As a runner, you know the hunger for pushing your limits. The feeling of pushing past what you thought your body could do is intoxicating. But nothing can bring your training to a grinding halt faster than a tibial stress fracture. That’s why runners often feel the hairs on the back of their neck stand up when they start to feel tibial stress fracture symptoms. At Alterra, we specialize in getting runners back on track, quite literally. Today, let's dive into the world of tibial stress fractures - those sneaky injuries that can derail your training plans faster than a surprise hill at the Boston Marathon. Whether you're preparing for your first 5K or your tenth marathon, understanding the symptoms, causes, and treatment of these fractures is crucial for every runner's toolkit. So lace up (mentally, at least) and let's explore how to keep your shins happy and keep you on the road.
A tibial stress fracture is a type of bone stress injury (BSI) where a fracture line is present on imaging, but the warning signs of a stress fracture often present themselves before this occurs. Bone stress injuries are graded from 1-4, and the grades are based on how much edema is visible on imaging on both the outside of the bone and in the bone marrow. A tibial stress fracture is considered a grade 4 BSI. (1)
Tibial Stress Fracture Symptoms
Common tibial stress fracture symptoms are pain in the lower third of the posterior medial aspect of the shin that is likely tender to touch and does not “warm up” or get better with activity. If the pain spans greater than or equal to 5 cm, it is considered medial tibial stress syndrome (a.k.a. Shin splints), and if it spans less than 5 cm, it is more likely to be a tibial bone stress injury or stress fracture. (2) These injuries will often hurt during AND after running, even when standing or walking, and will be alleviated by getting off your feet. While this is the most common location, tibial stress fracture symptoms can also present in the front of the tibia or on the tibia closer to the knee joint, however these are rare.
Imagine you’re looking downwards at your shin and your foot is at roughly 12 o'clock. The posterior medial aspect of your tibia is at around 7 o'clock on your right side, or 5 o’clock on your left.
While not all pain in this location is due to a BSI or tibial stress fracture, all pain in this location should be assessed by a professional because the potential downside of missing this diagnosis is huge. A missed tendinopathy diagnosis can lead to a more flared up tendon that takes longer to heal, while a missed tibial stress fracture diagnosis can lead to a full fracture that requires surgery to fix. On top of that, even professionals can miss this diagnosis.
I had a patient in the clinic who was experiencing pain in the upper part of her tibia near the knee joint that her doctor diagnosed as bursitis. This is not a common location for a bone stress injury, so that diagnosis was logical. However, after taking this patient’s history and doing a thorough evaluation, I was convinced that it wasn’t bursitis, and I wanted her to get imaging just to be sure. When she eventually got an MRI, it was confirmed that she had a grade 3 bone stress injury. We caught it before it turned into a true fracture thankfully, but even professionals can get this one wrong, so don’t guess!
If you think you may have a stress fracture or bone stress injury, act like you do until it is ruled out and seek medical attention. Running and even sometimes walking on a stress fracture is dangerous and can lead to a full fracture, which can mean months of rehab before getting back to running.
Training Causes of Tibial Stress Fractures
To put it most simply, bone stress injuries happen because of repetitive stress on bone tissue that eventually starts to break down. This type of injury happens frequently to military recruits and runners, often because of the sudden increase in weight bearing activity. Risk of developing a bone stress injury is higher with sudden increases in activity level than overall or absolute activity level. (1)
This applies to how many miles, the frequency of runs, AND intensity of the workouts. In other words, doing a tough track workout when you haven’t done speed work in a long time can still cause problems even if the overall mileage is comparable to your recent training.
Contrary to popular belief, tibial stress fractures are not so much caused by the impact of the body on the ground. (3) Moreso, they are caused by the pulling force of the calf muscles on their bony attachments. This may be why running on softer surfaces doesn’t completely eliminate the risk of developing a stress fracture because the muscles still have to work just as hard on softer surfaces to maintain efficiency.
Nutritional Causes of Tibial Stress Fractures
Think of bones as a reservoir of minerals (i.e. calcium). Our bodies tightly regulate calcium, so when we don’t eat enough calcium, our body takes it from our bones. Additionally, inadequate nutrition can cause decreased presence of hormones like testosterone, estrogen, and growth hormone, all of which have a direct impact on the formation of bone. There is a robust body of evidence connecting inadequate fueling with decreased bone mineral density, and therefore bone stress injuries.
The international olympic committee (IOC) published a consensus statement about relative energy deficiency syndrome (REDs), which highlighted the connection between underfueling and a bunch of physiological consequences including decreased bone health. (4)
Some of the things that I see in the clinic that makes me want to investigate nutrition further with a client are:
History of BSI or stress fracture
Amenorrhea (loss of period) for females
Low sex drive/decreased frequency of morning erections for males
History of GI upset/IBS
Runners on a restrictive diet of any kind (vegan, low FODMAP, keto, etc.)
Frequent illness
Low energy
Treatment of Tibial Stress Fractures
Treatment of tibial stress fractures requires a complete cessation of running activities for a variable length of time based on the severity of the injury. The chart below is based on research by Hoenig et al about average time to return to sport based on BSI grade.
The reason why tibial stress fractures are so difficult to recover from is because they require you to stop running. If the thought of not running leaves a pit in your stomach, you understand why this is a hard recovery. With tendinopathy, there is some wiggle room with continuing to run while rehabbing. But with tibial stress fractures, complete cessation of running activities is necessary, and sometimes even requires the use of crutches to off weight the injured leg to allow the bone to heal. That is why early detection and prevention are key.
While rest is ultimately the most effective treatment strategy initially, the next phase of treatment is about very slowly and gradually reintroducing weight bearing exercise to the system. When tolerated, these athletes should start performing bone building exercises like strength training under loads that are heavy enough to stimulate an increase in bone mineral density.
I’ve talked to people dealing with stress fractures who were just given a walk-run progression by their physician and were told that they do not need to follow up again. In my professional opinion, this oversimplified approach is a recipe for re-injury. Having a closely monitored return to running plan with referral to a sports nutritionist as needed is essential to ensure that you are responding well to the plan, and that adjustments do not need to be made.
When healthy, performing strength training, fueling properly, and making smart training decisions to gradually increase your workload are the three most effective strategies for you to decrease your risk of developing a stress fracture, tibial or otherwise.
Final Thoughts on Tibial Stress Fracture Symptoms
Tibial stress fractures are serious injuries, but armed with this new knowledge, you are more prepared to manage your risk by:
Making smart training decisions by using a plan or working with a trustworthy coach
Incorporating strength training into your routine to build strong bones with help from our strength training for runners ebook
Listening to your body and looking out for the symptoms of a tibial bone stress injury to ensure early detection.
Ensuring you are adequately fueling your body for the demands that it is subjected to
At Alterra, we specialize in helping runners get to the root cause of their injuries so that they can stay on track with their training and enjoy running without pain. If you're a local runner in Boston's Back Bay and are experiencing some tibial stress fracture symptoms, we'd love to help! Book a free discovery call to chat with a therapist today.
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Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.
Sources
Warden SJ, Davis IS, Fredericson M. Management and prevention of bone stress injuries in long-distance runners. J Orthop Sports Phys Ther. 2014;44(10):749-765. doi:10.2519/jospt.2014.5334
Milgrom C, et al. Medial tibial stress fracture diagnosis and treatment guidelines. J. Sci. Med. Sport. 2021; 24(6): 526 - 530.
Matijevich ES, Branscombe LM, Scott LR, Zelik KE (2019) Ground reaction force metrics are not strongly correlated with tibial bone load when running across speeds and slopes: Implications for science, sport and wearable tech. PLoS ONE 14(1): e0210000. https://doi.org/10.1371/journal.pone.0210000
Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br. J. Sports Med. 2023;57:1073-1098.
Hoenig T, Tenforde AS, Strahl A, Rolvien T, Hollander K. Does Magnetic Resonance Imaging Grading Correlate With Return to Sports After Bone Stress Injuries? A Systematic Review and Meta-analysis. AJSM. 2022;50(3):834-844. doi:10.1177/0363546521993807
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