MEDIAL TIBIAL STRESS SYNDROME
Exercise-Induced Leg Pain | Bone Stress Continuum | Training Errors | Activity Modification
BONE STRESS INJURY CONTINUUM
Critical Must-Knows
- Clinical diagnosis - diffuse posteromedial tenderness exceeding 5cm length
- Continuum with stress fractures - same pathophysiology, different severity
- Training load errors are the most common modifiable risk factor
- MRI gold standard if imaging needed - shows periosteal/marrow edema
- Activity modification, not complete rest - evidence-based approach
Examiner's Pearls
- "MTSS pain improves with warm-up; stress fracture pain worsens with activity
- "Female athlete triad/RED-S must be screened in recurrent cases
- "Bone scan has high sensitivity but poor specificity for MTSS
- "Shock-wave therapy emerging as promising treatment modality
Clinical Imaging
Imaging Gallery
Critical Exam Points - Medial Tibial Stress Syndrome
Diagnosis
- MTSS is a CLINICAL diagnosis - imaging not required for typical presentations
- Diffuse tenderness over greater than 5cm of posteromedial tibial border
- Pain on palpation of the distal two-thirds of the medial tibial border
- Exclude stress fracture: focal tenderness, night pain, worsening with activity
Pathophysiology
- Traction periostitis from soleus, FDL, tibialis posterior insertions
- Bone stress reaction from repetitive bending loads on tibia
- Continuum from periosteal reaction through to cortical stress fracture
- Risk factors: training errors, biomechanics, low bone density, female sex
Imaging
- MRI is GOLD STANDARD - periosteal and marrow edema visible
- X-ray usually normal but may show periosteal reaction chronically
- Bone scan: sensitive but NOT specific (high false positive rate)
- CT rarely indicated - better for established stress fractures
Management
- Activity MODIFICATION not complete rest - pain-guided return
- Address training load errors - 10% rule for weekly increase
- Correct biomechanics: orthoses, footwear, gait retraining
- Screen for RED-S/female athlete triad in recurrent cases
At a Glance Table
MTSS vs Tibial Stress Fracture - Key Distinctions
| Feature | MTSS | Tibial Stress Fracture |
|---|---|---|
| Tenderness pattern | Diffuse (greater than 5cm) | Focal (less than 5cm) |
| Tenderness location | Posteromedial tibial border | Any cortex (anterior higher risk) |
| Pain with warm-up | Typically improves | Worsens with activity |
| Night pain | Uncommon | Common |
| Pathophysiology | Periosteal reaction | Cortical stress reaction/fracture |
| X-ray findings | Usually normal | May show fracture line/periosteal reaction |
| MRI findings | Periosteal edema only | Marrow edema + cortical involvement |
| Recovery time | 6-8 weeks | 12-16+ weeks (depends on grade) |
| Management | Activity modification | Complete rest from impact |
| Risk if untreated | Progression to stress fracture | Complete fracture |
Epidemiology
- Most common overuse leg injury
- 13-17% of running injuries
- Up to 35% prevalence in athletes
- Female runners 3x higher risk
- Peak incidence: 18-25 years
Risk Factors
- Training errors - sudden increase in load
- Female gender (lower bone density)
- Overpronation of foot
- Low BMI and relative energy deficiency
- Previous MTSS history
Key Clinical Points
- Diffuse tenderness posteromedial tibial border
- Pain length typically exceeds 5cm (vs stress fracture)
- Pain improves with warm-up initially
- Clinical diagnosis - imaging not always needed
- Rule out compartment syndrome if atypical
Essential Mnemonics
STRESS
Memory Hook:The STRESS on your shins - what causes shin splints!
SPLINTS
Memory Hook:SPLINTS history - shin pain is not always shin splints!
MODIFY
Memory Hook:MODIFY the approach - don't just rest!
PREVENT
Memory Hook:PREVENT shin splints before they happen!
SHINS
Memory Hook:Sore SHINS - the classic shin splints features!
FRACTURE
Memory Hook:FRACTURE - the red flags that distinguish stress fracture from MTSS!
Overview and Epidemiology
Medial tibial stress syndrome (MTSS), commonly known as "shin splints," is the most common cause of exercise-induced leg pain, affecting up to 35% of athletes at some point. It represents a stress reaction of the tibial cortex along the posteromedial border, existing on a continuum with tibial stress fractures. MTSS is a clinical diagnosis but understanding its relationship to stress fractures is critical for exam success.
Key Exam Concept
MTSS vs tibial stress fracture exists on a continuum of bone stress injury:
- MTSS: Periosteal reaction, diffuse tenderness over greater than 5cm, pain that improves with exercise warm-up
- Stress fracture: Focal cortical involvement, point tenderness less than 5cm, pain that worsens with continued exercise
Both conditions share common risk factors (training errors, biomechanics, bone health) but management differs significantly.
Critical Differentials to Exclude
Exercise-induced leg pain has several serious mimics:
Must exclude:
- Tibial stress fracture - point tenderness, worsening pain, risk of complete fracture
- Chronic exertional compartment syndrome - requires pressure testing
- Popliteal artery entrapment - vascular claudication, requires ABI/angiography
- Lumbar radiculopathy - dermatomal symptoms, neural tension signs
- Deep vein thrombosis - swelling, warmth, Homans sign
If symptoms are unilateral, focal, or include neurological/vascular features, investigate further before diagnosing MTSS.
Pathophysiology and Mechanisms
Anatomic Basis of MTSS
The posteromedial tibial border serves as the attachment site for multiple deep posterior compartment muscles:
- Soleus - via soleal line and middle third of tibia
- Flexor digitorum longus (FDL) - posterior tibia
- Tibialis posterior - interosseous membrane and posterior tibia
Repetitive traction from these muscles, combined with tibial bending stresses, causes periosteal reaction and bone stress injury at the posteromedial border - the classic "shin splints" location.
Tibial Anatomy
Posteromedial Border
- Distal 2/3 most commonly affected
- Junction of posterior and medial tibial surfaces
- Direct subcutaneous position allows easy palpation
- Attachment of deep crural fascia
- Minimal soft tissue coverage
Muscle Attachments
- Soleus - soleal line to middle tibia
- FDL - posterior tibial surface
- Tibialis posterior - interosseous membrane
- All exert traction force on periosteum
- Repetitive loading causes inflammation
Pathophysiology
MTSS vs Tibial Stress Fracture
| Feature | MTSS | Stress Fracture |
|---|---|---|
| Tenderness pattern | Diffuse (over 5cm) | Focal (under 5cm) |
| Pain with warm-up | Typically improves | Worsens with activity |
| Night pain | Uncommon | Common |
| MRI findings | Periosteal edema only | Marrow edema + cortical line |
| X-ray findings | Usually normal | May show fracture line |
| Treatment duration | 6-8 weeks modification | 6-12 weeks rest |
| Risk of progression | Low with proper management | Risk of complete fracture |
Bone Stress Continuum
Classification Systems
Fredericson MRI Classification
The Fredericson classification grades tibial stress injuries on MRI. Higher grades correlate with longer recovery times and greater activity restriction. This is the most clinically useful system for guiding return-to-play timelines.
Grade 1 - Periosteal Edema Only:
- T2-weighted signal in periosteum only
- No marrow involvement
- Recovery: 2-3 weeks
- Management: Activity modification
Grade 2 - Periosteal + Marrow Edema (T2):
- Periosteal AND bone marrow edema on T2/STIR
- No T1 marrow signal change
- Recovery: 4-6 weeks
- Management: Reduce training load 50%
Grade 3 - Marrow Edema on All Sequences:
- Marrow edema visible on T1 AND T2 images
- More extensive marrow involvement
- Recovery: 6-9 weeks
- Management: Non-impact activity only
Grade 4a - Multiple Focal Cortical Changes:
- Multiple focal intracortical signal abnormalities
- No discrete fracture line
- Recovery: 9-12 weeks
- Management: Complete rest from running
Grade 4b - Cortical Fracture Line:
- Linear cortical fracture line visible
- Highest risk of progression
- Recovery: 12-16+ weeks
- Management: Protected weight bearing, possible surgery
Higher grades require progressively longer recovery periods.
GRADES
Memory Hook:GRADES of stress injury - higher grade = longer recovery
Fredericson Classification - Quick Reference
| Grade | MRI Findings | Recovery Time | Management |
|---|---|---|---|
| Grade 1 | Periosteal edema only | 2-3 weeks | Activity modification |
| Grade 2 | Periosteal + marrow edema (T2) | 4-6 weeks | Reduce training load 50% |
| Grade 3 | Marrow edema T1 and T2 | 6-9 weeks | Non-impact activity only |
| Grade 4a | Focal cortical abnormalities | 9-12 weeks | Complete rest from running |
| Grade 4b | Linear fracture line | 12-16+ weeks | Protected WB, possible surgery |
Clinical Assessment
Clinical Examination
MTSS is diagnosed clinically. Key examination features:
Positive findings:
- Diffuse tenderness along posteromedial tibial border (greater than 5cm)
- Location: distal two-thirds of tibia most common
- Pain on resisted ankle plantarflexion or toe flexion (loads deep compartment)
Negative findings (should be absent):
- No focal "point" tenderness (suggests stress fracture)
- No neurological deficits (suggests radiculopathy)
- No vascular compromise (suggests PAES or DVT)
- No compartment fullness/pain with passive stretch (suggests CECS)
Physical Examination
MTSS Findings
- Diffuse posteromedial tenderness exceeding 5cm
- Tenderness along distal 2/3 of tibial border
- Pain with resisted plantarflexion
- Pain with single-leg hop (provocative test)
- May have slight palpable periosteal thickening
Red Flags to Exclude
- Focal tenderness less than 5cm (stress fracture)
- Swelling of compartments (CECS or DVT)
- Neurological deficit (radiculopathy, nerve entrapment)
- Diminished pulses or claudication (vascular)
- Night pain, systemic symptoms (exclude tumor)
Differential Diagnosis
Exercise-Induced Leg Pain - Differential Diagnosis
| Condition | Key Features | Investigation |
|---|---|---|
| MTSS | Diffuse posteromedial tenderness, improves with warm-up | Clinical diagnosis, MRI if needed |
| Tibial stress fracture | Focal tenderness, worsens with activity, night pain | MRI or bone scan |
| Chronic exertional compartment syndrome | Cramping/burning with exercise, resolves with rest | Compartment pressure testing |
| Popliteal artery entrapment | Claudication, diminished pulses with exercise | ABI, duplex, angiography |
| Effort thrombosis/DVT | Swelling, warmth, calf tenderness | D-dimer, duplex ultrasound |
| Lumbar radiculopathy | Dermatomal symptoms, neural tension signs | MRI lumbar spine |
Investigations
Imaging Strategy
MTSS is a clinical diagnosis - imaging is NOT required for typical presentations.
Indications for imaging:
- Diagnostic uncertainty (focal tenderness, atypical features)
- Failure to improve with 4-6 weeks of appropriate management
- High-level athlete needing accurate prognosis/timeline
- Concern for stress fracture progression
MRI is the gold standard - demonstrates periosteal edema, marrow edema, and fracture lines with high sensitivity and specificity.
Imaging Modalities
Findings: Usually NORMAL in MTSS
- May show periosteal reaction in chronic cases
- Stress fracture may show cortical irregularity, fracture line (late finding)
- Sensitivity less than 50% for stress injuries
Role: Primarily to exclude other pathology (tumor, infection)
Limitations: Cannot differentiate MTSS from early stress fracture
Laboratory Testing
Routine Labs
Not routinely indicated for typical MTSS
Consider if:
- Recurrent stress injuries
- Suspected metabolic bone disease
- Female athlete triad/RED-S
- Systemic symptoms present
If Investigating
- Vitamin D (25-OH vitamin D)
- Calcium (serum and 24hr urine)
- PTH if calcium abnormal
- TSH for thyroid dysfunction
- Bone density (DEXA) if concern
Management
Management Philosophy
Modern MTSS management emphasizes activity modification rather than complete rest:
Key principles:
- Reduce load - decrease running volume/intensity, cross-train
- Address risk factors - training errors, biomechanics, footwear
- Pain-guided return - activities that don't cause pain during or after
- Screen for RED-S - energy availability, bone health, menstrual function
- Progressive return - gradual increase in impact activities
Complete rest is generally NOT recommended - it leads to deconditioning without addressing underlying factors.
Non-Operative Management
Immediate phase:
- Reduce running volume by 50-75%
- Avoid high-impact activities
- Cross-train: swimming, cycling, elliptical
Pain-guided return:
- Activity should not cause pain during exercise
- No pain within 2 hours after activity
- No pain next morning
If pain occurs, reduce load and progress more slowly
Return to Running Protocol
Surgical Technique
Surgery - Rarely Indicated
Surgical intervention for MTSS is rarely needed (less than 5% of cases) and reserved for refractory symptoms despite comprehensive conservative management. Most cases resolve with activity modification and addressing underlying risk factors.
Surgical Indications
Consider surgery only if:
- Persistent symptoms despite 6+ months of appropriate conservative treatment
- Significant impact on athletic or military career
- Documented fascial involvement on imaging (thickened deep posterior fascia)
- Failed trial of all non-operative options including biomechanical correction
- Patient understands variable success rates and rehabilitation requirements
Contraindications:
- Active training errors not addressed
- Underlying RED-S or bone health issues not optimized
- Unrealistic expectations
- Less than 6 months conservative management
Procedure:
- Release of deep posterior fascia overlying tibialis posterior and FDL
- Reduces traction on tibial periosteum
- Can be performed open or endoscopically
Technique:
- Longitudinal incision over posteromedial tibia
- Identify deep crural fascia
- Release fascia covering tibialis posterior and FDL
- Ensure complete release over symptomatic area
- Inspect periosteum (may cauterize if inflamed)
Evidence: Variable success rates (60-90% in small series)
Complications and Prevention
Progression to Stress Fracture
The primary concern with inadequately managed MTSS is progression to tibial stress fracture:
Risk factors for progression:
- Continued training through pain
- Failure to address training load errors
- Underlying low energy availability (RED-S)
- Low bone density
- Female sex
Prevention: Pain-guided activity modification and addressing modifiable risk factors prevents progression in the vast majority of cases.
Prevention Strategies
Modifiable Risk Factors
- Training errors - sudden volume/intensity increases
- Footwear - worn shoes, inappropriate for foot type
- Surface - excessive hard surface running
- Biomechanics - overpronation, muscle imbalances
- Energy availability - inadequate nutrition
Non-Modifiable Risk Factors
- Female sex (3x higher risk)
- Previous MTSS history
- Bone density (genetic component)
- Tibial anatomy (narrow diaphysis)
- Age (peak in young adults)
Postoperative Care and Rehabilitation
Postoperative Management
Following surgical fasciotomy for refractory MTSS, rehabilitation focuses on gradual return to loading while allowing fascial healing and addressing underlying biomechanical factors that contributed to the initial problem.
Goals:
- Wound healing
- Control swelling
- Maintain ankle ROM
- Prevent complications
Activities:
- Protected weight bearing with crutches
- Elevation when resting
- Ice therapy 3-4 times daily
- Ankle pumps and circles
- Gentle active ROM within pain limits
Precautions:
- No impact activities
- Monitor wound for infection
- Keep surgical site clean and dry
Focus on wound healing and swelling control.
Outcomes and Prognosis
Natural History
With appropriate management, MTSS has an excellent prognosis:
- 85-90% resolve with conservative management
- Average recovery time: 6-8 weeks with activity modification
- Recurrence rate: 20-30% if underlying factors not addressed
- Progression to stress fracture: less than 10% with appropriate load management
- Surgical intervention needed: less than 5% of cases
Favorable Prognostic Factors
- Early recognition and management
- Good compliance with activity modification
- Address of training errors
- Correction of biomechanical issues
- Adequate energy availability
- No previous stress fracture history
- Male gender
Poor Prognostic Factors
- Continued training through pain
- Multiple recurrences
- Underlying RED-S or low bone density
- Anterior tibial location (higher fracture risk)
- Failure to address biomechanics
- Poor training load management
- Concomitant stress fracture
Recovery Timeline by Severity
| Presentation | Conservative Management | Expected Recovery | Return to Sport |
|---|---|---|---|
| Early MTSS (mild symptoms) | Activity modification 25-50% | 3-4 weeks | 4-6 weeks |
| Established MTSS (moderate) | Activity modification 50-75% | 6-8 weeks | 8-10 weeks |
| Severe MTSS (MRI Grade 2) | Significant load reduction | 8-12 weeks | 12-16 weeks |
| Progression to stress fracture | Complete rest from impact | 12-16+ weeks | 16-20+ weeks |
| Recurrent/refractory MTSS | Comprehensive management ± surgery | Variable, 3-6 months | 6-9 months |
Long-Term Outcomes After MTSS
- 87% athletes returned to sport at pre-injury level
- Mean time to return: 8.4 weeks with structured program
- Recurrence rate 28% in first year
- Recurrence strongly associated with inadequate rehabilitation
- No long-term disability in successfully treated cases
Return to Sport Timeline
Evidence Base
MRI Classification Correlates with Recovery
- Developed MRI grading system for tibial stress injuries
- Higher grades correlate with longer recovery times
- Grade 1 (periosteal edema): 2-3 week recovery
- Grade 4 (fracture line): 12+ week recovery
Risk Factors for MTSS in Athletes
- Systematic review of risk factors for MTSS
- Female sex increases risk 3-fold
- Previous MTSS is strong risk factor
- BMI extremes (high and low) increase risk
- Navicular drop (pronation) associated with MTSS
Activity Modification vs Rest for MTSS
- Systematic review comparing treatment approaches
- Activity modification as effective as complete rest
- Complete rest leads to deconditioning without benefit
- Graded return-to-running protocols show good outcomes
Shockwave Therapy for Refractory MTSS
- RCT comparing ESWT to surgery for chronic MTSS
- ESWT showed 76% success rate at 15 months
- Comparable to surgical fasciotomy
- Less invasive alternative for refractory cases
Female Athlete Triad and Stress Injuries
- IOC consensus statement on relative energy deficiency in sport
- Low energy availability leads to bone stress injuries
- Menstrual dysfunction is a red flag
- Early intervention improves bone health outcomes
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Female Marathon Runner with Bilateral Leg Pain
"A 22-year-old female runner presents with 4 weeks of bilateral leg pain. Examination shows diffuse tenderness along the posteromedial tibial borders. She's training for a marathon and recently increased her weekly mileage. How do you approach this case?"
Military Recruit with Focal Tibial Tenderness
"A 19-year-old male soldier presents with right leg pain worsening over 3 weeks of infantry training. Examination shows focal tenderness over a 2cm area of the mid-tibial shaft. What is your approach?"
Recurrent MTSS with Female Athlete Triad Features
"A 17-year-old female cross-country runner has recurrent bilateral shin pain despite two previous periods of rest. She has irregular periods and is underweight. How do you manage this complex case?"
MCQ Practice Points
MTSS Diagnosis
Q: What is the characteristic clinical finding that distinguishes MTSS from tibial stress fracture? A: Diffuse tenderness over greater than 5cm of the posteromedial tibial border. Point tenderness less than 5cm suggests stress fracture.
Imaging in MTSS
Q: What is the gold standard imaging modality for suspected MTSS? A: MRI - demonstrates periosteal edema on T2/STIR sequences. X-rays are usually normal in MTSS.
MTSS Pathophysiology
Q: What is the underlying mechanism of MTSS? A: Traction periostitis from soleus, FDL, and tibialis posterior muscles combined with repetitive tibial bending loads causing periosteal reaction at the posteromedial border.
Management Principle
Q: What is the key management principle for MTSS? A: Activity modification (not complete rest) with pain-guided return to activity. The 10% rule limits weekly training increase.
MTSS Risk Factors
Q: What is the most common modifiable risk factor for MTSS? A: Training errors (sudden increase in volume, intensity, or change in running surface). Female sex increases risk 3-fold but is non-modifiable.
Definition and Diagnosis
- MTSS is a clinical diagnosis - imaging not required
- Diffuse tenderness over greater than 5cm posteromedial tibial border
- Pain improves with warm-up (vs stress fracture worsens)
- Distal 2/3 of tibia most commonly affected
- Single-leg hop test provocative
- Must exclude stress fracture if focal tenderness
Pathophysiology
- Traction periostitis from soleus, FDL, tibialis posterior
- Bone stress continuum with stress fractures
- Repetitive tibial bending loads
- Periosteal reaction on histology
- NOT purely muscular origin
- Same risk factors as stress fractures
Imaging
- MRI is gold standard for imaging
- Periosteal edema on T2/STIR sequences
- X-ray usually normal in MTSS
- Bone scan: sensitive but NOT specific
- Fredericson classification grades severity
- CT has limited role in MTSS
Risk Factors
- Female sex increases risk 3-fold
- Training errors most common modifiable factor
- Previous MTSS history
- Overpronation of foot
- Low BMI and RED-S
- Hard running surfaces
Management Principles
- Activity MODIFICATION not complete rest
- Pain-guided return to activity
- 10% rule for weekly training increase
- Address biomechanics and footwear
- Screen for RED-S in recurrent cases
- Surgery rarely indicated (under 5%)
Prognosis
- 85-90% resolve conservatively
- Average recovery 6-8 weeks
- Recurrence 20-30% if factors not addressed
- Progression to fracture under 10%
- Excellent long-term prognosis
- Return to pre-injury level in 87%
Common MCQ Scenarios
Classic MCQ Vignettes and Expected Answers
| Clinical Scenario | Most Likely Diagnosis | Next Best Investigation | Definitive Management |
|---|---|---|---|
| Runner with diffuse posteromedial tibial tenderness over 8cm, pain improves with warm-up | MTSS | None - clinical diagnosis | Activity modification 50%, biomechanics |
| Athlete with focal 3cm tibial tenderness, night pain, worsening with activity | Tibial stress fracture | MRI tibia | Complete rest from impact, protected WB |
| Female runner, recurrent MTSS, irregular periods, low BMI | MTSS with RED-S | DEXA scan, vitamin D, menstrual workup | Increase energy availability, MDT approach |
| MTSS not improving after 6 months conservative management | Refractory MTSS | MRI to exclude stress fracture | Consider ESWT or surgical fasciotomy |
| MRI shows periosteal edema only, no marrow involvement | Fredericson Grade 1 | None - confirms MTSS | Activity modification 2-3 weeks |
Key Numbers for MCQs
Australian Context
In Australia, medial tibial stress syndrome is commonly seen in military recruits, elite athletes, and recreational runners. Management follows evidence-based international guidelines with some local considerations.
Australian Defence Force: MTSS is one of the most common reasons for medical downgrading during recruit training. The ADF has implemented graduated physical training programs to reduce incidence, with emphasis on progressive load increases and early intervention for symptomatic recruits.
Sports Medicine Australia: Guidelines emphasize the importance of multidisciplinary care for recurrent stress injuries, particularly screening for relative energy deficiency in sport (RED-S) in female athletes. The Female Athlete Triad Coalition of Australia provides resources for sports physicians.
Imaging access: MRI for suspected stress injuries is generally accessible through public and private systems. Medicare rebates apply for MRI when clinically indicated (not required for typical MTSS). Bulk-billing sports medicine clinics often have direct access to imaging.
Evidence-based management: Australian sports medicine practitioners follow international consensus statements on stress injury management, including the IOC consensus on RED-S and British Journal of Sports Medicine return-to-play guidelines. Extracorporeal shockwave therapy (ESWT) is available in major cities for refractory cases.
Prevention programs: Many running clubs and athletics organizations have adopted injury prevention programs based on Australian Institute of Sport recommendations, focusing on training load management, biomechanical assessment, and bone health screening.
Medial Tibial Stress Syndrome (Shin Splints)
High-Yield Exam Summary
Key Numbers
- •**35%** - Athletes affected at some point
- •**5cm** - Tenderness length distinction (MTSS greater than 5cm, stress fracture less than 5cm)
- •**3x** - Female sex increases risk
- •**6-8 weeks** - Typical MTSS recovery
- •**12+ weeks** - Stress fracture (Grade 4) recovery
- •**10%** - Maximum weekly training increase (prevention)
- •**50%** - Load reduction recommended in acute MTSS
Clinical Diagnosis
- •Diffuse posteromedial tibial tenderness (greater than 5cm)
- •Distal 2/3 of tibia most commonly affected
- •Pain IMPROVES with warm-up (vs stress fracture worsens)
- •No focal point tenderness (that's stress fracture)
- •Positive single-leg hop test
- •Clinical diagnosis - imaging NOT required for typical cases
Fredericson MRI Classification
- •**Grade 1**: Periosteal edema only - 2-3 week recovery
- •**Grade 2**: Periosteal + marrow edema (T2) - 4-6 weeks
- •**Grade 3**: Marrow edema T1 AND T2 - 6-9 weeks
- •**Grade 4a**: Focal cortical abnormalities - 9-12 weeks
- •**Grade 4b**: Linear fracture line - 12-16+ weeks
Critical Differentials
- •**Tibial stress fracture** - focal tenderness, worsening pain
- •**CECS** - compartment fullness, pressure testing diagnostic
- •**Popliteal artery entrapment** - claudication, vascular testing
- •**Lumbar radiculopathy** - dermatomal symptoms
- •**DVT** - swelling, warmth
Management Principles
- •Activity MODIFICATION not complete rest
- •Pain-guided return (no pain during, after, or next morning)
- •Address training errors (10% weekly increase maximum)
- •Footwear/orthoses for overpronation
- •Cross-train to maintain fitness
- •Screen for RED-S in recurrent cases
Viva Buzzwords
- •'Bone stress continuum'
- •'Traction periostitis'
- •'Pain-guided return to activity'
- •'Relative energy deficiency in sport (RED-S)'
- •'Fredericson classification'
- •'Activity modification preferred over complete rest'