Tibial Stress #

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I would appreciate management opinions on the following case.
14 year old multi-eventer with a 3 year history of tibial stress # ( 6 in total) over the anterior aspect of the left tibial mid-shaft. Recur on pole vaulting training, and running training.

She goes into POP for 6 weeks, followed by Rest and Ice Rx. She returns to activity only to break down again.

Mechanically, of note she ahs a slight genuvarum/tibiovarum, and moderately ligament lax. she has no soft tissue tightness of any lower limb muscle group, and all resisted musculature strength was normal.

Her rcsp is mildly pronated, and not at EROM.

She is a forefoot striker when she runs/pole vaults. She cannot change her technique, as she is right handed ( with respect to carrying the pole).

I cannot determine a mechanical cause to her recurrence, or a mechanical solution, so can I beg some advice from the forum?

I will enclose an X-ray tomorrow

 

Peter - you may have answered your own question:

Check the menstrual history.

 

I agree with Craig that menstrual history must be checked. Stress fractures have a higher incidence in amenorrheic females compared to normally menstruating females.

Also stress fractures in the anterior cortex of the tibia are prone to delayed or non-union (look for the ‘dreaded black line’ on plain x-ray). If conservative measures fail after 6 months (including immobilisation, correcting biomechanical, nutritional and metabolic risk factors and ultrasonic bone stimulation where accessible), a surgical opinion should be sought. Stress fractures of the anterior cortex are a completely different kettle of fish to posterormedial stress fractures.

 

Peter:

I don't agree that period irregularities are the probable main cause of this young lady's problems. She has at least 2 other problems.

1. Doing too much high intensity exercise/sports at a young age before her bones are fully matured. Parents should be counseled on not pushing their child too hard and pushing her right out of the sport due to frustration caused by increased frequency of injury.

2. Forefoot striking, especially in high varus forefoot positions, will increase abduction bending moments on tibia and lead to medial tibial fractures. Are the injuries on the anterior or medial crest of tibia?

If she is in varus at forefoot striking, simple addition of forefoot varus wedges to her track spikes will probably greatly decrease her injury frequency. Video analysis would be quite helpful here. See my lecture on medial tibial stress syndrome and medial tibial stress fractures to better understand the pathomechanics of these injuries.

Hope this helps.

 

Thanks Chaps for your advice. Her stress # is on the anterior tibial crest.

The X-ray is too big to post on here.

Anyone up for a PM with X-ray?

 

Peter:

Here is the x-ray of your patient so everyone can see it.

 

I agree with Kevin. From personal experience, being a 400m hurdler with tibial stress fracture. A forefoot extrinsic varus wedge would be more than ideal with the valgus bending stress that goes throughout the tibia, especially on synthetic track. I would possibly just use a 350 density EVA
While she cannot change her technique on the actual vault, I would also view her stride, to make sure she isn't overstriding. I would say there would be an inc. risk of shin related injuries in vaulters and hurdlers, and abnormal stress through the tibia with an athlete that places their foot strike infront of the body in attempt to maintain a stride pattern.
Tell her to keep her chin up, they're not much fun for a track athlete!

regards, Mike

 

Unfortunately it looks like the dreaded black line to me. If you can be confident that you've exhausted conservative treatments for this girl and she doesn't suffer from metabolic/nutritional/mentrual problems, then she really needs to see a surgeon. The poor girl has been suffering for 3 years.

 

Peter:

Unfortunately, for your patient, she appears to have a anterior tibial mid-shaft stress fracture which are very prone to nonunion and fracture recurrence. They often require extraordinary measures to allow return to activity, including bone grafting or tibial rodding in some cases.

Here is a good discussion of this hard-to-treat injury.

http://www.postgradmed.com/issues/2002/02_02/perron.htm

 

Dr Kirby and Kent,

Thank you for your quick responses. As I posted previously, I could not elicit any overt mechanical cause, and to have this clarified is great.

 

sorry to pitch in late on this thread but have just read back through it and had the following question:


If she is in varus at forefoot striking, simple addition of forefoot varus wedges to her track spikes will probably greatly decrease her injury frequency

For athletes who use orthoses in there training shoes, with or without a forefoot varus extention, would you use this modification in there spikes in combination with any other shoe modification i.e. scf cobra pad! or (in your experiance) is this enough on its own for the above example?

I would anticipate that a runner used to this level of support would feel unsupported in there spike with just the forefoot extention!

 

Gareth:

In a track spike, I would add a varus forefoot extension and also a modified cobra style insole modification to give some varus support to the heel and support to the medial longitudinal arch to work along with the varus forefoot extension.

 

Thank you for your reply!:good: I will try it down the track tomorrow night and see how it feels (no better clinical example than on your own feet).

regards

G