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Bilateral Stress Fractures of the Anterior Part of the Tibial Cortex. A Case Report*

Most stress fractures of the tibia, when treated appropriately, heal without sequelae. A stress fracture of the anterior part of the cortex of the tibia, an uncommon variant, is associated with atypical clinical and radiographic findings, has a propensity for nonunion, and can result in a complete fracture. We report the case of a patient who had chronic, bilateral stress fractures of the anterior part of the tibial cortex.

A twenty-one-year-old male college football player who was in his junior year was first seen by us because of a five-year history of recurrent pain in both shins. The pain had worsened in September 1996, during the early part of the football season, when practices were held twice a day. Typically, the pain was most severe when the patient began running but would subside within a few minutes and then return on cessation of weight-bearing activity. The patient had not missed any games or practice sessions.

Clinical examination revealed moderate tenderness along the medial border of the distal and middle thirds of the right tibia, extending for a distance of twelve centimeters, and mild tenderness in the corresponding area of the left tibia. The patient had marked bilateral pes planus and rigidity of the midfoot and forefoot. The subtalar and ankle joints had a normal range of motion.

Radiographs had been made at regular intervals during the five years before the patient was evaluated in our office, and all had revealed normal findings. A triple-phase isotope bone scan was performed to confirm the provisional diagnosis of a stress fracture. The blood-pool images demonstrated mildly increased radionuclide uptake in the right as compared with the left tibia. The delayed-phase images showed four small, discrete areas of moderately increased uptake along the anterior border of the middle third of the right tibia and …