Rev. bras. ortop. vol.48 número6

rev bras ortop.2013;48(6):574–577

w w w . r b o . o r g . b r

Case

Report

Segmental

Stress

Fracture

of

Tibia

in

Recreational

Running:

A

Case

Report

夽

,

夽夽

Alexandre

de

Paiva

Luciano

,

Nelson

Franco

Filho

,

Fernando

Adami

,

Luiz

Carlos

de

Abreu

a_{DepartmentofMedicine,UniversityofTaubaté,Taubaté,SP,Brazil}

b_{StudyGrouponSportsArthroscopyandTraumatology,UniversityHospitalofTaubaté,Taubaté,SP,Brazil}

c_{OrthopedicsandTraumatologyService,UniversityHospitalofTaubaté,Taubaté,SP,Brazil}

d_{ABCSchoolofMedicine,SantoAndré,SP,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received13August2012

Accepted19October2012

Keywords:

Fractures,stress

Tibia Running Athletes

a

b

s

t

r

a

c

t

Oneofthefirststepstobetakeninordertoreducelesionsinsports,suchasstressfractures,

istoknowthenatureandextensionofthispathology.Whatfollowsisacasereportof

segmentalstressfractureofthetibiainrecreationalathletes,whichisconsideredsomewhat

rareintheliterature.Casereport:a40-year-oldfemalepatientwhostartedtohavefollow-up

medicalchecksduetounusualpaininherrightleg,concentratedmainlyontheproximal

regionofthekneeandankle,aftera10-kmrunforaperiodofonemonth.Segmentalstress

fractureofthetibiawasdiagnosedafterclinicalresearchandfurtherexaminations.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.Allrightsreserved.

Fratura

por

estresse

segmentária

na

tíbia

em

corredora

recreacional

Palavraschave:

Fraturasdeestresse

Tíbia Corrida Atletas

r

e

s

u

m

o

Osprimeirospassosparasereduziremlesões,comoafraturadeestressenoesporte,é

conhecereaprofundaroestudodanaturezaeaextensãodessapatologia.Aseguir,

apre-sentamosumrelatodecasodefraturaporestressesegmentardatíbia,consideradorarona

literaturaconsultada.Descric¸ãodoquadroclínico:trata-sedepacientede40anos,feminino,

queiniciouseguimentomédicopordoresincaracterísticasnapernadireita,concentradas

principalmenteemregiãoproximaldojoelhoedotornozelodireitos,duranteapráticade

corridaderuade10kmhaviaummês.Apósinvestigac¸ãoclínicaepormeiodeexames

complementares,diagnosticou-sefraturadeestressesegmentardatíbia.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Todososdireitosreservados.

夽_{Pleasecitethisarticleas:dePaivaLucianoA,FilhoNF,AdamiF,deAbreuLC.Fraturaporestressesegmentárianatíbiaemcorredora}

recreacional.RevBrasOrtop.2013;48:574–577.

夽夽

WorkdoneattheDepartmentofOrthopaedicsandTraumatology,DepartmentofMedicine,UniversityofTaubaté,Brazilandthe

DisciplinesMethodologyofScientificResearchandScientificWriting,SantoAndré,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:alexandrepaiva76@ig.com.br(A.dePaivaLuciano).

2255-4971/$–seefrontmatter©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

rev bras ortop.2013;48(6):574–577

575

Introduction

Withthegrowingconcernforhealthandqualityoflifethat

hasbeenseen particularlyoverthe lasttwodecades,

ever-greaternumbersofpeopleareseentobedoingexercise.This

hasledtoaconsiderableincreaseinthefrequencyof

diag-nosesofstressfractures.Theseinjurieshaveanundesirable

effect,sincetheyreducethebenefitsrelatingtosportsandact

asabarrieragainstmaintaininghealthandqualityoflife.

Thefirststeptowardsdiminishingsportsinjuriessuchas

stressfracturesistohavein-depthknowledgeofthenature

andextentofthesepathologicalconditions.

Inthefollowing,wepresent acasereportonsegmental

stressfractureofthetibia.

Description

of

the

Clinical

Condition

The patient was a 40-year-old woman born and living in

Taubaté(SP).Shesaidthatshehadbeenpracticingrunningin

thestreetsforsixmonthsandshewascurrentlybeing

accom-paniedbyasportsadviser.Hertrainingwasdividedintofour

sessionsperweek,namely:a“regenerative”runonMondays;

“sprint”trainingonanathleticsrunningtrackonWednesdays,

“pace”trainingonFridays;andlongtrainingorcompetitions

atweekends.Thepatientwasdoingregularsportspractice,

butsaidthathervolumewasgraduallyincreasingandthat

shehadstartedhigh-intensitytrainingonanathleticsrunning

tracktwomonthsearlier.

Shestartedtohavemedicalfollow-upduetounusualpain

inherrightleg,concentratedmainlyintheregionoftheright

kneeandankleduring10-kmpracticerunsonemonthearlier.

Shesaidthatshehadnotbeenmaking chronicuseofany

medications,hadnothadanyprevioussurgeryandhadnot

hadanypreviouslydiagnosedchronicdiseases.

On physicalexaminationat the timeof admission, she

weighed65kg,herheightwas1.72mandherBMIwas21.97.

Shedidnothaveanypathologicalfascies.

Evaluation of the type of static and dynamic steps:

pronatedsteps.

Physicalexaminationoftheknee:

• Inspection:knees withphysiologicalvalgusinfrontview,

withoutrecurvatuminlateralview;withoutanyincreasein

volume.

• Bone palpation: medial tibial plateau painful on

palpa-tion,butwithoutpainonpalpationofthemedialfemoral

condyle.

• Palpationofsofttissues:medialcollateralligamentpainful

onpalpationatitsinsertioninthetibia.Sartorius,gracilis

and semitendinosusmusclespainfulattheirinsertionin

thetibia.

• Jointstabilitytests:negative.

• Meniscaltests:negative.

• Patellofemoraltests:negativeforpatellofemoralsyndrome.

• Degreeofmobility:extension0◦,flexion135◦,internaland

externalrotation10◦_.

Physicalexaminationontheankle:

• Inspection:pronatedsteponwalkingandrunning.

• Bonepalpation:medialstructures–painonmedial

palpa-tionofthedistaltibia;lateralstructures–nopain.

• Palpation ofsoft tissues: regions of interest – Zone III –

medialmalleolus:deltoidligament,tendons:posteriortibial

tendon,longflexorofthetoesandlongflexorofthehallux

freefrompain;ZoneIV–dorsumofthefootbetweenthe

malleoli:tendons:anteriortibialtendon,longextensorof

thehalluxandlongextensorofthetoesfreefrompain.

• Anklestabilitytests:negative.

• Degreeofjointmobility:dorsiflexion20◦,plantarflexion50◦,

subtalarinversion5◦_{andsubtalareversion5}◦_.

Basedon the physicalexaminationdescribed above,we

continued the diagnostic investigation and the search for

associatedpathologicalconditionsbymeansofthefollowing

examinations:

• Radiologicalexaminations:radiographsandscanometryon

thelowerlimbs–withoutsignificantalterations;rightlower

limb:920.1mm;leftlowerlimb:920.4mm(Fig.1).

• BonedensitometryonApril23,2010(Fig.2):patternwithin

normalityfortheproximalregionofthefemur.

576

1.42

1.18

0.94

40 60 80 0

2 100

2.0

0.0

–2.0

–4.0 0.70

Age (years)

BMD g/cm

2

L1-L4 Comparison with references

T

value

Osteoporosis* Osteopenia* Normal*

Figure2–Bonedensitometry.

• MagneticresonanceimagingoftheankleonApril23,2010

(Fig.3).

• MagneticresonanceimagingofthekneeonApril23,2010

(Fig.4).

Discussion

Insportspractice,stressfracturesareclinicalentitiesthatalso

fitintothewell-knownoverusesyndrome.1,2

The etiology of stress fractures can be best described

asacceleratedboneremodelinginresponsetosubmaximal

repetitivestress.Thebonerespondsandformsnewperiosteal

boneasanextrareinforcement.However,iftheosteoclastic

activitycontinuestoexceedthemeannumberofosteoblasts

fornewboneformation,afractureinthecorticalbonemay

eventuallyoccur.3

Therisksoffractureduetostressareinfluencedbyvarious

factorsandaredividedintointrinsicfactors(sex,age,ethnicity

andmusclestrength),extrinsicfactors(trainingregimen,type

offootwearused,trainingsurfaceandtypeofsport),

biome-chanicalfactors(bonemineraldensityandbonegeometry),

anatomicalfactors(footmorphology,leglengthdiscrepancy

andknee alignment), hormonalfactors(delayedmenarche,

menstrualdisordersandcontraceptives)andnutritional

fac-tors(calciumandvitaminDdeficiencies,fooddisordersand

thefemaleathletetriad).2,3

Studieshaveshownthatfemaleathletespresentgreater

numbersofstressfracturesthanshownbymen.3,4

Stressfracturesgenerallyoccuringroupsofyoung

indi-vidualswhoaresubjectedtointensephysicalactivities,such

asmilitaryrecruits,dancers,runnersandathletesingeneral.

This typeof fracture occurs mainly inbones of the lower

extremities,such asthe metatarsus,fibula, calcaneus and,

mostfrequently,thetibia.5

Thetibiaisthecommonestsiteforstressfracturestooccur

inathletes.Thelocationofthefracturesvariesaccordingto

thetypeofsportpracticed.Inrunners,fracturesarefoundat

thetransitionfromthemiddletodistalthird.5

Thedifferentialdiagnosisshouldincludebothmiddletibial

stress syndrome (MTSS) and chronic compartmental

syn-drome(CCS).6

Magneticresonanceimagingmayalsodiagnosestress

frac-turesatanearlystage.Thesignsareboneedema,whichmay

Figure3–Radiologicalexaminationsshowinganareaof hypersignalonT2weightedimage,inthedistalregionof therighttibia,withsolutionofcontinuityintheposterior corticalbone,whichmaycorrespondtoastressfracture.

befoundintheregionanteriortothetibialcorticalbone,inthe

bonemarrow,orevenafractureline,asinthecasedescribed.7

Intheinitialphaseofthetreatment,itisrecommended

thatspecificphysiotherapeuticmeasuresshouldbeusedto

reducethepainfulcondition,suchascryotherapy,TENS,

ultra-sound toaccelerate bone tissue productionand laser as a

healing method. In addition, anti-inflammatory drugs are

used to reduce prostaglandin synthesis, which is

respon-sible for activating the free nerve ends that take sensory

informationtothebrainandincreasetheperceptionofpain.8

rev bras ortop.2013;48(6):574–577

577

Figure4–AreaofhypersignalonT2weightedimage,inthe proximalregionoftherighttibia,withsolutionof

continuityintheposteriorcorticalbone,whichmay correspondtoastressfracture.

includedassoonasthepainfulconditionhasbeenreduced.

Thus,lower-limbexercisesareinitiallydoneinaclosedkinetic

chainandtheninanopenkineticchain.9

Stressfractures thatare consideredtopresent highrisk

shouldbetreatedsurgically,giventhatthechancesofsuccess

withconservativetreatmentarelow.10

Intheliteratureinvestigated,wefoundcasesofbilateral

stressfracturesinthelowerlimbs.11_{However,wedidnotfind}

casesofsegmentalfractures ofthetibia, which provesthe

rarity ofthe casereportedhere.Likethe majorityofstress

fractures,thefracturesdiagnosedinthiscasewereconsidered

tobelow-riskcasesandweretreatedassuch.Thiscasewas

conductedinaccordancewithaprotocoldescribedinthe

liter-ature,withtwophasesoftreatment.10_{Phase1ischaracterized}

bypaincontrolthrough medicalprescriptionofanalgesics;

reductionorcessationofsportsmovementsthatcause

symp-toms;andintroductionofphysiotherapeuticmethods.Phase

2ischaracterizedbythemeasuresofPhase1plusagradual

returntosport;inthisphase,correctionofpredisposing

fac-torsisimportant(typeoffloor,typeofsteps,biomechanics

ofrunningandregularrenewaloffootwear).Phase2begins

whentheathleteisfreefrompainandpresentsnormal

nobil-ity,around10–14daysafterthestartofsymptoms.Thetime

takentoreturntosportsmovementsdependsonmany

fac-tors,includingtheseverityandchronicityoftheinjuryand

theathlete’sfunctionalmorbiditylevel.10

Conflicts

of

Interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.WardenSJ,HurstJA,SandersMS,TurnerCH,BurrDB,LiJ.

Boneadaptationtoamechanicalloadingprogram

significantlyincreasesskeletalfatigueresistance.JBone

MinerRes.2005;20(5):809–16.

2.NattivA,PufferJC,CasperJ.Stressfractureriskfactors,

incidence,anddistribution:a3yearprospectivestudyin

collegiaterunners.MedSciSportsExerc.2000;32Suppl5:S347.

3.LavienjaAJ,BraamLM,MarjoHJ,KnapenGeusensP,BrounsF,

VermeerC.Factorsaffectingbonelossinfemaleendurance

athletes.Atwo-yearfollow-upstudy.AmJSportsMed.

2003;31(6):889–95.

4.WarrenMP,PerlrothNE.Theeffectsofintenseexerciseonthe

femalereproductivesystem.JEndocrinol.2001;170(1):3–11.

5.JensenA,DahlS.Stressfractureofthedistaltibiaandfibula

throughheavylifting.AmJIndMed.2005;47(2):181–3.

6.YatesB,WhiteS.Theincidenceandriskfactorsinthe

developmentofmedialtibialstresssyndromeamongnaval

recruits.AmJSportsMed.2004;32(3):772–80.

7.ProvencherMT,BaldwinAJ,GormanJD,GouldMT,ShinAY.

Atypicaltensile-sidedfemoralneckstressfractures:thevalue

ofmagneticresonanceimaging.AmJSportsMed.

2004;32(6):1528–34.

8.MollonB,daSilvaV,BusseJW,EinhornTA,BhandariM.

Electricalstimulationforlongbonefracture-healing:a

meta-analysisofrandomizedcontrolledtrials.JBoneJoint

SurgAm.2008;90(11):2322–30.

9.BodenBP,OsbahrDC,JimenezC.Low-riskstressfractures.

AmJSportsMed.2001;29(1):100–11.

10.BodenBP,OsbahrDC.High-riskstressfractures:evaluation

andtreatment.AmAcadOrthopSurg.2000;8(6):344–53.

11.SciberrasN,TaylorC,TrimbleK.Bilateraldistaltibialstress

fracturesinamilitaryrecruit.BMJCaseReports.2012,