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Friends,

I am treating a 32 year old female ER physician (5'4", 105lbs) who runs and swims, who a year ago ran a marathon starting with patello femoral pain at the start of the race. She ran with discomfort for most of the race. When she finished she had patello femoral pain, high tib pain oand significant medial long arch strain, especially on the medial aspect of her foot ( deltoid ligament). After recovering from the race some weeks later, she had pain the left antero lateral left tib, a couple inches below the knee. (rare). She took a great deal of time off running, doing other non weight bearing activities but upon running, it always came back.

Mechanically, straight legs, loose jointed, good ROM isn all planes and joints, no restrictions. Legs measure and appear equal. Straight strong pelvis, significant hindfoot varum, low medial arch. Forefoot to hindfoot alignment is good, although first is unstable, L and R. Very efficient and smooth. She did not wear orthotics before the marathon. but I have her in semi-rigid devices that keep her hindfoot very straight, relative to her lower leg, midfoot, medial long arch is well supported, with poron on the dorsal surface of the medial long arch.

Question: has anyone else seen a high tib stress fracture in a runner? If so, what helped?

the following are her comments as an MD:


"The MRI in October showed the bone marrow contusion/edema, but no actual stress fracture. The one in March showed the bone marrow contusion was essentially unchanged, but they now saw a stress fracture through it. They don't actually comment on how acute it looks or if there's any evidence of healing. It's anterolateral on the tibia, and just subarticular (odd location). I think this location might be prone to non-unions and can sometimes be a distraction-type injury, as opposed to the compression that you usually see in stress fractures. But, I don't know if this is the case for me or not. It also seems like an extraordinary long time for a stress fracture to heal, in my opinion, but I could be a bit biased. Also seems strange that the actual fracture has appeared over the last couple of months, when I haven't been running."

Any comments or help regarding this lady's condition will be greatly appreciated.

Best regards

Freeman Churchill, Certified Pedorthist (Canada)

 

Re: high tib stress fracture in runner

Freeman:

Glad to see you learned how to start a new thread on Podiatry Arena.;)

We had a discussion on tibial stress fractures just a few months ago.

Also here is a good review article on stress fractures.

A high fracture of the tibia, since it is likely in cancellous bone, should heal uneventfully with a couple of months of rest from impact activities (i.e. no running, no jumping). Swimming is the safest exercise initially, then easing into biking, and elliptical trainer, rowing machine and/or pool running as pain permits.

Once they can run again, watching the patient run and trying to find gait abnormalities is probably the most helpful in preventing further injuries. I believe that forefoot striking runners are much more likely to have tibial stress fractures than rearfoot striking runners.

It may also be helpful to take a good history on this runner, and other runners, as to why the injury occurred. Here is an article I wrote over a quarter century-ago as a podiatry student (my first paper ever published) on taking a proper history in runners (Kirby KA, Valmassy RL: The runner-patient history: What to ask and why. JAPA, 73: 39-43, 1983).

Hope this helps.