Skip to main content

Advertisement

Log in

Tibial Stress Injuries

An Aetiological Review for the Purposes of Guiding Management

  • Injury Clinic
  • Published:
Sports Medicine Aims and scope Submit manuscript

Abstract

In the last 30 years, few advances have been made in the management of tibial stress injuries such as tibial stress fracture and medial tibial stress syndrome (MTSS). Tibial overuse injuries are a recognised complication of the chronic, intensive, weight-bearing training commonly practised by athletic and military populations. Generally, the most effective treatment is considered to be rest, often for prolonged periods. This is a course of action that will significantly disrupt an active lifestyle, and sometimes end activity-related careers entirely.

There is now considerable knowledge of the nature of tibial stress injuries, such that presently accepted management practices can be critically evaluated and supplemented. Most recent investigations suggest that tibial stress injuries are a consequence of the repetitive tibial strain imposed by loading during chronic weight-bearing activity. Evidence is presented in this article for an association between repeated tibial bending and stress injury as a function of: (i) strain-related modelling (in the case of MTSS), and (ii) a strain-related positive feedback mechanism of remodelling (in the case of stress fracture). Factors that influence the bending response of the tibia to loading are reviewed. Finally, a guide for injury prevention and management based on research observations is presented.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. D’Ambrosia R, Drez D. Prevention and treatment of running injuries. Thorofare (NJ): Charles B. Slack, Inc., 1982

    Google Scholar 

  2. Fredericson M, Bergman G, Hoffman KL, et al. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995; 23: 472–81

    Article  PubMed  CAS  Google Scholar 

  3. Hunter-Griffin LY. Clinics in sports medicine: overuse injuries. Philadelphia (PA): W.B. Saunders, 1987

    Google Scholar 

  4. Jackson DW, Bailey D. Shin splints in the young athlete: a non-specific diagnosis. Phys Sports Med 1975; 3: 45–51

    Google Scholar 

  5. Michael RH, Holder LE. The soleus syndrome: a cause of medial tibial stress (shin splints). Am J Sports Med 1985; 13: 87–94

    Article  PubMed  CAS  Google Scholar 

  6. Burr DB. Bone, exercise and stress fracture. In. Holloszy JO, editor. Exercise and sport sciences review. Baltimore (MD): Williams and Wilkins, 1997: 171–94

    Google Scholar 

  7. Burr DB, Milgrom C, Boyd RD, et al. Experimental stress fractures of the tibia: biological and mechanical etiology in rabbits. J Bone Joint Surg 1990; 72: 370–5

    CAS  Google Scholar 

  8. Grimston SK, Zernicke RF. Exercise-related stress responses in bone. J Appl Biomech 1993; 9: 2–14

    Google Scholar 

  9. Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med 1987; 15: 46–58

    Article  PubMed  CAS  Google Scholar 

  10. Coady CM, Micheli LJ. Stress fractures in the pediatric athlete. Clin Sports Med 1997; 16: 225–38

    Article  PubMed  CAS  Google Scholar 

  11. Burrows HJ. Fatigue infraction of the middle of the tibia in ballet dancers. J Bone Joint Surg 1956; 38: 83–94

    Google Scholar 

  12. Daffner RH. Anterior tibial striations. Am J Roengenol 1984; 143: 651–3

    CAS  Google Scholar 

  13. Rolf C, Ekenman I, Tornqvist H, et al. The anterior stress fracture of the tibia: an atrophic pseudoarthrosis?. Scand J Med Sci Sports 1997; 7: 249–52

    Article  PubMed  CAS  Google Scholar 

  14. Devas MB. Stress fractures of the tibia in athletes or ’shin soreness’. J Bone Joint Surg 1958; 40: 227–39

    Google Scholar 

  15. Jackson DW, Strizak AM. Stress fractures in runners excluding the foot. In. Mack RP, editor. Symposium on the foot and leg in running sports. St. Louis (MO): C.V. Mosby, 1982: 109–22

    Google Scholar 

  16. Beck BR, Osternig LR. Medial tibial stress syndrome: the location of muscles of the leg in relation to symptoms. J Bone Joint Surg 1994; 76: 1057–61

    PubMed  CAS  Google Scholar 

  17. Saxena A, O’Brien T, Bunce D. Anatomic dissection of the tibialis posterior muscle and its correlation to medial tibial stress syndrome. J Foot Surg 1990; 29: 105–8

    PubMed  CAS  Google Scholar 

  18. Beck TJ, Ruff CB, Mourtada FA, et al. Dual-energy x-ray absorptiometry derived structural geometry for stress fracture prediction in male U.S. Marine Corps recruits. J Bone Miner Res 1996; 11: 645–53

    Article  PubMed  CAS  Google Scholar 

  19. Milgrom C, Giladi M, Simkin A, et al. The area moment of inertia of the tibia: a risk factor for stress fractures. J Biomech 1989; 22: 1243–8

    Article  PubMed  CAS  Google Scholar 

  20. Chang PS, Harris RM. Intramedullary nailing for chronic tibial stress fractures: a review of five cases. Am J Sports Med 1996; 24: 688–92

    Article  PubMed  CAS  Google Scholar 

  21. Jones BH, Harris JMcA, Vinh TN, et al. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev 1989; 17: 379–422

    PubMed  CAS  Google Scholar 

  22. Sullivan D, Warren RF, Pavlov H, et al. Stress fractures in 51 runners. Clin Orthop 1984; 187: 188–92

    PubMed  Google Scholar 

  23. Taube RR, Wadsworth LT. Managing tibial stress fractures. Phys Sports Med 1993; 21: 123–30

    Google Scholar 

  24. Clement DB. Tibial stress syndrome in athletes. J Sports Med 1974; 2: 81–5

    Article  PubMed  CAS  Google Scholar 

  25. Hayes WC. Biomechanics of cortical and trabecular bone: implications for assessment of fracture risk. In. Mow VC, Hayes WC, editors. Basic orthopaedic biomechanics. New York: Raven Press, 1991: 93–142

    Google Scholar 

  26. Martin RB, Burr DB. Structure, function, and adaptation of compact bone. New York: Raven Press, 1989

    Google Scholar 

  27. Myburgh KH, Charette S, Zhou L, et al. Influence of recreational activity and muscle strength on ulnar bending stiffness in men. Med Sci Sports Exerc 1993; 25: 592–6

    PubMed  CAS  Google Scholar 

  28. Murray PDF. Bones. A study of the development and structure of the vertebrate skeleton. Cambridge: Cambridge University Press, 1985

    Google Scholar 

  29. Biewener AA, Taylor CR. Bone strain: a determinant of gait and speed?. J Exp Biol 1986; 123: 383–400

    PubMed  CAS  Google Scholar 

  30. Rubin CT, Lanyon LE. Dynamic strain similarity in vertebrates: an alternative to allometric limb bone scaling. J Theor Biol 1984; 107: 321–7

    Article  PubMed  CAS  Google Scholar 

  31. Schaffler MB. Stiffness and fatigue of compact bone at physiological strains and strain rates [dissertation]. Morgantown (WV): West Virginia University, 1985

    Google Scholar 

  32. Churches AE, Howlett CR. Functional adaptation of bone in response to sinusoidally varying controlled compressive loading of the ovine metacarpus. Clin Orthop 1982; 168: 265–80

    PubMed  Google Scholar 

  33. Churches AE, Howlett CR, Waldron KJ, et al. The response of living bone to controlled time-varying loading: method and preliminary results. J Biomech 1979; 12: 35–45

    Article  PubMed  CAS  Google Scholar 

  34. Forwood MR, Turner CH. The response of rat tibiae to incremental bouts of mechanical loading: a quantum concept for bone formation. Bone 1994; 15: 603–9

    Article  PubMed  CAS  Google Scholar 

  35. Goodship AE, Lanyon LE, McFie H. Functional adaptation of bone to increased stress. J Bone Joint Surg 1979; 61: 539–46

    PubMed  CAS  Google Scholar 

  36. Hert J, Liskova M, Landa J. Reaction of bone to mechanical stimuli: Pt 1. Continuous and intermittent loading of tibia in rabbit. Folia Morphol 1971; 19: 290–317

    CAS  Google Scholar 

  37. Hert J, Pribylova E, Liskova M. Reaction of bone to mechanical stimuli: Pt 3. Microstructure of compact bone of rabbit tibia after intermittent loading. Acta Anat 1972; 82: 218–30

    Article  PubMed  CAS  Google Scholar 

  38. O’Connor JA, Lanyon LE, MacFie H. The influence of strain rate on adaptive bone remodelling. J Biomech 1982; 15: 767–81

    Article  PubMed  Google Scholar 

  39. Raab-Cullen DM, Akhter MP, Kimmel DB, et al. Bone response to alternate-day mechanical loading of the rat tibia. J Bone Miner Res 1994; 9: 203–11

    Article  PubMed  CAS  Google Scholar 

  40. Raab-Cullen DM, Akhter MP, Kimmel DB, et al. Periosteal bone formation stimulated by externally induced bending strains. J Bone Miner Res 1994; 9: 1143–52

    Article  PubMed  CAS  Google Scholar 

  41. Rubin CT, Lanyon LE. Regulation of bone formation by applied dynamic loads. J Bone Joint Surg 1984; 66: 397–402

    PubMed  CAS  Google Scholar 

  42. Rubin CT, Lanyon LE. Regulation of bone mass by mechanical strain magnitude. Calcif Tissue Int 1985; 37: 411–7

    Article  PubMed  CAS  Google Scholar 

  43. Rubin CT, Lanyon LE. Osteoregulatory nature of mechanical stimuli: function as a determinant for adaptive remodeling in bone. J Orthop Res 1987; 5: 300–10

    Article  PubMed  CAS  Google Scholar 

  44. Wolff J. Das Gesetz der Transformation der Knochen. Berlin: Hirschwald Verlag, 1892

    Google Scholar 

  45. Huddleston AL, Rockwell D, Kulend DN, et al. Bone mass in lifetime tennis athletes. JAMA 1980; 244: 1107–9

    Article  PubMed  CAS  Google Scholar 

  46. Jones HH, Priest JD, Hayes WC, et al. Humeral hypertrophy in response to exercise. J Bone Joint Surg 1977; 59: 204–8

    PubMed  CAS  Google Scholar 

  47. Lee EJ, Long KA, Risser WL, et al. Variations in bone status of contralateral and regional sites in young athletic women. Med Sci Sports Exerc 1995; 27: 1354–61

    PubMed  CAS  Google Scholar 

  48. Frost HM. Bone ‘mass’ and the mechanostat. Anat Rec 1987; 219: 1–9

    Article  PubMed  CAS  Google Scholar 

  49. Milgrom C, Giladi M, Simkin A, et al. An analysis of the biomechanical mechanism of tibial stress fractures among Israeli infantry recruits: a prospective study. Clin Orthop 1988; 231: 216–21

    PubMed  Google Scholar 

  50. Swissa A, Milgrom C, Giladi M, et al. The effect of pre-training sports activity on the incidence of stress fractures among military recruits: a prospective study. Clin Orthop 1989; 245: 256–60

    PubMed  Google Scholar 

  51. Gross TS, Edwards JL, McLeod KJ, et al. Strain gradients correlate with sites of periosteal bone formation. J Bone Miner Res 1997; 12: 982–8

    Article  PubMed  CAS  Google Scholar 

  52. Burr DB, Forwood MR, Fyhrie DP, et al. Bone microdamage and skeletal fragility in osteoporotic and stress fractures. J Bone Miner Res 1997; 12: 6–15

    Article  PubMed  CAS  Google Scholar 

  53. Johnson LC, Stradford HT, Geis RW, et al. Histogenesis of stress fractures [abstract]. J Bone Joint Surg 1963; 45: 1542

    Google Scholar 

  54. Li G, Zhang S, Chen G, et al. Radiographic and histologic analyses of stress fracture in rabbit tibias. Am J Sports Med 1985; 13: 285–94

    Article  PubMed  CAS  Google Scholar 

  55. Rubin CT, Harris McA, Jones BH, et al. Stress fractures: the remodeling response to excessive repetitive loading [abstract]. Trans Orthop Res Soc 1984; 303

    Google Scholar 

  56. Burr DB, Martin RB, Schaffler MB, et al. Bone remodeling in response to in vivo fatigue microdamage. J Biomech 1985; 18: 189–200

    Article  PubMed  CAS  Google Scholar 

  57. Eriksen EF, Gundersen HJG, Melsen F, et al. Reconstruction of the formative site in iliac trabecular bone in 20 normal individuals employing a kinetic model for matrix and mineral apposition. Metab Bone Dis Relat Res 1984; 5: 243–52

    Article  PubMed  CAS  Google Scholar 

  58. Eriksen EF, Melsen F, Mosekilde L. Reconstruction of the resorptive site in iliac trabecular bone: a kinetic model for bone resorption in 20 normal individuals. Metab Bone Dis Relat Res 1984b; 5: 235–42

    Article  PubMed  CAS  Google Scholar 

  59. Carter DR, Hayes WC. The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg 1977; 59A: 954–62

    Google Scholar 

  60. Rice JC, Cowin SC, Bowman JA. On the dependance of the elasticity and strength of cancellous bone on apparent density. J Biomech 1988; 21: 155–68

    Article  PubMed  CAS  Google Scholar 

  61. Schaffler MB, Burr DB. Stiffness of compact bone: effects of porosity and density. J Biomech 1988; 21: 13–6

    Article  PubMed  CAS  Google Scholar 

  62. Carter DR, Hayes WC. Compact bone fatigue damage. Clin Orthop 1977; 127: 265–74

    PubMed  Google Scholar 

  63. Carter DR, Caler WE, Spengler DM, et al. Fatigue behavior of adult cortical bone: the influence of mean strain and strain range. Acta Orthop Scand 1981; 52: 481

    Article  PubMed  CAS  Google Scholar 

  64. Carter DR, Caler WE, Spengler DM, et al. Uniaxial fatigue of human cortical bone: the influence of tissue physical characteristics. J Biomech 1981; 14: 461

    Article  PubMed  CAS  Google Scholar 

  65. Carter DR, Harris WH, Vasu R, et al. The mechanical and biological response of cortical bone to in vivo strain histories. In. Cowin SC, editor. Mechanical properties of bone. New York: American Society of Mechanical Engineers, 1981: 81–92

    Google Scholar 

  66. Currey JD. The mechanical properties of bone. Clin Orthop 1970; 73: 210–31

    Google Scholar 

  67. Currey J. The mechanical adaptations of bone. Princeton (NJ): Princeton University Press, 1984

    Google Scholar 

  68. Zioupos P, Currey JD. The extent of microcracking and the morphology of microcracks in damaged bone. J Materials Sci 1994; 29: 978–86

    Article  Google Scholar 

  69. Johnell O, Rausing A, Wendeberg B, et al. Morphological bone changes in shin splints. Clin Orthop 1982; 167: 180–4

    PubMed  Google Scholar 

  70. Chisin R, Milgrom C, Giladi M, et al. Clinical significance of non-focal scintigraphic findings in suspected tibial stress fractures. Clin Orthop 1987; 220: 200–5

    PubMed  Google Scholar 

  71. Emery SE, Heller JG, Petersilge CA, et al. Tibial stress fractures after a graft has been obtained from the fibula. J Bone Joint Surg 1996; 78: 1248–51

    PubMed  CAS  Google Scholar 

  72. Dugan RC, D’Ambrosia R. Fibular stress fractures in runners. J Fam Pract 1983; 17: 415–8

    PubMed  CAS  Google Scholar 

  73. McBryde AM. Stress fractures in runners. Clin Sports Med 1985; 4: 737–52

    PubMed  Google Scholar 

  74. Garcia JE, Grabhorn LL, Franklin KJ. Factors associated with stress fractures in military recruits. Mil Med 1987; 152: 45–8

    PubMed  CAS  Google Scholar 

  75. Kowal DM. Nature and causes of injuries in women resulting from an endurance training program. Am J Sports Med 1980; 8: 265–9

    Article  PubMed  CAS  Google Scholar 

  76. McKenzie DC, Clement DB, Taunton JE. Running shoes, orthotics and injuries. Sports Med 1985; 2: 334–47

    Article  PubMed  CAS  Google Scholar 

  77. Scully TJ, Besterman G. Stress fracture: a preventable training injury. Mil Med 1982; 147: 285–7

    PubMed  CAS  Google Scholar 

  78. Andrish JT, Bergfeld JA, Walheim J. A prospective study on the management of shin splints. J Bone Joint Surg 1974; 56: 1697–700

    PubMed  CAS  Google Scholar 

  79. Gilbert RS, Johson HA. Stress fractures in military recruits: a review of twelve years experience. Mil Med 1966; 131: 716–21

    Google Scholar 

  80. Greaney RB, Gerber FH, Laughlin RL, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 1983; 146: 339–46

    CAS  Google Scholar 

  81. Jackson D. Shin splints: an update. Phys Sports Med 1978; 6: 51–61

    Google Scholar 

  82. Leabhart JW. Stress fracture of the calcaneus. J Bone Joint Surg 1959; 41: 1285–90

    PubMed  Google Scholar 

  83. Montgomery LC, Nelson FRT, Norton JP, et al. Orthopedic history and examination in the etiology of overuse injuries. Med Sci Sports Exerc 1989; 21: 237–43

    PubMed  CAS  Google Scholar 

  84. Provost RA, Morris JM. Fatigue fracture of the femoral shaft. J Bone Joint Surg 1969; 51: 487–98

    PubMed  CAS  Google Scholar 

  85. Milgrom C, Giladi M, Stein M, et al. Medial tibial pain: a prospective study of its cause among military recruits. Clin Orthop 1986; 213: 167–71

    PubMed  Google Scholar 

  86. Mustajoki P, Laapio H, Meurman K. Calcium metabolism, physical activity, and stress fractures [letter]. Lancet 1983; II: 797

    Article  Google Scholar 

  87. Zahger D, Abramovitz A, Zelikovsky L, et al. Stress fractures in female soldiers: an epidemiological investigation of an outbreak. Mil Med 1988; 153: 448–50

    PubMed  CAS  Google Scholar 

  88. Reeder MT, Dick BH, Atkins JK, et al. Stress fractures: current concepts of diagnosis and treatment. Sports Med 1996; 22: 198–212

    Article  PubMed  CAS  Google Scholar 

  89. Wen DY, Puffer JC, Schmalzried TP. Lower extremity alignment and risk of overuse injuries in runners. Med Sci Sports Exerc 1997; 29: 1291–8

    Article  PubMed  CAS  Google Scholar 

  90. Hoeberigs JH. Factors related to the incidence of running injuries: a review. Sports Med 1992; 13: 408–22

    Article  PubMed  CAS  Google Scholar 

  91. Macera CA. Lower extremity injuries in runners: advances in prediction. Sports Med 1992; 13: 50–7

    Article  PubMed  CAS  Google Scholar 

  92. Macera CA, Pate RR, Powell KE, et al. Predicting lower extremity injuries among habitual runners. Arch Intern Med 1989; 149: 2565–8

    Article  PubMed  CAS  Google Scholar 

  93. Marti B, Vadar JP, Minder CE, et al. On the epidemiology of running injuries: the 1984 Bern Grand-Prix study. Am J Sports Med 1988; 16: 265–94

    Article  Google Scholar 

  94. Walter SD, Hart LE, McIntosh JM, et al. The Ontario cohort study of running-related injuries. Arch Intern Med 1989; 149: 2561–4

    Article  PubMed  CAS  Google Scholar 

  95. Loy DJ, Voloshin AS. Biomechanics of stair walking and jumping. J Sports Sci 1991; 9: 137–49

    Article  PubMed  CAS  Google Scholar 

  96. Fredericson M. Common injuries in runners. Diagnosis, rehabilitation and prevention. Sports Med 1996; 21: 49–72

    Article  PubMed  CAS  Google Scholar 

  97. Lanyon LE, Hampson WGJ, Goodship AE, et al. Bone deformation recorded in vivo from strain gauges attached to the human tibial shaft. Acta Orthop Scand 1975; 46: 256–68

    Article  PubMed  CAS  Google Scholar 

  98. Robbins SE, Gouw GJ. Athletic footwear and chronic overloading: a brief review. Sports Med 1990; 9: 76–85

    Article  PubMed  CAS  Google Scholar 

  99. Frederick EC, Cavanaugh PR. Correspondence. Med Sci Sports Exerc 1992; 24: 144–5

    Article  PubMed  CAS  Google Scholar 

  100. Kim W, Voloshin AS. Dynamic loading during running on various surfaces. Hum Mov Sci 1992; 11: 675–89

    Article  Google Scholar 

  101. Burr DB, Milgrom C, Fyhrie D, et al. In vivo measurement of human tibial strains during vigorous activity. Bone 1996; 18: 405–10

    Article  PubMed  CAS  Google Scholar 

  102. Brody D. Running injuries. CIBA Clinical Symposium, 1980: 32 (4): 2–36

    Google Scholar 

  103. Schuster RO. Foot types and the influence of the environment on the foot of the long distance runner. Ann N Y Acad Sci 1977; 881–7

    Google Scholar 

  104. James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med 1978; 6: 40–50

    Article  PubMed  CAS  Google Scholar 

  105. Marti B. Health effects of recreational running in women: some epidemiological and preventive aspects. Sports Med 1991; 11: 20–51

    Article  PubMed  CAS  Google Scholar 

  106. van Mechelen W. Running injuries: a review of the epidemiological literature. Sports Med 1992; 14: 320–35

    Article  PubMed  Google Scholar 

  107. Bowerman RF. The control of arthropod walking. Comp Biochem Physiol 1977; 56: 231–47

    Article  CAS  Google Scholar 

  108. Gehlsen GM, Seger A. Selected measures of angular displacement, strength, and flexibility in subjects with and without shin splints. Res Q Exerc Sport 1980; 51: 478–85

    PubMed  CAS  Google Scholar 

  109. Rasmussen W. Shin splints: definition and treatment. J Sports Med 1974; 2: 111–7

    Article  PubMed  CAS  Google Scholar 

  110. Slocum DB. The shin splint syndrome. Medical aspects and differential diagnosis. Am J Surg 1967; 114: 875–81

    CAS  Google Scholar 

  111. Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors for stress fractures in track and field athletes: a twelve-month prospective study. Am J Sports Med 1996; 24: 810–8

    Article  PubMed  CAS  Google Scholar 

  112. Hill DB. Production and absorption of work by muscle. Science 1962; 131: 897–903

    Article  Google Scholar 

  113. McMahon T. Muscles, reflexes and locomotion. Princeton (NJ): Princeton University Press, 1984

    Google Scholar 

  114. Nordin M, Frankel V. Biomechanics of bone. In. Nordin M, Frankel V, editors. Basic biomechanics of the musculoskeletal system. Philadelphia (PA): Lea and Febiger, 1989: 3–29

    Google Scholar 

  115. Paul IL, Munro MB, Abernathy PJ, et al. Musculo-skeletal shock absorption: relative contribution of bone and soft tissues at various frequencies. J Biomech 1978; 11: 237–9

    Article  PubMed  CAS  Google Scholar 

  116. Pauwels F. Biomechanics of the locomotor apparatus. Contributions on the functional anatomy of the locomotor apparatus. Berlin: Springer-Verlag, 1980

    Google Scholar 

  117. Radin EL. Role of muscles in protecting athletes from injury. Acta Med Scand 1986; Suppl. 711: 143–7

    Google Scholar 

  118. Radin EL, Simon SR, Rose RM, et al. Practical biomechanics for the orthopedic surgeon. New York: John Wiley and Sons, 1979

    Google Scholar 

  119. Volpin G, Petronius G, Hoerer D, et al. Lower limb pain and disability following strenuous activity. Mil Med 1989; 154: 294–7

    PubMed  CAS  Google Scholar 

  120. Yoshikawa T, Mori S, Santiesteban AJ, et al. The effects of muscle fatigue on bone strain. J Exp Biol 1994; 188: 217–33

    PubMed  CAS  Google Scholar 

  121. Clarke TE, Coper BL, Hamill CL, et al. The effect of varied stride rate upon shank deceleration in running. J Sports Sci 1985; 3: 41–9

    Article  PubMed  CAS  Google Scholar 

  122. Nyland JA, Shapiro R, Stine RL, et al. Relationship of fatigued run and rapid stop to ground reaction forces, lower extremity kinematics, and muscle activation. J Sports Phys Ther 1994; 20: 132–7

    CAS  Google Scholar 

  123. Mann RA. Biomechanics of running. In. Mack RP, editor. Symposium on the foot and leg in running sports. St. Louis (MO): C.V. Mosby, 1982: 1–29

    Google Scholar 

  124. Cook SD, Kester MA, Brunet ME, et al. Biomechanics of running shoe performance. Clin Sports Med 1985; 4: 619–26

    PubMed  CAS  Google Scholar 

  125. Myburgh KH, Grobler N, Noakes TD. Factors associated with shin soreness in athletes. Phys Sports Med 1988; 16: 129–34

    Google Scholar 

  126. Grimston SK, Engsberg JR, Kloiber R, et al. Bone mass, external loads, and stress fracture in female runners. Int J Sports Biomech 1991; 7: 293–302

    Google Scholar 

  127. McKeag DB, Dolan C. Overuse syndromes of the lower extremity. Phys Sports Med 1989; 17: 108–23

    Google Scholar 

  128. Lilletvedt J, Kreighbaum E, Phillips RL. Analysis of selected alignment of the lower extremity related to the shin splint syndrome. J Am Podiatry Assoc 1979; 69: 211–7

    PubMed  CAS  Google Scholar 

  129. Viitasalo JT, Kvist M. Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. Am J Sports Med 1983; 11: 125–30

    Article  PubMed  CAS  Google Scholar 

  130. DeLacerda FG. A study of anatomical factors involved in shin splints. J Ortho Sports Phys Ther 1980; 2: 55–9

    CAS  Google Scholar 

  131. Messier SP, Pittalla KA. Etiological factors associated with selected running injuries. Med Sci Sports Exerc 1988; 20: 501–5

    PubMed  CAS  Google Scholar 

  132. Allen M, Webster CA, Stortz M, et al. Fitness class injuries: floor surface, malalignments and a new ’squat test’. Ann Sports Med 1986; 3: 14–8

    Google Scholar 

  133. Mubarak SJ, Gould RN, Lee YF, et al. The medial tibial stress syndrome: a cause of shin splints. Am J Sports Med 1982; 10: 201–5

    Article  PubMed  CAS  Google Scholar 

  134. Subotnik SI. The flat foot. Phys Sports Med 1981; 9: 85–91

    Google Scholar 

  135. Sommer HM, Vallentyne SW. Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc 1995; 27: 800–4

    PubMed  CAS  Google Scholar 

  136. Milgrom C, Giladi M, Kashtan H. A prospective study of the effect of a shock-absorbing orthotic device on the incidence of stress fractures in military recruits. Foot Ankle 1985; 6: 101–4

    PubMed  CAS  Google Scholar 

  137. Simkin A, Leichter I, Giladi M, et al. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle 1989; 10: 25–9

    PubMed  CAS  Google Scholar 

  138. Brunet ME, Cook SD, Brinker MR, et al. A survey of running injuries in 1505 competitive and recreational runners. J Sports Med Phys Fitness 1990; 30: 307–15

    PubMed  CAS  Google Scholar 

  139. Hulkko A, Orava S. Stress fractures in athletes. Int J Sports Med 1987; 8: 221–6

    Article  PubMed  CAS  Google Scholar 

  140. Grimston SK, Engsberg JR, Kloiber R, et al. Menstrual, calcium and training history: relationship to bone health in female runners. Clin Sports Med 1990; 2: 119–28

    Google Scholar 

  141. Myburgh KH, Hutchins J, Fataar AB, et al. Low bone density is an etiologic factor for stress fractures in athletes. Ann Intern Med 1990; 113: 754–9

    PubMed  CAS  Google Scholar 

  142. Cann CE, Cavanaugh DJ, Schnurpfiel, et al. Menstrual history is the primary determinant of trabecular bone density in women runners [abstract]. Med Sci Sports Exerc 1988; 20: S59

    Google Scholar 

  143. Drinkwater BL, Nilson K, Chestnut CH, et al. Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med 1984; 311: 277–81

    Article  PubMed  CAS  Google Scholar 

  144. Barrow GW, Saha S. Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med 1988; 16: 209–16

    Article  PubMed  CAS  Google Scholar 

  145. Cann CE, Martin MC, Genant HK, et al. Decreased spinal mineral content in amenorrheic women. JAMA 1984; 251: 626–9

    Article  PubMed  CAS  Google Scholar 

  146. Cameron KR, Wark JD, Telford RD. Stress fractures and bone loss: the skeletal cost of intense athleticism?. Excel 1992; 8: 39–55

    Google Scholar 

  147. Orava S, Karpakka J, Hulkko A, et al. Diagnosis and treatment of stress fractures located at the mid-tibial shaft in athletes. Int J Sports Med 1991; 12: 419–22

    Article  PubMed  CAS  Google Scholar 

  148. Daffner RH, Martinez S, Gehweiler JA. Stress fractures in runners. JAMA 1982; 247: 1039–41

    Article  PubMed  CAS  Google Scholar 

  149. Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone. Radiography, scintigraphy, and MR imaging. Clin Sports Med 1997; 16: 275–90

    Article  PubMed  CAS  Google Scholar 

  150. Ammann W, Matheson GO. Radionuclide bone imaging in the detection of stress fractures. Clin J Sports Med 1991; 1: 115–22

    Article  Google Scholar 

  151. Giladi M, Ziv Y, Aharonson Z, et al. Comparison between radiography, bone scan, and ultrasound in the diagnosis of stress fractures. Mil Med 1984; 149: 459–61

    PubMed  CAS  Google Scholar 

  152. Matin P. Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries. Semin Nucl Med 1988; 18: 90–112

    Article  PubMed  CAS  Google Scholar 

  153. Roub LW, Gumerman LW, Hanley EN, et al. Bone stress: a radionuclide imaging perspective. Radiology 1979; 132: 431–8

    PubMed  CAS  Google Scholar 

  154. Rupani HD, Holder LE, Espinola DA, et al. Three-phase radionuclide bone imaging in sports medicine. Radiology 1985; 156: 187–96

    PubMed  CAS  Google Scholar 

  155. Zwas ST, Elkanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med 1987; 28: 452–7

    PubMed  CAS  Google Scholar 

  156. Somer K, Meurman KOA. Computed tomography of stress fractures. J Comp Assist Tomogr 1982; 6: 109–15

    Article  CAS  Google Scholar 

  157. Burks RT, Lock TR, Negendank WG. Occult tibial fracture in a gymnast: diagnosis by magnetic resonance imaging: a case report. Am J Sports Med 1992; 20: 88–91

    Article  PubMed  CAS  Google Scholar 

  158. Yousem D, Magid D, Fishman EK, et al. Computed tomography of stress fractures. J Comp Assist Tomogr 1986; 10: 92–5

    Article  CAS  Google Scholar 

  159. Salzstein RA, Pollack SR. Electromechanical potentials in cortical bone: II experimental analysis. J Biomech 1987; 20: 271–80

    Article  PubMed  CAS  Google Scholar 

  160. Bassett CAL, Becker RO. Generation of electric potentials by bone in response to mechanical stress. Science 1962; 137: 1063–4

    Article  PubMed  CAS  Google Scholar 

  161. Gross D, Williams WS. Streaming potential and the electromechanical response of physiologically-moist bone. J Biomech 1982; 15: 277–95

    Article  PubMed  CAS  Google Scholar 

  162. Harrigan TP, Hamilton JJ. Bone strain sensation via transmembrane potential changes in surface osteoblasts: loading rate and microstructural implications. J Biomech 1993; 26: 183–200

    Article  PubMed  CAS  Google Scholar 

  163. Christel P, Cerf G, Pilla AA. Modulation of rat radial osteotomy repair using electromagnetic current induction. In. Becker RO, editor. Mechanisms of growth control. Springfield (IL): Charles C. Thomas, 1981: 237–50

    Google Scholar 

  164. Cochran GVB, Kadaba MP, Palmieri VR. External ultrasound can generate microampere direct currents in vivo from implanted piezoelectric materials [short communication]. J Orthop Res 1988; 6: 145–7

    Article  PubMed  CAS  Google Scholar 

  165. Norton LA, Bourret LA, Rodan GA. Molecular changes in hard tissue cells in response to bioelectric proliferative signals. In. Becker RO, editor. Mechanisms of growth control. Springfield (IL): Charles C. Thomas, 1981: 180–91

    Google Scholar 

  166. Scott G, King JB. A prospective, double-blind trial of electrical capacitive coupling in the treatment of non-union of long bones. J Bone Joint Surg 1994; 76: 820–6

    PubMed  CAS  Google Scholar 

  167. Sharrard WJW. A double-blind trial of pulsed electromagnetic fields for delayed union of tibial fractures. J Bone Joint Surg 1990; 72: 347–55

    CAS  Google Scholar 

  168. Wilber MC, Russell HL. Central bioelectric augmentation in the healing of fractures. In. Brighton CT, Black J, Pollack SR, editors. Electrical properties of bone and cartilage. Experimental effects and clinical applications. New York: Grune and Stratton, 1979: 597–604

    Google Scholar 

  169. Benazzo F, Mosconi M, Beccarisi G, et al. Use of capacitive coupled electric fields in stress fractures in athletes. Clin Orthop 1995; 310: 145–9

    PubMed  Google Scholar 

  170. Morris RH. Medial tibial syndrome: a treatment protocol using electric current. Chiropr Sports Med 1991; 5: 5–8

    Google Scholar 

  171. Brighton CT, Pollack SR. Treatment of recalcitrant non-union with a capacitively coupled electrical field. A preliminary report. J Bone Joint Surg 1985; 67-A(4): 577–85

    Google Scholar 

  172. Hamanishi C, Kawabata T, Yoshii T, et al. Bone mineral density changes in distracted callus stimulated by pulsed direct electrical current. Clin Orthop 1995; 312: 247–52

    PubMed  Google Scholar 

  173. McLeod KJ, Rubin CT. Frequency specific modulation of bone adaptation by induced electric fields. J Theor Biol 1990; 145: 385–96

    Article  PubMed  CAS  Google Scholar 

  174. McLeod KJ, Rubin CT. The effect of low-frequency electric fields on osteogenesis. J Bone Joint Surg 1992; 74: 920–9

    PubMed  CAS  Google Scholar 

  175. Rubin CT, McLeod KJ, Lanyon LE. Prevention of osteoporosis by pulsed electromagnetic fields. J Bone Joint Surg 1989; 71: 411–7

    PubMed  CAS  Google Scholar 

  176. Skerry TM, Pead MJ, Lanyon LE. Modulation of bone loss during disuse by pulsed electromagnetic fields. J Orthop Res 1991: 9: 600–8

    Article  PubMed  CAS  Google Scholar 

  177. Rubin CT, Donahue HJ, Rubin JE, et al. Optimization of electric field parameters for the control of bone remodeling: exploitation of an indigenous mechanism for the prevention of osteopenia. J Bone Miner Res 1993; 8: S573–81

    Article  PubMed  Google Scholar 

  178. Whitelaw GP, Wetzler MJ, Levy AS, et al. A pneumatic leg brace for the treatment of tibial stress fractures. Clin Orthop 1991; 270: 301–5

    PubMed  Google Scholar 

  179. van Mechelen W. Can running injuries be effectively prevented?. Sports Med 1995; 19: 161–5

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Belinda R. Beck.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Beck, B.R. Tibial Stress Injuries. Sports Med 26, 265–279 (1998). https://doi.org/10.2165/00007256-199826040-00005

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00007256-199826040-00005

Keywords

Navigation