Leg Pain in a Runner: Tibial Stress Fracture (Part 2)

Recently a long distance runner presented with leg pain of 4-5 months. The pain came on suddenly during a long training run. The patient attempted to run through the pain, because it was not too bad, for 2 months. Then, common sense dictated stopping running for the last 2 months. The pain is not only not better (can I throw a few more nots around) but now hurts walking around which it never did before. He tried changing shoes and icing occasionally. These measures did not help. 

In a runner with leg pain developed with long distance training, the diagnosis is a stress fracture until proven otherwise. The following 3 X-rays just taken show a healing tibial stress fracture with marked amount of new bone formation. Try to look along the normal border of the bone. As the normal border gets obscure, this is the new bone forming. Unlike this X-ray, you normally do not see a fracture line with a stress fracture only the subtle new bone formation. 

On this oblique view, one can really see the fracture line. Fractures look bad for a long time for 2 reasons. The fracture line looks worse then it really is since there is more water content near the fracture itself in the bone. More water makes the fracture look worse. Fractures heal inside out, so total healing may have occurred internally, but the X-ray still shows signs of the fracture still present.

Due to the compression forces and the muscle contractions of the leg muscles, most running stress fractures on the tibia occur on the back surface of the bone. This makes it hard to locate and hard to see any swelling.