How Do You Treat a 21-Year-Old Basketball Player Who Has Magnetic Resonance Imaging Evidence of Tibial Diaphyseal Edema Not Resolved After 3 Months of Protected Weight Bearing?
Shane J.
Nho,
MD, MS
Jeremy A.
Alland,
BA
The patient is a 21-year-old male basketball player who originally presented with magnetic resonance imaging (MRI) evidence of tibial diaphyseal edema. The edema is unresolved after 3 months of protected weight bearing. It is suspected that the patient is experiencing a stress fracture of the tibia.
The tibia is the most common site for a stress fracture, representing as much as 75% of the total occurrence in certain patient populations. A study in 2005 reported Finnish military recruits as a high-risk population for stress fractures, appearing in as much as 64% of the population.1 The general athletic population has a relatively low incidence (<1%), but the subpopulation of runners has an incidence of approximately 20%.1 The vast majority appear as transverse fractures; however, longitudinal fractures do occur.
Risk factors can be caused by genetic abnormalities or can be developed through overuse. Congenital and developmental factors, such as smaller tibial width and knee malalignment, have been shown to be associated with stress fractures.
Tibial stress fractures are classified as either low risk or high risk based mostly upon the specific location of the injury. Low-risk fractures appear on the posterior medial tibia, representing an injury due to compression. A low-risk injury is unlikely to progress to complete failure. High-risk fractures are less common and appear in the middle third of the anterior cortex, representing an injury to the tension aspect of the tibia. High-risk injuries often progress to complete failure and result in significant further injury if untreated.2
The physician should first take a detailed history of the patient to aid in the differential diagnosis. It is important to discuss how long the patient has been symptomatic and to get a description of the pain. Determine the intensity of the pain, the location, what makes it worse, and what makes it better. Also discuss the patient’s daily athletic activity, both before and after the injury. Additionally, the patient’s dietary habits and supplements are also important information to obtain. For female patients, the female triad of anorexia, amenorrhea, and osteoporosis should be considered in any stress fracture.
After a sufficient history, the physician should conduct the physical exam. The physician should palpate the leg, buttocks, and lower back as the injury permits. The range of motion and strength of the limb must be examined. Also of importance is the gait of the patient; pay close attention to any compensation or abnormalities. The physician should check the distal circulation, sensation, and mobility, and stretch the patient’s toes to elicit associated pain. Lastly, laboratory tests should be obtained to determine if there is evidence of infection, blood clot, or tumor based on clinical suspicion. If the patient has had recurrent stress fractures, the physician should obtain a dual-emission X-ray absorptiometry scan and basic laboratory serum calcium, albumin, 25-hydroxyvitamin D, phosphorus, and bone alkaline phosphatase. More extensive workup should warrant a referral to a metabolic bone specialist.
A physical exam that indicates a possible stress fracture must be imaged to provide a complete differential diagnosis. In the office setting, orthogonal views using plain radiographs of the tibia can be obtained at the initial presentation (Figure 29-1). It can take over a month after the onset of pain to be reflected in a plain radiograph, and therefore, may not be diagnostic for acute injuries.3 MRI is the most effective diagnostic tool for the tibial stress fracture (Figure 29-2).
Figure 29-1. Plain radiographs of left tibia for a 22-year-old runner with distal tibial pain. (A) Anteroposterior view without evidence of fracture. (B) Lateral view without evidence of fracture.
Figure 29-2. MRI images. (A) Coronal T2-weighted image demonstrating a stress fracture at the anterior aspect of the middle tibia. (B) Sagittal T2-weighted image demonstrating increased signal in the middle aspect of the anterior tibia. (Arrow) Stress fracture.
A bone scan may also be used to confirm the diagnosis. A stress fracture shows fusiform uptake, which differs from the linear uptake of shin splints.
This patient has MRI evidence of tibial diaphyseal edema that is unresolved with 3 months of protected weight bearing. Due to the unresolved edema, shin splints can be ruled out, which should resolve with protected weight bearing. Periostitis would also resolve with protected weight bearing. The laboratory tests can provide some indication if infection, blood clot, or tumor is a potential cause of the injury. Basketball does not generally restrict the blood flow to the tibial region, which rules out exercise-induced compartment syndrome. The diagnosis is most likely tibial stress fracture. Basketball players spend a considerable amount of time jumping, which would place the patient at risk of compression side injury. A compression injury occurs at the posterior medial tibia and is considered low risk.
A low-risk tibial stress fracture rarely proceeds to complete fracture, and therefore, the treatment remains conservative with nonsurgical options. Initial treatment involves restriction of all activity to prevent weight bearing. The physician may recommend a pneumatic leg brace, which decreases force and increases venous congestion at the area of the injury.4 The patient will be prescribed analgesia with the dosage based upon weight and age. If the injury prevents proper gait, crutches can be prescribed. Other noninvasive treatment options (ie, bone stimulator, pulsed ultrasound) have not shown to improve healing from rest and weight-bearing restrictions.5,6 Low-risk fractures generally heal in 1 to 2 months, with return to play in 3 to 4 months. The symptoms, however, tend to improve in 2 to 6 weeks, and the patient may gradually return to activities when the edema and pain are resolved.
In the case of a high-risk stress fracture of the anterior tibia (tension injury), the athlete cannot return to play until the fracture is completely healed. The treatment of a high-risk injury should initially follow the same conservative options as the low-risk injury. For high-risk fractures, it usually requires 4 to 6 months to completely resolve with rest and immobilization, at which point, the patient can gradually return to play. If the conservative approach is not effective, a surgical approach may be considered. An intramedullary nailing of the tibia in cases of stress fractures has been shown to be effective in patients that were unresponsive to a minimum of 4 months of nonoperative management.7 Radiographic healing of the fracture postoperation occurs after approximately 3 months and return to play occurs around 4 months. Surgical complications include anterior knee pain and recurrence of the fracture. Intramedullary nailing has been shown to be more effective than external fixation in terms of tibial alignment, but there are no differences in infection rates and healing time.8
The 21-year-old patient may gradually return to activities with resolution of symptoms and after 2 to 6 weeks of immobilization, analgesics, and rest. If pain and swelling remain, the immobilization should be continued for a full 1 to 2 months. Without pain and swelling, the patient may return to play in approximately 3 to 4 months. The physician may indicate a return to play earlier with complete resolution of the symptoms and imaging indications. The patient should be monitored for circulation issues due to the pneumatic brace. Surgical options should be avoided for this patient if possible.
References
1. Valimaki V, Alfthan H, Lehmuskallio E, et al. Risk factors for clinical stress fractures in male military recruits: a prospective cohort study. Bone. 2005;37(2):267-273.
2. Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Management and return to play of stress fractures. Clin J Sport Med. 2005;15(6):442-447.
3. Heyworth BE, Green DW. Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr. 2008;20(1):58-61.
4. Swenson EJ, DeHaven KE, Sebastianelli WJ, Hanks G, Kalenak A, Lynch JM. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997;25(3):322-328.
5. Beck BR, Matheson GO, Bergman G, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? Am J Sports Med. 2008;37(3):545-553.
6. Rue JP, Armstrong DW, Frassica FJ, Deafenbaugh M, Wilckens JH. The effect of pulsed ultrasound in the treatment of tibial stress fractures. Orthopedics. 2004;27(11):1192-1195.
7. Varner KE, Younas SA, Lintner DM, Marymount JV. Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing. Am J Sports Med. 2005;33(7):1071-1076.
8. Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma. 1998;12(1):1-7.