Tibial stress fractures are the most common stress fractures in athletes, but their symptoms are often confused with other disorders of the lower part of the leg, like compartment syndrome and inflammation of shin-muscle tendons. How can you tell if you might have a tibial stress fracture?
Bear in mind that stress fractures can sometimes be troubling to diagnose.
Routine X-rays often fail to detect them, and a more costly procedure called a bone scan must frequently be performed in order to confirm the presence of truly traumatised bone tissue. In a bone scan, radioactive material is injected into the blood. Bone tissue which is ‘remodelling’ and rebuilding itself at the site of a stress fracture will accumulate more of the infused radioisotope, compared with normal bone, and the affected bony area will show up as a dark splotch on a ‘scintigram’.
The pain produced by a stress fracture is ordinarily quite different from that caused by a compartment syndrome, for example (compartment syndrome is a condition in which pressure builds up in one of the compartmentalised sections of a leg during activity; the spike in pressure can produce pain, numbness, and weakness in the affected area). Sometimes called ‘crescendo pain’, stress fracture pain tends to build up gradually during the act of running, beginning as an annoying irritation and becoming a throbbing torment as an athlete continues to run(1). There is usually little of the numbness, weakness, and swelling associated with compartment syndrome, and pain is usually not present to a significant degree when the athlete is at rest. Sometimes, there is a specific point of tenderness in the lower leg, which is often felt on the inside of the calf when deep pressure is applied with the fingers. Often, the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site.
If the problem is not a stress fracture but rather inflammation of the tendons of the shin muscles (tendinitis), the pain is often quite diffuse, running up and down the lower part of the leg along the tibia. It is true that tendinitis can mimic a stress fracture by producing crescendo pain, but tendinitis discomfort is often less localised than stress-fracture pain and usually can’t be produced simply by tapping on the bone. With shin tendinitis, there is usually none of the numbness associated with compartment syndromes. Naturally, if your shin-area pain is a continuing problem, you should seek the advice of a sports-medicine doctor.
If you do develop a stress fracture, don’t just rest until symptoms of the fracture lessen, and then blithely resume your training. Stress fractures are usually not accidents – they happen for a reason, and you must try to identify the source of your problem. Your stress fracture could be the result of your increasing the intensity or volume of your training too quickly, before you have developed the strength and fatigue-resistance to handle such training effectively. Alternatively, your stress fracture may be the simple result of overtraining – carrying out far more training than your tibias could ever hope to handle. Naturally, improper nutrition may be a cause of stress fractures, or in some cases a partial cause; if you develop a stress fracture, you should have a nutritional analysis carried out to see if your diet is deficient in protein or in key bone-building minerals such as calcium and magnesium. You may also want to consider having your sex-hormone levels checked, since low concentrations of testosterone or oestrogen may increase the risk of stress fracture.
Tibial stress fractures are definitely not fun. They can stop training in its tracks, they are painful, and, while it is often said that they require two to three months to heal, the reality is that up to six months may be needed to restore the bone to normalcy and remove most traces of pain, and some athletes may require a year or more for full recovery. Thus, prevention of tibial stress fractures is key, and the best prevention includes the consumption of a nutritionally adequate diet, avoidance of too-rapid increases in the volume and intensity of training, and the utilisation of special exercises which promote the fatigue resistance of shin muscles (remember that your shin muscles are less able to protect your tibias when they are tired).
Here are several shin-muscle strengtheners which you can employ regularly in your training to help decrease your risk of tibial-area problems:
To carry these out, simply stand with your back to a wall, with your heels about the length of your feet away from the wall. Then, lean back until your buttocks and shoulders rest against the wall. Dorsiflex both ankles simultaneously, bringing the tops of your feet toward your shins, while your heels remain in contact with the ground. Bring your toes as far toward your shins as you can, and then lower your feet back toward the ground, but do not allow your forefeet to contact the ground before beginning the next repeat. Simply lower your feet until they are quite close to the ground, and then begin another repetition.
Once you have finished about 30 repetitions, maintain your basic position with your back against the wall, dorsiflex your ankles to close-to-their-fullest extent, and then quickly plantar flex and dorsiflex your ankles 30 times over a very small range of motion (much smaller than the nearly full range you use for the basic repetitions; the emphasis should be on great quickness, while maintaining coordination). These short, quick, ankle movements are called ‘pulses’.
Complete about 30 repetitions and then 30 pulses of the wall shin raises, without hesitating in between. You will very likely notice a fair amount of shin-muscle fatigue as you do this, which is an indication that the strength and fatigue resistance of your shin muscles needs some reinforcing. Rest for about a minute (walking around and shaking your legs to ease the tightness in your shins, if necessary), and then repeat the 30 basic repetitions and 30 pulses. Perform this overall routine a couple of times each week (it can be easily incorporated into your warm-ups, for example).
As your shin muscles improve their strength and fatigue resistance, you may progress with the exercise over time by increasing the number of sets and repetitions. Your ultimate progression will be to begin carrying out the exercise on one leg at a time.
Walk quickly and briskly on your heels for about 20 metres, with your toes pointed straight ahead. Then, without hesitation, rotate your legs outward at the hips so that your toes are pointing outward (duck style), and walk for 20 more metres, high up on your heels. Quickly, rotate your legs inward at the hips so that your toes are pointing inward (knock-kneed style), and walk expeditiously on your heels for 20 more metres. Rest for a minute, and repeat the routine.
On a very soft and forgiving surface, hop forward for about 10 metres on your right heel, taking quick, small hops and preventing the bottom of your right foot from hitting the ground (stay back on your right heel). As you do this, keep your upper body loose, relaxed, erect, and coordinated, and do not look down at your foot. Rest for a moment, repeat, and then carry out the same routine with your left foot. Once you are really skilled with the exercise, you may also hop on your heels with toes pointing in and out and use a weighted vest for added resistance.
Stand in a relaxed and comfortable position, with your feet directly under your shoulders and your knees slightly flexed. Then, bound forward about 12 to 15 inches, landing on your left heel only and remaining stationary once you have landed. As you land, keep your right foot off the ground, and try to prevent the bottom of your left foot from touching the ground; you should be supporting your body weight on your left heel area. Next, push off the ground with your left heel, and bound forward onto your right heel, again maintaining a stationary position once you land and keeping full body weight on your right heel area (don’t let the bottom of your right foot touch the ground).
Continue in this manner until you have covered about 15 metres, using erect body posture at all times and avoiding eye contact with your feet. As you improve your ability to carry out this exercise, you may increase the distance of your bounds and your overall speed of motion. Make sure that you begin this exercise on a very forgiving surface (sand, soft dirt, grass, a ‘tuned’ gym floor, etc).
Using a sturdy bench or box about six to 10 inches in height, begin by standing on the edge of the structure with the front portions of your feet over the edge (the edge of the platform will be just behind the middles of your feet, so that your toes are angled just slightly downward). Keep your knees slightly bent and your arms relaxed at your sides. Drop – don’t jump or step – from the elevated surface to the ground. To drop, simply let your feet slide off the edge of the platform. As you descend toward the ground, prepare for landing by flexing your legs lightly at your knees and hips, and cock your elbows back. As your feet hit the ground, instantaneously jump forward as far as possible, land on both feet, and maintain a relaxed, stationary position (that completes one rep). You should try for maximal intensity and effort in your jump, and also the shortest-possible ground-contact time. Start with just one set of five reps for the first few times you do this exercise, and progress to a greater number of sets and reps over time.
The ultimate progression with this exercise, of course, is to carry it out on one leg at a time (for example, you would stand on your platform with your right foot only, slide off, land on the right foot, and then explode forward, landing on your right foot and holding your position). This exercise should improve shin-muscle strength and also promote better bone density in your tibias.
If you would like to use these exercises to improve your shin strength and protect your tibias, don’t rattle them all off on your first day! The exercises are challenging, and each puts a certain amount of controlled stress on your tibias; doing them altogether without prior experience might be too stressful for your poor shin bones. Instead, try each of the exercises on separate days (as mentioned, they can be easily incorporated in your warm-ups), and then gradually increase the number of exercises you do on a single day. Once you feel comfortable completing the quintet during one workout, you may use the ensemble of five exertions a couple of times per week and achieve a great protective effect.