Most stress fractures are managed conservatively with rest and restricted weight-bearing, and a gradual return to sport. Athletes with a high-risk stress fracture often do not respond to conservative management and may require surgical intervention.
Tibial Stress Fracture - Treatment
Tibial stress fractures (also known as fatigue fractures) are generally uncomplicated and respond well to conservative treatment. The most important principle in treating any stress fracture is to employ rest and weight-bearing restriction for as long as needed to allow the symptoms to resolve (1,2).
However, stress fractures known as high-risk stress fractures (HRSFs) may require a more aggressive approach because of the limited potential for these fractures to heal with non-operative measures.
Treatment of low-risk stress fractures
Posterior tibial diaphysis stress fractures (posterior TDSFs) are located at the compression side of the tibia when it bends during loading, and they heal well with conservative management because the compressive forces induce osteogenesis, promotes stability, and makes nonunion unlikely.
The most important principle in treating posterior TDSFs is to employ rest and limited weight-bearing for 2-6 weeks until symptoms have resolved (3,4). Once the pain resolves, the individual may gradually increase weight-bearing and start low-impact exercises, such as stationary cycling, swimming and running in water.
When such activities are performed pain-free, the athlete may progress to using an elliptical trainer (cross-trainer) and running on a treadmill with handrail support. Once the patient can perform low-impact activities for prolonged periods without pain, high-impact activities may be initiated, including running and sports specific training (2,4).
Exercising should always be performed with limited pain, and progression between exercises should be guided by symptoms
Treatment of high-risk stress fractures (HRSF)
A systematic review from 2015 found that over 70 % of anterior tibial diaphysis stress fractures (anterior TDSFs) required operative intervention (3). Of the 111 anterior TDSFs treated surgically, 96 % returned to sport. Most of these had tried and failed conservative treatment before surgery (3).
Despite a high-risk of failure with conservative treatment for anterior TDSFs, the general principle is to attempt an initial period of conservative management for up to 6 months with non-weight-bearing (with or without immobilization), to see if union is achieved (2,3). If symptoms fail to resolve, operative intervention should be considered. Elite level athletes may be exceptions to this, and early surgical intervention is often considered (2,4).
If union has not been achieved within six months of conservative management, surgical treatment should be considered (2,3). Various surgical techniques are being used, including intramedullary nailing (metal rod through the tibia), plate fixation (metal plate covering the fracture), and excision and drilling (2,3). Postoperative physical therapy with a gradual increase in weight-bearing is recommended by most studies (3). After surgery, the average time to return to play is 10-16 weeks (2).
Several studies show that supplemental use of a pneumatic brace (aircast) can allow athletes to return to activity sooner (3). By unloading and stabilizing the tibia at the site of the stress fracture, the brace seems to hasten healing time.
Maintaining some level of activity is essential to reduce the negative impact that the injury will have on the athlete's overall physical fitness. Loss of physical fitness can be reduced with appropriate cross training, and it is recommended that athletes keeps in contact with their trainer and physical therapist about appropriate ways to exercise and how to progress tibial loading as symptoms improve.
The choice of training should be based on the type of injury, the severity of the symptoms, sport specific demands and the athlete's preferences.
Reduce known risk factors
In order to avoid a relapse, the athlete should work on reducing known risk factors for tibial stress fractures. In addition to appropriate load management, there are many factors that may be addressed, some of which are described below.
Optimizing your diet
A good diet including an adequate caloric intake is important for bone health, especially in women. Therefore, any caloric deficit and associated hormonal disorders should be addressed (read more about the Female Athlete Triad). In addition, the athlete should ensure adequate calcium, vitamin D, and protein intake. Several studies show protective effects of vitamin D and calcium supplementation among female recruits (5,6).
Active smoking and history of smoking seems to increase the risk of stress fractures, however, some studies have inconsistent results (7). The detrimental effect on smoking on tissue healing and bone health is, however, well documented (7).
Running surface and footwear/insoles
Many of the known risk factors for tibial stress fractures, such as running/marching on hard surfaces, high peak hip adduction during gait, poor foot pronation/higher, and pes cavus foot alignment are believed to limit shock absorption and inducing higher strains on the tibia (2,4,8).
Several studies show that shock-absorbing footwear/insoles have a preventive effect among soldiers (8,9). The age of the footwear also seem to matter, possibly due to loss of shock absorption (9).
It is still unclear as to what extent footwear matters in the development of tibial stress fractures in runners. The general recommendation is to run with comfortable shoes that provide adequate shock absorption.
Increasing hip muscle strength
Studies have shown that athletes with high peak hip adduction during running have a higher risk of developing a tibial stress fracture (10,11). Several researchers note that increased peak hip adduction likely places higher strains on the tibia.
Hyperadduction of the hip have been linked to a reduction in hip abduction strength (12), however, the connection between hip abduction muscle strength and risk of developing tibial stress fractures is still unclear. A greater degree of hip adduction during running may simply be related to running kinematics and not to a muscular strength deficit, which is better targeted with gait retraining.
Increasing the muscular strength of the hip abductors, especially when there is a known strength deficit, may improve shock absorption and is recommended for some athletes (2).
Preventing a relapse
The main cause of bone stress injuries, including tibial stress fractures and medial tibial stress syndrome, is increased training loads coupled with inadequate rest. Rest should be included in the training planning as an equally important part of the training regime as the training itself.
Matcuk, G. R., Mahanty, S. R., Skalski, M. R., Patel, D. B., White, E. A., & Gottsegen, C. J. (2016). Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emergency radiology, 23(4), 365-375.
McInnis, K. C., & Ramey, L. N. (2016). High‐risk stress fractures: diagnosis and management. PM&R, 8, S113-S124.
Robertson, G., & Wood, A. (2015). Return to sports after stress fractures of the tibial diaphysis: a systematic review. British medical bulletin, 114(1), 95-111.
Boden, B. P., Osbahr, D. C., & Jimenez, C. (2001). Low-risk stress fractures. The American journal of sports medicine, 29(1), 100-111.
Lappe, J., Cullen, D., Haynatzki, G., Recker, R., Ahlf, R., & Thompson, K. (2008). Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. Journal of Bone and Mineral Research, 23(5), 741-749.
Tenforde, A. S., Sayres, L. C., Sainani, K. L., & Fredericson, M. (2010). Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature. PM&R, 2(10), 945-949.
Schwellnus, M. P., Jordaan, G., & Noakes, T. D. (1990). Prevention of common overuse injuries by the use of shock absorbing insoles: a prospective study. The American journal of sports medicine, 18(6), 636-641.
Gardner Jr, L. I., Dziados, J. E., Jones, B. H., Brundage, J. F., Harris, J. M., Sullivan, R., & Gill, P. (1988). Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. American journal of public health, 78(12), 1563-1567.
Milner, C. E., Ferber, R., Pollard, C. D., Hamill, J., & Davis, I. S. (2006). Biomechanical factors associated with tibial stress fracture in female runners. Medicine & Science in Sports & Exercise, 38(2), 323-328.
Milner, C. E., Davis, I. S., & Hamill, J. (2005). Is Dynamic Hip And Knee Malalignment Associated With Tibial Stress Fracture In Female Distance Runners?: 1823 2: 45 PM-3: 00 PM. Medicine & Science in Sports & Exercise, 37(5), S346.
Popp, K. L., McDermott, W., Hughes, J. M., Baxter, S. A., Stovitz, S. D., & Petit, M. A. (2017). Bone strength estimates relative to vertical ground reaction force discriminates women runners with stress fracture history. Bone, 94, 22-28.
Luedke, L. E., Heiderscheit, B. C., Williams, D. B., & Rauh, M. J. (2015). Association of isometric strength of hip and knee muscles with injury risk in high school cross country runners. International journal of sports physical therapy, 10(6), 868.
Taylor‐Haas, J. A., Hugentobler, J. A., DiCesare, C. A., Lucas, K. C. H., Bates, N. A., Myer, G. D., & Ford, K. R. (2014). Reduced hip strength is associated with increased hip motion during running in young adult and adolescent male long‐distance runners. International journal of sports physical therapy, 9(4), 456.
Verrelst, R., Willems, T. M., De Clercq, D., Roosen, P., Goossens, L., & Witvrouw, E. (2014). The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study. Br J Sports Med, 48(21), 1564-1569.