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Is this a stress fracture?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Apr 5, 2012.

  1. David Smith

    David Smith Well-Known Member

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    Dear All

    My stepson's girlfriend, a young lady of 24, has been training for the London marathon but a few weeks ago she had a mild medial tibial pain that has become severe enough today to make walking, or even semi weight bearing, very painful. The painful area is the medial tibia just superior to the medial malleolus and between the ant tib and post tib tendons and extending about 50mm up the tibia. It is very tender to light touch. I would diagnose a stress fracture, she had 2 x rays two weeks apart but they both were negative to fracture. The attending physio said "it might be a ligament or something, so wait and see how it goes":bang: Anyway I have recommended a bone scan or MRI. There are no other painful tissues. Do you think this is likely to be a stress fracture?

    Dave Smith
  2. Dave:

    This is likely a medial tibial stress fracture or medial tibial stress syndrome. In most cases, pain with walking or semi-weight bearing means medial tibial stress fracture. You had better prepare her for the fact that she, unfortunately, likely won't be doing the marathon.

  3. Dave,

    Agreed with you and Kevin.

    I once suffered a BAD case of MTSS. It actually took over a year to dissipate after stopping running (Military). Kept me up at night for months and made me yell if it was even lightly palpated. Even the heating in a car or sock pressure would start the nagging pain!

    Nothing on X-Ray a month apart. "it is bruising and soft tissue" was the conclusion of the Medic and Physio, yet i could barely walk.

    A podiatrist i visited in desperation had non of it, Insisted on an MRI and we had the conclusion.... Stress fractures of the tibia (what a surprise). The area of calcification is still tender to this day after longer walks etc.

    The Podiatrists professional and common sense approach led to me entering our Profession as it happens.

    The pain was acute when provoked and had a dull ache constantly. When ever there is a definite focal tenderness when palpating the tibia, and the characteristic ache, i always suspect the possibility of stress fracture or osseous "Activity".

    I don't know about the experience of others, but it tends to follow with the runners that i have treated, that if the pain is focal and acute on light palpation, followed by discomfort the following day after rest then a period of enforced/relative rest and refraining from aggravating activities is required for 4-6 weeks as a minimum?

    This is with orthoses correction.

    If the area is slightly tender or sore only after activity and recoups within a few hours i tend to consider it likely that soft tissue and mild if any bone involvement presents and is more easily and quickly treated.

    Let us know as i find Tibial Stress Syndrome very interesting from a personal perspective also:)
  4. DTT

    DTT Well-Known Member

    Hi Dave
    I agree with Kevin Also, If you look at the " john Bishop week of Hell Sport Releif challange" on the last leg of the last marathon he sustained a Tibial Stress Fracture and expressed the same symptoms of pain on examination as you are describing. He ran the last ( I think 10 miles) in a splint:eek:
    I cant find the exact you tube vid for it but I'm sure if you google it you can get the part with the examination , symptoms and TX from the full video.
    Hope that helps my friend
  5. David Smith

    David Smith Well-Known Member

    Yeah thanks Kevin, Steve and Del

    I had decided on stress fracture, the signs and symptoms were all right but I had not seen one that low on the tibia before, on the other hand there are no other tissues there that could be symptomatic apart from periosteum.

  6. Dave:

    Actually, tibial stress fractures and MTSS are most common at the junction between the middle third and distal third of the tibia....at the area of the tibia with the lowest area moment of inertia (i.e. cross-sectional diameter/thickness). With bending moments being placed on long bones, which area will bend the most and have the most stress? The portion of the long bone with the smallest area moment of inertia.

  7. I actually missed the distal nature originally in the post, have to absolutely agree that focal point tenderness at around 6 - 8cm is usual, as per literature and Prof kirby Precision Intricast collection:cool: states. Normally however you can actually feel that it is bone/fascia as you move the tendons and palpate the anterior edge of the Tibia?

    Can you get them to a bone scan to aid our education :D

  8. Dr. Steven King

    Dr. Steven King Well-Known Member

    Aloha Steve,
    The US military is trying to do something about this common painful pathology. Stress fractures cost our US Army over $100 million per year on treatment and off duty time.
    -fellow stress fracture victim

    SITIS Archives - Topic Details
    Program: SBIR
    Topic Num: A11-109 (Army)
    Title: Advanced Composite Insoles for the Reduction of Stress Fractures
    Research & Technical Areas: Biomedical


    Acquisition Program: Office of the Principal Assistant for Acquisition
    Objective: To develop a composite boot orthotic that will decrease the risk of musculoskeletal overuse injuries and increase ambulatory performance by reducing loading rates, while increasing energy storage and energy return.

    Description: Musculoskeletal injuries of the lower legs are a primary problem in military populations. Injury rates during military training range from 1-16%, and up to 30% in elite infantry units (1). Specific injuries include stress syndrome, muscle sprains, ankle sprains, knee pain, and metatarsal stress fractures (2). Some of the risk factors associated with high injury rates include high running mileage and high amounts of weekly exercise, both examples of movements where an individual is exposed to high repetitive impact forces. Footwear selection plays a major role in the injury risk of the musculoskeletal system. Current military boot applications require stiff thick sole and midsole materials to protect from puncture wounds. Heavy rubber and rigid polyurethane foams are used in most military boots. Under impact testing, military footwear (jungle and leather combat boots) has been shown to have less shock-absorbing capabilities than traditional footwear (3). As a result, extra layers of soft foam have been needed in boots as insoles to reduce repetitive impact shock and stress fractures. Although these materials provide some protection against excessive impact, they also increase the weight and height of the footwear. An increase in boot height can have a negative effect on balance and increase peak pressures in sensitive areas of the foot, both which can increase the risk of injury. An increase in boot weight will speed up the onset of fatigue on an individual, again increasing the risk of injury through the increase of inadvertent falls as a result of a Warfighter’s failing to lift their feet to avoid obstacles on an uneven terrain. In summary, the current military boot contains a cushioning system which causes excessive stress on the metatarsal heads, ankle and knee joints. Efforts to mitigate this lack of cushioning increase the weight of the boot (4), which can be correlated to increased fatigue, which can lead to inadvertent falls and more injuries. The challenge is to find an innovative solution that will decrease the risk of musculoskeletal overuse injuries and increase ambulatory performance by reducing loading rates, while increasing energy storage and energy return. Advanced lightweight composite materials, such as carbon fibre and Kevlar have proven to protect our vehicles and soldiers as shielding and personal body armour. The objective is to develop and test advanced composite orthotic designs that will reduce loading rates, while increasing energy storage and energy return, all while lowering the overall weight of the footwear.

    PHASE I: Phase I will include multiple concept designs and development of a working orthotic and synergistic “boot housing.” The prototype will be supported with an analysis of the predicted biomechanical performance benefits, such as the reduction of internal load and the increased energy return of the orthotic. Performance considerations for the orthotic should include: 1) outperforming ASTM F2412-05 puncture standards; 2) reducing outsole and midsole weight of combat boots by >10%; 3) reducing injury risk by >10%; 3) a significant decrease in oxygen consumption; 4) be fire retardant; and 5) increase subjective comfort ratings by 10% when compared to traditional combat boot. Phase I will also include a feasibility evaluation that will address practical factors, such as useful life expectancy of the orthotic, and manufacturing costs.

    PHASE II: Finalize Phase I design and perform multiple biomechanical evaluations of the different prototypes, which may result in revisions to the prototype. Specific biomechanical testing will include: 1) muscle activation (EMG); 2) kinetics & kinematics (e.g., joint angles, angular displacements, and moments); 3) pressure distribution; 4) oxygen consumption (VO2); 5) impulse; 6) comfort; and 7) impact testing. Revised prototypes will be further assessed using biomechanical methods for validation and functional effectiveness. A prospective study will also be executed to add credibility to the reduction of injury risk claims. Sourcing solutions for mass production should also be validated in this Phase.

    PHASE III: The end result of Phase-I/Phase-II research efforts will validate applications and further develop synergistic orthotic boot coverings (uppers and soles). The advanced orthotic system and accompanying boot and shoe systems will be integrated into the current service uniforms for the military and paramilitary government entities including all branches of the military, Homeland Security, fire and police departments, and NASA. The commercial applications will continue with incorporation of orthotic technology in prosthetics, braces, and crutch systems used for the treatment of neurologic and diabetic wounds by the Veterans Administration and general public.

    References: 1. Kenton R. Kaufman PhD, Stephanie Brodine MD, and Richard Shaffer PhD. Military training-related injuries: Surveillance, research, and prevention. American Journal of Preventive Medicine. Volume 18, Issue 3, Supplement 1, April 2000, Pages 54-63. 2. Hinz P, Henningsen A, Matthes G, Jäger B, Ekkernkamp A, Rosenbaum D. Analysis of pressure distribution below the metatarsals with different insoles in combat boots of the German Army for prevention of march fractures. Gait Posture. 2008 Apr;27(3):535-8. 3. Williams, Karen M. ; Brodine, S. K. ; Shaffer, R. A. ; Hagy, J. ; Kaufman, K. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA. Biomechanical Properties of Infantry Combat Boot Development. National technical Information Service, US department of Commerce, 1997. 4. 2000: Stefanyshyn D J; Nigg B M, Energy aspects associated with sport shoes. Sportverletzung Sportschaden : Organ der Gesellschaft für Orthopädisch-Traumatologische Sportmedizin 2000;14(3):82-9.

    Keywords: Combat Boots, Advanced Composite Materials, Injury Risk, Energy Return, Biomechanics, Stress Fractures
  9. David Smith

    David Smith Well-Known Member


    After not being able to get a bone scan or MRI without at least a two week wait for an appointment at the local hospital :bang: she returned to Birmingham and went to A&E there with my referral and request and they confirmed a stress fracture and at present she has been put in a cast. NB after she had been in the Aircast boot for 3-4 days, before returning to Birmingham, she reported that the painful symptoms were much reduced.

    Dave Smith
  10. DTT

    DTT Well-Known Member

    Glad shes on the mend Dave :drinks
    cheers Mate
  11. Dr. Steven King

    Dr. Steven King Well-Known Member


    I have thought lately if the term "Stess Fracture" should be called a "Strain Fracture"?

    Because only after strain is achieved do we really have a fracture.

    Bone (or composite materials) are often subject to stress and when they finally reach UTS and change shape is when can we call it a "fracture".

    The fact that strain means relative change in shape or size implies that it is dimensionless and has no units.

    Stress, on the other hand, has dimension of force per unit area, or, less often, force per unit length.

    Ultimate tensile strength (UTS), often shortened to tensile strength (TS) or ultimate strength,[1][2] is the maximum stress that a material can withstand while being stretched or pulled before failing or breaking.

    If an attenuated tendon can be called a strain then why not an attenuated bone?

    A Hui Hou,
  12. David Smith

    David Smith Well-Known Member

    I see your reasoning but I would stick with stress fracture since it is the stress that causes strain and therefore fracture.
  13. David Smith

    David Smith Well-Known Member

    BTW My now stepdaughter was fine after treatment.
  14. Lab Guy

    Lab Guy Well-Known Member

    David , it's about time your back from vacation!

  15. Dr. Steven King

    Dr. Steven King Well-Known Member

    Mahalo Dave,

    I am happy to hear your loved one is "mo bettah".

    I do not want to take on the establishment with this concept of stress vs. strain. It is just fun concept to consider with knoweledgeable collegues such as yourself.

    But strain implies stress, because how else do you cause a strain without placing an object under stress?

    A hui hou,
  16. Lab Guy

    Lab Guy Well-Known Member

    I agree. If I understand correctly, it is the repeated stress, the internal forces within the bone that are battling the external loads that is causing deformation (strain). It is true there is a direct relationship between stress and strain. Yet, when we speak of causality, stress is the cause and strain is the effect.

    Forces cause tissue damage/deformation. Deformation or Strain does not cause Force. Strain is not going to cause a stress fracture.

  17. Dr. Steven King

    Dr. Steven King Well-Known Member

    Good Logic Steve,

    It is important to realize what stress and strain truely are defined as and perhaps i could leave "stess fracture" be as it is,,,or call it a "strained fracture" because that is what it is.

    But how then can we ever use the term strain in our diagnoses (ie tendon strain, groin strain) if it was caused by stress? I guese the term "groin stress" would be a bit too scary of a diagnosis for folks.

    A Hui Hou,
  18. Lab Guy

    Lab Guy Well-Known Member

    I understand where you are coming from and you have a point. I my opinion, I think its important to use the most appropriate terms clinically that best describes the injury. I think using the word stress for injury to bone is best as bone has a higher elastic modulus than tendon, it is stiffer. When we see a bone fracture, we think not of strain but of stress, of forces causing that that fracture.

    Tendon and ligaments are viscoelastic structures and when they are injured beyond the yield point, they are lengthened, they deform which initiates the cascade of inflammation to the area.

    Deformation or Strain is much more descriptive of injuries to soft tissue even though the stress is behind the injury. Bone undergoes compression loading/shortening and the trabecula produces compressive stress to resist the shortening. For injuries to bone, Stress seems the more appropriate term to use clinically.

    Tendons and ligaments undergo tension loading and tensile stress within the tendon/ligament prevents the structure from being pulled apart. Clinically you see lengthening, attenuation of the tendon fibrils. Strain seems a more appropriate term than stress for soft tissue injuries.

  19. David Smith

    David Smith Well-Known Member

    Groin strain is a vague statement of the pathological change in a non specific tissue and even if it were more precise e.g. adductor brevis strain it is still the expression of pathological change in tissue status.

    Whereas Stress Fracture is a statement about what caused the pathological change.

    The former requires an additional statement for the reader to know what caused the strain even tho, in this case of course, the implication of the statement is clear since there is only one causal option.

  20. Steven, David and Colleagues:

    I would basically agree with your analysis here Steven, however, I think we should clarify terminology for those following along.

    Stress, in engineering terminology, is defined as a force acting over a given cross-sectional area of tissue. For example, if a 100 N external tension load is placed across a tendon that has a 1.0 cm^2 (read 1 cm squared) cross-section, then the tension stress at that area of tendon would be 100 N/cm^2.

    Strain, in engineering terminology, is defined as a dimensionless number representing the deformation of a tissue subjected to external loads. For example, if a 100 mm long tendon is subjected to an external tension load that causes it to lengthen to be now 102 mm, then the strain would be 2%, or .02.

    In regards to stress fractures, external loads cause both internal stresses (i.e. forces) and internal strains (i.e. deformations) within the bone that can, over time, lead to microscopic or macroscopic disruption of the bone. Saying that stress fractures are due only to increased stress is not totally accurate and saying that stress fractures are due only to increased strain is not totally accurate since "stress" and "strain" are two separate measurement parameters that, for each biological structure, are dependent upon each other through their stress-strain behaviors. It would be better to say that stress fractures are due to increased stress and strain within bone.

    In regards to the term, muscle strain, this is a medical term and not an engineering term. Muscle strain is defined as a muscle injury due, usually, to increased tensile forces. In general, ligamentous injuries are known as "sprains" and muscle injuries are known as "strains", by conventional medical terminology.

    Please don't confuse medical terminology that has been used over the decades and is still in use within many medical disciplines with more precise physics/engineering terminology that can be mathematically quantified and has quite strict definitions. Their meanings are quite different, depending on their use.

    Hope this helps.:drinks
  21. Dr. Steven King

    Dr. Steven King Well-Known Member

    Mahalo Kevin,

    A very insightful reply.

    "In regards to the term, muscle strain, this is a medical term and not an engineering term. Muscle strain is defined as a muscle injury due, usually, to increased tensile forces. In general, ligamentous injuries are known as "sprains" and muscle injuries are known as "strains", by conventional medical terminology.

    Please don't confuse medical terminology that has been used over the decades and is still in use within many medical disciplines with more precise physics/engineering terminology that can be mathematically quantified and has quite strict definitions. Their meanings are quite different, depending on their use."

    Perhaps we can continue to press for conventional historic medical terms to be more "mathematically quantiable" by using "the more precise physics/engineering terminology".

    Either way this has been an informative thread,,Thanks Dave and Crew.

    A Hui Hou,
  22. Lab Guy

    Lab Guy Well-Known Member

  23. Dr. Steven King

    Dr. Steven King Well-Known Member

  24. Lab Guy

    Lab Guy Well-Known Member

    If i have a patient present with a fracture of the 5th metatarsal caused by an inversion ankle sprain then how does your statment apply when the peroneal tendon remains intact?


    I may be incorrect in my understanding as I am not an engineer. The way I understand it is that strain is dimensionless, strain is measured on the amount or percentage of shortening or lengthening.

    The Peroneus Brevis tendon has a lower Elastic modulus than the base of the 5th metatarsal. The tendon can deform more, it can elongate more before reaching the plastic deformation and failure resulting in a rupture.

    The base of the 5th metatarsal bone can avulse due to the tension from the insertion of the PB tendon pulling on its insertion. Since the elastic modulus of the bone is higher, it is stiffer, less elastic, more prone to go to failure and fracture especially when loaded abruptly and forcefully in an inversion injury. Bone is more brittle and shortens/lengthens very little which is why the bone fractures when it goes beyond its zone of optimal stress.

    Perhaps your patient's humors are in balance but he or she just wasn't paying attention walking over the curb.

    Patients are not too interested in an explanation as they are in getting healed. Tell your patient he has a fracture and needs a BK cast to prevent the PB distracting the fragment. He will be happy.

    Have a good weekend.

  25. Dr. Steven King

    Dr. Steven King Well-Known Member

    Mahalo Steve,

    I will apply your cure and also suggest that the patient goes on a low Black Bile diet and refrains from walking on any surfaces with curbs in the future.

    A Hui Hou,
  26. Lab Guy

    Lab Guy Well-Known Member



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