Diagnosis and treatment of medial tibial stress fractures

How can they be diagnosed and treated effectively and timely?

Medial tibial stress fractures (MTSF) occur with lengths of tibial tenderness up to ten cm. Although the hop test seems to be a sensitive tool to establish the presence of an MTSF, the fulcrum test does not appear to have an association with the presence of stress fractures. Moreover, self-reported pain scores are not predictive of medial tibial stress fracture. These findings were derived from a prospective study conducted by an Israeli research group among military personnel.

It was found that MTSFs occur with lengths of tibial tenderness up to ten cm. The usual threshold of 5 cm of tibial tenderness, which is commonly used to differentiate MTSS and MTSF, is not supported by the findings in this study or by existing literature.

The hop test had a sensitivity of 100 percent, specificity of 45 percent, a positive predictive value of 74 percent, and a negative predictive value of 100 percent considering the presence of pain and tenderness, with an odds ratio of 57.52. Conversely, the fulcrum test did not appear to have an association with the presence of stress fracture. Self-reported pain scores were not predictive of medial tibial stress fracture.

In case of requiring a bone scan, the rest periods were as follows: grade I – 1 week; grade II – 2 weeks; grade III – 4 weeks; grade IV – 6 weeks. When managed according to protocol, symptoms resolved in two thirds of the cases.


> From: Milgrom et al., J Sci Med Sport 24 (2021) 526-530 (Epub ahead of print). All rights reserved to Sports Medicine Australia. Click here for the online summary.

Expert opinion

Anyone who has suffered or treated someone affected even if it's only by MTSS, knows how debilitating and hard to treat it can be. Thus, this study provides a really useful evidence-based resource on how to diagnose and manage medial tibial pain. Additionally, it helps highlight the fact that commonly used clinical measures such as the 5 cm of tenderness are a result of tradition and not necessarily actual evidence.

It is worth noting, however, that the study population was composed of military personnel, which is a population with specific needs and mindset. The results may therefore not be entirely generalisable to other populations. Nevertheless, this algorithm is definitely nice to have ready to consult when dealing with cases of medial tibial pain.

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