to a structural issue. What can happen or what some patients have, everybody’s different with regard to their leg shape and their foot shape, but what makes the big difference is the shape of the arch of your foot.

Basically you can have a couple of different types of arches here. And these are just three here that I’m drawing primarily. This is just a side view of a foot. I know it looks a little abnormal and I apologize for it. But this is when a person’s weight bearing on the ground, and this is a high arched patient. If they are weight-bearing and they stand up and they have a good arch there, that means that you do not have a collapsible arch and you don’t have flat feet, but you do have a high arch.

This is called a neutral arch here, and this is where the arch collapses. When you stand up the whole arch collapses. What that does, if you look at a person when they’re standing up, it overloads the lower leg. This is basically just somebody’s foot here turning outward. But this is showing you the collapsed arch portion here of their foot. And it increases the stress across the lower leg. This is just a very crude drawing here. Just basically to understand that the arch collapsing is something to take seriously and that’s when you want to consider something like an orthotic.

Another way to to diagnose a collapsed arch or flat foot, aside from just looking at your feet when you’re weight-bearing is to look at the bottom of your shoe. If you look at the bottom of your shoe when there is a certain wear pattern on the bottom of the shoe and it’s more worn on the outside of the shoe than on the inside of the shoe, then you’re running on the outside of your foot and you’re probably more likely to have a high arch here. So it might be a good idea to look into getting an orthotic to help balance out your foot when you’re running.

You have more wear on the inside of your shoe, that means you may have a flexible flat foot that’s wearing out the inside of your shoe and these are the patients that you need to definitely consider some sort of orthotic to give you that medial support for the arch to give you a more stable arch when you’re running, because you do not want to overload the bones and tendons along the inside of the foot.

Now that is a structural issue. That is an imbalance across, the stresses across the knee and the leg and that something to evaluate and have your orthopedic surgeon evaluate, and that’s one possible cause of the stress fractures. Now number two, it could be a metabolic or an endocrine issue which could be secondary to a couple of things. Number one is calcium levels, number two is vitamin D levels, and number three is a possibility of parathyroid issues. These three help the bone heal and help normalize your levels with regards to healing potential within the bone itself

If you have an early black line here, a stress fracture, it’s important that your physician talk to you about what causes that stress fracture. They may diagnose it and say you have a stress fracture and you stay off of it for a period of time and you get better. Well the problem is that you still don’t know why you got it. It could be the way your arches are in your foot, it could be the way you’re running, it could be the fact that you have low calcium or low vitamin D, or issues with your parathyroid. These are all things that need to be worked up and evaluated because if you don’t treat the underlying cause for the stress fracture, you’re going to continue having problems and you’re going to continue going back for treatment.

Typically with these fractures if you’ll catch them early enough it can be a very easy treatment of using protected weight-bearing as well as a modification of your activities and using a special boot that allows you to stabilize this area to allow it to heal. Sometimes even a bone stimulator can be used, where it’s a device that you put on the outside of this fracture that helps increase your healing capacity, and you wear it a couple of times a day to increase your healing at this fracture site.

So it’s very key that you make the diagnosis early and that you be evaluated by an orthopedic surgeon and that you find out what is the cause of your stress fracture, so that it doesn’t propagate and become a full fracture. So that being said, that really is the basics behind this. There’s a lot more detail regarding stress fractures. If you do have this problem, I suggest being evaluated by an orthopedic surgeon or sports medicine specialist.

That being said if you do have a fracture that does break, the treatment for that fracture is an intramedullary rod that you put a rod down the shaft of the tibia, this is the front view, this is the side view here, to actually bring those bone fragments together to allow them to heal. And that’s a very standard procedure that we do plenty of in orthopedics, but the key is to prevent it from getting to that point

So like I mentioned before, if you’re having these symptoms that aren’t resolving I suggest that you go get evaluated by your orthopedic surgeon and maybe get some x-rays and evaluation and get a diagnosis early, so you can prevent these problems from getting worse in the future.

If you have questions, please feel free to visit my website at and or feel free to call my office at 281-633-8600. Thank you very much.


Dr. J. Michael Bennett

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