The anatomy and biomechanics of the tibia play a critical role in the development and management of tibial stress fractures. Posterior calf musculature and the relative anterior tibial avascularity lead to a high rate of nonunion, delayed union, and fracture in â€œhigh-riskâ€ tension-sided anterior tibial cortex stress fractures. Fracture location at the compressive side of the tibia and the abundant vasculature are favorable characteristics in â€œlow-riskâ€ posteromedial tibial stress fractures. The differential diagnosis of patients with overuse injuries of the leg includes stress fracture, medial tibial stress syndrome, exertional compartment syndrome, popliteal artery entrapment syndrome, and multiple nerve entrapment syndromes, among others. Risk factors for tibial stress fracture include prior stress fracture, recent increases in training intensity and/or duration, improper training technique or equipment, the female athlete triad, calcium and vitamin D deficiency, and inadequate caloric intake. The history and physical examination of a patient with a tibial stress fracture generally indicates focal point tenderness at the site of the fracture, unremitting pain with weight-bearing activity, and pain with hop and tuning fork testing. Magnetic resonance imaging is the imaging modality with the best diagnostic sensitivity and specificity. Non-operative treatment is generally successful in low-risk posteromedial tibial stress fractures. Surgical treatment, including reamed intramedullary rodding and anterior tension-band plating, is a successful treatment for chronic anterior mid-diaphyseal tibial fractures that have failed nonsurgical treatment. These procedures have produced high union rates, low complication rates, and early return to sport.
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