Evidence-Based Treatment and Outcomes of Tibial Bone Stress Injuries

Abstract

Abstract: Bone stress injury (BSI) of the tibia is relatively common in athletes and is a spectrum of impairments that include medial tibial stress syndrome (MTSS), tibial stress reaction, and tibial stress fracture. Identification of nutritional, hormonal, and biomechanical risk factors is crucial to prevent persistent or recurrent injury. A basic and important mechanical risk factor, especially in those with chronic or recurrent injury, may be subtle to severe abnormalities in gait and ankle flexibility. MRI injury grading can provide a framework for expected healing time; treatment must be individualized and evolution of a patient's symptoms should guide the progression to return to sport after a prescribed period of rest. The vast majority of tibial BSIs can be managed nonoperatively and surgery is largely reserved for those who have undergone exhaustive conservative management without success, those with multiple recurrences, or high-level competitive athletes with the most severe grades of injury. The current review aims to highlight current concepts in the treatment of tibial BSI, with a particular focus on the high-risk population of adolescent athletes. Key Concepts:•Management of tibial bone stress injuries (BSIs) centers around rest from the offending activity and the identification and correction of any contributing nutritional, metabolic, or biomechanical risk factors.•Treatment must be individualized, and complete clinical resolution of symptoms should precede return to activity.•Anterior cortex-based tibial stress fractures, with a radiographic finding often referred to as the “dreaded black•line,” and other high-risk BSIs may require up to 4-6 months of relative rest or surgical treatment.•Recurrent tibial BSI is common and gait/neuromuscular training may be especially helpful in preventing chronic and repeated injury.•In athletes with high-grade tibial BSI refractory to conservative treatment, surgical fixation such as intramedullary nailing and tension band plating can be considered. However, complication and re-operation rates may be relatively high.