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Stress Injury, Leg
Kirkland W. Davis, MD, FACR; Andrew Sonin, MD, FACR; Donna G. Blankenbaker, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        • Diagnostic Checklist

          TERMINOLOGY

          • Synonyms

            • Stress fracture, shin splints, medial tibial stress syndrome (MTSS), stress response, stress reaction
          • Definitions

            • Fatigue fracture: stress fracture due to abnormal stress on normal bone
            • Insufficiency fracture: stress fracture due to normal stress on abnormal bone
            • Shin splints: refers to clinical condition of tibial pain in legs usually associated with running
              • a.k.a. MTSS
              • Represents range of injuries from stress edema to periostitis to frank cortical fracture of distal 2/3 of tibia

          IMAGING

          • General Features

            • Radiographic Findings

              • CT Findings

                • MR Findings

                  • Imaging Recommendations

                    • Nuclear Medicine Findings

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Staging, Grading, & Classification

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    DIAGNOSTIC CHECKLIST

                                    • Consider

                                      • Image Interpretation Pearls

                                        • Reporting Tips

                                          Selected References

                                          1. Mohile N et al: Chronic lower leg pain in athletes: overview of presentation and management. HSS J. 16(1):86-100, 2020
                                          2. Almekinders LC et al: Common and uncommon injuries in ultra-endurance sports. Sports Med Arthrosc Rev. 27(1):25-30, 2019
                                          3. Moen MH et al: A prospective study on MRI findings and prognostic factors in athletes with MTSS. Scand J Med Sci Sports. 24(1):204-10, 2014
                                          4. Beck BR et al: Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT severity grades to clinical severity and time to healing. Radiology. 263(3):811-8, 2012
                                          5. Kijowski R et al: Validation of MRI classification system for tibial stress injuries. AJR Am J Roentgenol. 198(4):878-84, 2012
                                          6. Reshef N et al: Medial tibial stress syndrome. Clin Sports Med. 31(2):273-90, 2012
                                          7. Miller T et al: The classification systems of stress fractures: a systematic review. Phys Sportsmed. 39(1):93-100, 2011
                                          8. Sourlas I et al: Proximal tibial stress fractures associated with primary degenerative knee osteoarthritis. Am J Orthop. 38(3):120-4, 2009
                                          9. Gaeta M et al: Diagnostic imaging in athletes with chronic lower leg pain. AJR Am J Roentgenol. 191(5):1412-9, 2008
                                          10. Heyworth BE et al: Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr. 20(1):58-61, 2008
                                          11. Jowett AJ et al: Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int. 29(7):716-21, 2008
                                          12. Woods M et al: Magnetic resonance imaging findings in patients with fibular stress injuries. Skeletal Radiol. 37(9):835-41, 2008
                                          13. Drabicki RR et al: Stress fractures around the knee. Clin Sports Med. 25(1):105-15, ix, 2006
                                          14. Fredericson M et al: Stress fractures in athletes. Top Magn Reson Imaging. 17(5):309-25, 2006
                                          15. Ruohola JP et al: Fatigue bone injuries causing anterior lower leg pain. Clin Orthop Relat Res. 444:216-23, 2006
                                          16. Wall J et al: Imaging of stress fractures in runners. Clin Sports Med. 25(4):781-802, 2006
                                          17. Young AJ et al: Evaluation and treatment of tibial stress fractures. Clin Sports Med. 25(1):117-28, x, 2006
                                          18. Kaeding CC et al: Management and return to play of stress fractures. Clin J Sport Med. 15(6):442-7, 2005
                                          19. Aoki Y et al: Magnetic resonance imaging in stress fractures and shin splints. Clin Orthop Relat Res. (421):260-7, 2004
                                          20. Tuan K et al: Stress fractures in athletes: risk factors, diagnosis, and management. Orthopedics. 27(6):583-91; quiz 592-3, 2004
                                          21. Wilder RP et al: Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 23(1):55-81, vi, 2004
                                          22. Spitz DJ et al: Imaging of stress fractures in the athlete. Radiol Clin North Am. 40(2):313-31, 2002
                                          23. Gibbon WW: Shin splints. Radiology. 207(3):826-7, 1998
                                          24. Shearman CM et al: Longitudinal tibial stress fractures: a report of eight cases and review of the literature. J Comput Assist Tomogr. 22(2):265-9, 1998
                                          25. Anderson MW et al: Shin splints: MR appearance in a preliminary study. Radiology. 204(1):177-80, 1997
                                          26. Batt ME: Shin splints--a review of terminology. Clin J Sport Med. 5(1):53-7, 1995
                                          27. Fredericson M 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. 23(4):472-81, 1995
                                          28. Beals RK et al: Stress fractures of the anterior tibial diaphysis. Orthopedics. 14(8):869-75, 1991
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Clinical Issues

                                                • Diagnostic Checklist

                                                  TERMINOLOGY

                                                  • Synonyms

                                                    • Stress fracture, shin splints, medial tibial stress syndrome (MTSS), stress response, stress reaction
                                                  • Definitions

                                                    • Fatigue fracture: stress fracture due to abnormal stress on normal bone
                                                    • Insufficiency fracture: stress fracture due to normal stress on abnormal bone
                                                    • Shin splints: refers to clinical condition of tibial pain in legs usually associated with running
                                                      • a.k.a. MTSS
                                                      • Represents range of injuries from stress edema to periostitis to frank cortical fracture of distal 2/3 of tibia

                                                  IMAGING

                                                  • General Features

                                                    • Radiographic Findings

                                                      • CT Findings

                                                        • MR Findings

                                                          • Imaging Recommendations

                                                            • Nuclear Medicine Findings

                                                              DIFFERENTIAL DIAGNOSIS

                                                                PATHOLOGY

                                                                • General Features

                                                                  • Staging, Grading, & Classification

                                                                    CLINICAL ISSUES

                                                                    • Presentation

                                                                      • Demographics

                                                                        • Natural History & Prognosis

                                                                          • Treatment

                                                                            DIAGNOSTIC CHECKLIST

                                                                            • Consider

                                                                              • Image Interpretation Pearls

                                                                                • Reporting Tips

                                                                                  Selected References

                                                                                  1. Mohile N et al: Chronic lower leg pain in athletes: overview of presentation and management. HSS J. 16(1):86-100, 2020
                                                                                  2. Almekinders LC et al: Common and uncommon injuries in ultra-endurance sports. Sports Med Arthrosc Rev. 27(1):25-30, 2019
                                                                                  3. Moen MH et al: A prospective study on MRI findings and prognostic factors in athletes with MTSS. Scand J Med Sci Sports. 24(1):204-10, 2014
                                                                                  4. Beck BR et al: Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT severity grades to clinical severity and time to healing. Radiology. 263(3):811-8, 2012
                                                                                  5. Kijowski R et al: Validation of MRI classification system for tibial stress injuries. AJR Am J Roentgenol. 198(4):878-84, 2012
                                                                                  6. Reshef N et al: Medial tibial stress syndrome. Clin Sports Med. 31(2):273-90, 2012
                                                                                  7. Miller T et al: The classification systems of stress fractures: a systematic review. Phys Sportsmed. 39(1):93-100, 2011
                                                                                  8. Sourlas I et al: Proximal tibial stress fractures associated with primary degenerative knee osteoarthritis. Am J Orthop. 38(3):120-4, 2009
                                                                                  9. Gaeta M et al: Diagnostic imaging in athletes with chronic lower leg pain. AJR Am J Roentgenol. 191(5):1412-9, 2008
                                                                                  10. Heyworth BE et al: Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr. 20(1):58-61, 2008
                                                                                  11. Jowett AJ et al: Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int. 29(7):716-21, 2008
                                                                                  12. Woods M et al: Magnetic resonance imaging findings in patients with fibular stress injuries. Skeletal Radiol. 37(9):835-41, 2008
                                                                                  13. Drabicki RR et al: Stress fractures around the knee. Clin Sports Med. 25(1):105-15, ix, 2006
                                                                                  14. Fredericson M et al: Stress fractures in athletes. Top Magn Reson Imaging. 17(5):309-25, 2006
                                                                                  15. Ruohola JP et al: Fatigue bone injuries causing anterior lower leg pain. Clin Orthop Relat Res. 444:216-23, 2006
                                                                                  16. Wall J et al: Imaging of stress fractures in runners. Clin Sports Med. 25(4):781-802, 2006
                                                                                  17. Young AJ et al: Evaluation and treatment of tibial stress fractures. Clin Sports Med. 25(1):117-28, x, 2006
                                                                                  18. Kaeding CC et al: Management and return to play of stress fractures. Clin J Sport Med. 15(6):442-7, 2005
                                                                                  19. Aoki Y et al: Magnetic resonance imaging in stress fractures and shin splints. Clin Orthop Relat Res. (421):260-7, 2004
                                                                                  20. Tuan K et al: Stress fractures in athletes: risk factors, diagnosis, and management. Orthopedics. 27(6):583-91; quiz 592-3, 2004
                                                                                  21. Wilder RP et al: Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 23(1):55-81, vi, 2004
                                                                                  22. Spitz DJ et al: Imaging of stress fractures in the athlete. Radiol Clin North Am. 40(2):313-31, 2002
                                                                                  23. Gibbon WW: Shin splints. Radiology. 207(3):826-7, 1998
                                                                                  24. Shearman CM et al: Longitudinal tibial stress fractures: a report of eight cases and review of the literature. J Comput Assist Tomogr. 22(2):265-9, 1998
                                                                                  25. Anderson MW et al: Shin splints: MR appearance in a preliminary study. Radiology. 204(1):177-80, 1997
                                                                                  26. Batt ME: Shin splints--a review of terminology. Clin J Sport Med. 5(1):53-7, 1995
                                                                                  27. Fredericson M 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. 23(4):472-81, 1995
                                                                                  28. Beals RK et al: Stress fractures of the anterior tibial diaphysis. Orthopedics. 14(8):869-75, 1991